Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Jagjeet Singh who died on 8 March 2024

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4 November 2024 concerning the death of Jagjeet Singh on 8 March 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Jagjeet’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Jagjeet’s care have been listened to and reflected upon.

Your Report raises concerns over a chronic shortage of inpatient mental health beds, both within the London region and nationally. In relation to Jagjeet’s care, you have raised that a bed on the mental health ward should have been available for him when he was discharged from the medical ward. 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 and additionally as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 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. 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 2023-25. This funding can be used to support mental health inpatient services as well as the wider system which should help to reduce pressures on local inpatient services, so that those who need to access beds can do so quickly and locally. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

24 December 2024

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. My Clinical Quality regional colleagues in London are engaging with North East London Integrated Care Board on the concerns raised in your Report and system arrangements for mental health inpatient beds.

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 Jagjeet, 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 Lee

Thank you for your Regulation 28 report to prevent future deaths dated 4 November 2024 about the death of Jagjeet Singh. 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 Jagjeet’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

I understand your concerns about a bed on the mental health ward not being available for Mr Singh when he was discharged from the medical wards. I note that you have also addressed these matters of concern to the Chief Executive of NHS England. I look forward to seeing her response and working with NHS England where appropriate, to avoid a repetition of the tragic events of this case.

I recognise the impact that a suitable bed not being available can have on a patient’s care, as exemplified in Jagjeet’s case.

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 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 inpatient admission being necessary.

I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the availability of specialist personality disorder rehabilitation units. I recognise that mental health services have been under significant strain in recent years due to the rise in demand.

Over the past few years, the NHS has been developing the community mental health framework with the aim of improving community support for people with severe mental illness, thus avoiding the need for an inpatient admission where possible and freeing up more beds.

NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with local health systems directed to reduce the average length of stay in adult acute mental health wards to deliver more timely access to local beds. And in areas where there is a clear need for more beds, this has been addressed in part through investment in new units.

It is also important that when people are discharged, this happens in a way that considers their needs on discharge and any risks to their safety. To help support safe and timely discharge decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support safe discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults.

As part of our mission to build an NHS fit for the future, we will make sure more mental health 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.

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