Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Sapphire Kathleen Bernard who died on 30 October 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 5 February 2025 concerning the death of Sapphire Kathleen Bernard on 30 October
2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sapphire’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Sapphire’s care have been listened to and reflected upon.

Your Report raises concerns over the lack of available mental health inpatient beds and the unsuitability of Accident & Emergency (A&E) departments as a holding place for those people waiting for mental health admissions, particularly for patients who are also neurodiverse.

The number of mental health beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary.

In some local areas there is a need for more beds. This is being addressed in part through investment in new units, however, this should be considered as part of a transformational approach. This is supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and prevent avoidable deterioration and hospital admission.  NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds, supported by delivering the 10 high impact actions for mental health discharges.

To address the wider system issues that impact on health services, a further £1.6 billion has been made available via the Better Care Fund from 2023-2025. This funding can be used to support mental health inpatient services as well as the wider system, National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 28 March 2025

which should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.

This is being supplemented by a further £42 million recurrent investment from 2024/25 for all Integrated Care Boards (ICBs) in the country, to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.

Crisis services, including Crisis Resolution Home Treatments Teams, are available at short notice to help individuals resolve a mental health crisis or to support them while it is happening. Additionally, from this year, all mental health providers in England offer access to 24/7 age-appropriate crisis support via the NHS 111 ‘select mental health option’ – making it easier to seek help.

NHS England’s ambition is not just to improve the access point and connection to the specialist mental health points of access, but to bring significant improvements and expansion in the mental health services that ‘sit behind’ the point of access, so that people can be facilitated to access support that meets their needs and preferences in a more timely way. To this effect, we are moving at pace and are beginning to measure response times to those presenting to urgent and emergency mental health services, either in the community and/or emergency departments, with the aim of supporting these people to access appropriate care more quickly.

NHS England recognises the unsuitability of emergency departments for people experiencing mental health crisis once their immediate physical health needs have been attended to. We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements. Due to this oversight, individual patient cases are being escalated at a national level and executive input is then sought to expedite care.

From Winter 2024/25 we have also introduced action cards for trusts and systems, articulating key actions to be taken by trusts and systems to reduce the time patients spend in emergency departments. These include specific actions for people with complex learning disabilities and autism.

NHS England’s South East region’s Mental Health, Learning Disability and Autism (MHLDA) Team are in the process of developing a Standard Operating Procedure (SOP) for managing mental health presentations with A&E departments. This has followed Quality & Safety visits to A&E departments, which have concluded that patients are safer being admitted. The SOP should be approved and finalised by April 2025 and findings are due to be shared with South East ICBs, as well as multi- disciplinary teams and the Urgent & Elective Care (UEC) Recovery Board.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Sapphire, are shared across the NHS at both a national and regional level and helps

us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Ms Schofield

Sapphire Bernard I write in response to your Regulation 28 report, dated 5 February 2025, setting out your concerns after hearing evidence at the Inquest in relation to the death of Sapphire Bernard.

I wish to begin by extending my sincere condolences to Sapphire’s family and friends. The inquest proceedings must have been an extremely difficult time for them.

I address your concerns as follows, following consultation with senior commissioners in the mental health team:

The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric bed. The role of NHS Sussex is to commission services based on local needs, working with partners within the NHS, councils and voluntary sectors to deliver high quality care. NHS Sussex commissions Sussex Partnership NHS Foundation Trust (SPFT) to provide most of the mental health services for Sussex. NHS Sussex commissions a comprehensive range of mental health and learning disability services from SPFT for people of all ages. This includes inpatient beds for children, adults and older people. Nationally, there has been an increased demand on mental health services since the end of the COVID 19 pandemic and NHS Sussex recognises this demand locally.

There are 302 commissioned acute adult care beds and 40 Independent sector beds. In addition to the 40 acute adult beds in the independent sector NHS Sussex and Sussex Partnership commissioned an additional 14 beds between January- March 2025 to support winter pressures. These have now been extended for Quarter one 2025/26 taking the total number of acute adult beds in the independent sector to 54. Further to this, SPFT have redesigned their acute dementia ward in Brighton & Hove to support population need which will reopen in May 2025 as an adult ward and increase the SPFT bed base by 15 adult beds.

To note, Sussex benchmarks above average for the number of beds in acute mental health wards for benchmarked areas nationally (as of 31st March 2023). There are 25 beds per 100,000 population in Sussex, compared to a national mean of 23.

NHS Sussex recognises that some people wait longer than we would like to access mental health inpatient care due to patient flow and acuity of patients, NHS Sussex are working closely with partners to improve timely discharge to support prompt admission.

In Sapphire’s case a bed was not found for her within a 19-day period. SPFT Mental Health Liaison Teams, assess patients in Emergency Departments and on acute hospital medical wards and seek community alternatives for patients as a matter of routine. These alternatives may include referrals to Crisis Resolution Home Treatment Teams, Havens, Staying Well services (crisis cafes), Recovery Houses and Assessment & Treatment Services. Sapphire’s supported accommodation placement issued notice on the 9th October 2023 and therefore they could not return to their accommodation with community support. Sapphire was repeatedly clinically reviewed during their admission to East Sussex Hospitals NHS Trust and the clinical opinion remained that they required inpatient psychiatric admission. Sapphire was issued with Section 17 leave to the hospital grounds whilst waiting for admission.

At the end of October 2023 there were 71 patients waiting for acute inpatient care across Sussex- the Trust manages its inpatient provision on a Sussex wide basis. Additionally, there were 115 patients classified as Clinically Ready for Discharge which is 25% of the Trust's acute in-patient bed provision

To support an improved oversight of patients who have increased waits within A&Es and inpatient wards in Sussex, both ESHT and SPFT host weekly provider calls to discuss patient flow with further escalation to NHS Sussex as required. Since 2023, NHS Sussex have oversight of high-level data (numbers not patient details) provided through a ‘live’ reporting system called SHREWD. This information includes patients who are waiting for a mental health bed. The patient data is available across the system for use by Providers, ICBs and regional NHS England colleagues.

The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed.

The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse. The environment in A&E can exacerbate and cause further deterioration in their mental health. East Sussex Healthcare NHS Trust (ESHT) have confirmed that Sapphire arrived in the Emergency department at 19.54 on 2nd October 2004. Sapphire was moved from Emergency department to Acute Admission Unit from 3rd – 20th October and then moved to De Cham ward on 20th October where they stayed until their discharge to SPFT inpatient services. ESHT’s policy supports the admission of patients awaiting mental health beds to acute inpatient beds to support patient experience.

All patients waiting for an inpatient mental health bed, both within the community and hospital settings, are clinically assessed by SPFT and are prioritised in accordance with their level of clinical risk. SPFT sets the criteria used to prioritise patients.

ESHT have developed a Mental Health Support Team in 2024, which includes a Head of Nursing (HoN), a registered Mental Health Nurse (RMN) and 11 Mental Health Support

Workers (MHSWs). The HoN commenced employment in January 2025 with ongoing recruitment to the MHSW posts. The MHSWs will work directly under the RMN to support and enhance close observational care of MH patients.

The primary function of the HoN for Mental Health is to act as a subject matter expert, advisor and educator to the team at large. ESHT is working closer with SPFT to discuss ways in which to improve inter-organisational working: this includes accessibility of service, time to referral, time to be seen, time to Mental Health unit or to Section as necessary.

ESHT is working to review and where appropriate to improve Mental Health patient safety, for example in the Mental Health rooms in A&E. NHS Sussex has no role in the set up or environment of an NHS Provider, however, updates are required for any new construction projects as part of the Commissioning process. For existing environments, it is the responsibility of NHS provider organisations to ensure they follow national guidance on the built environment and undertake national risk assessments.

This is the second inquest that I have heard where a death occurred following a lengthy wait in A&E for a psychiatric bed. In both cases the patients were transgender and had a diagnosis of autistic spectrum disorder.

SPFT as the lead Mental Health service provider manages the inpatient bed capacity to best support the needs of all mental health patients in Sussex and they will then clinically prioritise accordingly. Sussex Partnership Foundation Trust can flex their capacity on a gender basis within their overall number of beds.

As background, SPFT offer mixed sex accommodation within bed base as commissioners, NHS Sussex does not specify the numbers of mixed sex accommodation as this is dependent on demand and capacity. In 2011, the Department of Health wrote to all NHS Chief Executives to request that they eliminate mixed sex accommodation, with further National Guidance in 2019 regarding the delivery of same-sex accommodation. This aimed to prioritise the safety, privacy and dignity of all patients with a move to ensure people are treated where possible in single sex ward. CQC report Sexual Safety on Mental Health Wards 2018 national guidance on eliminating mixed sex accommodation on mental health wards.

SPFT, where possible, offer single-sex accommodation to safeguard people’s privacy and dignity. Where mixed-sex accommodation is available, men and women are in separate bays or rooms and have access to gender specific toilet and washing facilities. SPFT have a Mixed Sex Accommodation Policy Maximising Individual Dignity, which states, where possible, transgender patients are accommodated according to their preference (this may consider the pronouns that they currently use), with all transgender patients cared for in single rooms.

Thank you for bringing your concerns to my attention. I hope that we have provided you and Sapphire’s family with some assurance that NHS Sussex ICB has taken steps to address the concerns outlined in your report and that we are continuing to take action to prioritise patient safety.

Please contact me if I can be of any further assistance.