Dear Mr Wooderson,

Re: Inquest touching the death of James Oliver Sheppard

I write in relation to the above inquest which concluded on 8 May 2025.

On 8 May 2025 you made a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report was sent to the Department of Health and Social Care and to me, as the Chief Executive Gloucestershire Health and Care NHS Foundation Trust ("the Trust"). I am writing to provide you with the Trust response to your concerns which relate to insufficient beds available in psychiatric units to meet patient demand.

We are grateful for the acknowledgement during your concluding remarks at the inquest that the Trust is responsible for delivery of psychiatric beds locally and issues of commissioning and total levels of available resource are responsibilities held in the wider health system locally and nationally. As such, our response is focused on what we can influence. As examined during the hearing, particularly in consideration of the witness testimony provided by , significant work has been undertaken over the past few years to manage mental health bed capacity and patient flow within the Trust. Although bed availability and resourcing continue to present challenges across mental health wards nationally, the measures implemented by the Trust have improved the structure and efficiency of bed management systems and significantly reduced the use of Out of Area Placements over the past three years, clearly demonstrating the Trust commitment towards an ongoing improvement of processes to ensure that every possible effort is made to ensure that those patients who require in-patient mental health care have access to a bed as quickly as possible. Our further work is focused on reducing, wherever possible, the average length of stay of inpatients to ensure that the current number of beds are being used as efficiently and effectively as possible. The Trust will be monitored nationally on this measure as part of NHS England’s Performance Assessment Framework.

Chief Executive’s office Edward Jenner Court 1010 Pioneer Avenue Gloucester Business Park Brockworth Gloucester GL3 4AW

Tel. 0300 421 8348

In its ongoing efforts to improve the position locally, the Trust has also engaged in discussions with the local Integrated Care Board (NHS Gloucestershire ICB) and the development of an inpatient strategy is one of the agreed priorities for the Integrated Care System this year. We will ensure that the importance of adequate access to inpatient care is formally acknowledged through our Contract Management Board meeting with the ICB.

As a Trust, the safety and wellbeing of those we provide service to is paramount and despite the unfortunate circumstances in which this query has arisen, we welcome the opportunity you have provided for us to further address the issue of beds availability in psychiatric units. We will also note the response you receive from the Department of Health and Social Care on this issue which we are aware presents a challenge to mental health providers across the country. We have taken this opportunity, as we do with all inquests, to learn from this and continue to implement steps to ensure that we provide the best possible quality care.

Dear Mr Wooderson,

Thank you for the Regulation 28 report of 8 May 2025 sent to the Department of Health and Social Care about the death of James Oliver Sheppard. I am replying as the Minister with responsibility for mental health and patient safety.

Firstly, I would like to say how saddened I was to read of the circumstances of James’ death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns over insufficient bed availability in psychiatric units to meet patient demand.

I am sure you will appreciate that the number of mental health inpatient beds required to support a local population is dependent on both local mental health need.

I expect individual trusts and local health systems to effectively assess and manage bed capacity through the ‘flow’ of patients being discharged or moving to another setting.

The 2025-26 priorities and operational planning guidance sets a requirement for integrated care boards to take action to reduce the average length of stay in adult acute mental health beds, improving local bed availability and reducing the need for inappropriate out of area placements, and to reduce waits longer than 12 hours in A&E.

As part of our mission to build an NHS fit for the future, we will focus treatment away from hospital and inpatient care and improve community and crisis services, making sure more mental health crisis care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. This will hopefully reduce delays, through increasing bed availability, for those who need inpatient care the most.

In order to better support an individual and prevent them reaching a crisis point, NHS England is piloting a 24/7 Neighbourhood Mental Health Centre model in England, building on learning from international exemplars. Six early implementor sites are bringing together their community, crisis, and inpatient functions into one open access neighbourhood team which is available 24 hours a day, 7 days a week. This means people with mental health needs can walk in or self-refer as can their loved ones and system partners.

In addition, anyone in England experiencing a mental health crisis can now to speak to a trained NHS professional at any time of the day through a new mental health option on NHS
111. Trained NHS staff will assess patients over the phone and guide callers with next steps such organising face-to-face community support or facilitating access to alternatives services, such as crisis cafés or safe havens which provide a place for people to stay as an alternative to A&E or a hospital admission. The new integrated service can give patients of all ages, including children, the chance to be listened to by a trained member of staff who can help direct them to the right place.

As announced in the Budget, we are committing £26 million in capital investment to open new mental health crisis centres, reducing pressure on busy A&E services and ensuring people have the support they need when they need it.

On another note, the Government is also committed to tackling suicide as one the biggest killers in this country. The Suicide Prevention Strategy for England sets out priority areas for action to prevent suicides. This includes the need to provide tailored, targeted support to priority groups such people in contact with mental health services and providing effective crisis support within and outside of the NHS.

Through the Suicide Prevention Strategy, the British Transport Police Harm Reduction Team (HaRT) is working in partnership with Network Rail, mental health trusts and other key partners to provide support to individuals that present on railways multiple times. The pilot project has found that, following this support, people were significantly less likely to be present in the railway environment.

To support local areas to tackle suicides in high frequency locations and public spaces, Office for Health Improvement and Disparities (OHID) developed resources such as ‘Preventing suicides in public places: a practice resource’ which provides local areas with a step-by-step guide to identifying locations and taking action.

Samaritans has delivered suicide intervention training to over 27,000 members of the rail industry workforce. This is in addition to the Small Talk Saves Lives campaign which, in partnership with Network Rail and Samaritans, supports rail passengers to identify when someone is at risk of suicide and how to approach them

I hope this response is helpful. Thank you for bringing these concerns to my attention.