Dear Ms Topping

Charne Petit (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”)

Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 26 September 2024, in relation to the inquest touching upon the death of Charne Petit. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues.

In the PFD report, you raise concerns that Ms Petit was not adequately medicalised while she remained at Royal Surrey County Hospital (RSCH) awaiting an inpatient psychiatric bed.

We recognise the demand for mental health inpatient beds outweighs availability and that this places significant pressure on the health and care system, not only in Surrey, but also nationally. The King’s Fund outlines: “With the exception of the Covid-19 period, when many beds were closed due to infection control, the current numbers of mental health beds (17,836) are at their lowest level since data collection began in 2010/11. Bed occupancy has remained consistently over the recommended level of 85% – the point at which quality of care is at risk of being compromised. As a consequence, people who need to be admitted can face considerable delays in accident and emergency (A&E) while they wait for an available bed, or may be cared for in inappropriate environments, such as being admitted to a ward in an acute trust.”1.

At a national level, this lack of bed availability is a matter for the Secretary of State for Health to address. Nonetheless, the Trust and our staff work to provide appropriate treatment in the context of the impact of bed shortages to those who require inpatient treatment. In response to the national shortage of mental health acute beds, the Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice. This is an NHS England framework which provides a consistent approach to managing demand across the health and social care system and a procedure for managing surges in demand for inpatient mental health beds. OPEL bed meetings are convened every morning by locality

1 1 https://www.kingsfund.org.uk/insight-and-analysis/long-reads/mental-health-360-acute-mental-health-care- adults, 21 February 2024 21 November 2024

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Associate Directors to discuss any actions that can be undertaken to increase bed capacity as well support people awaiting hospital admission, including those waiting in acute hospitals.

If there are no beds available in the Trust, external options are considered including private sector providers. The use of private beds is dependent on availability, whether the person and their family are willing to access beds outside of Surrey, and acceptance of the referral by the private provider. Another option utilised is that the Trust will approach neighbouring Trusts to see if they can assist. Trusts have their own bed resource challenges however and there is often no scope to assist in this way.

We ensure that treatment and support is provided to a person to meet their mental health needs while awaiting a mental health bed by working collaboratively with our acute hospital partners. In those circumstances, the person receives mental health care and treatment from the Psychiatric Liaison Services (“PLS”). These are multidisciplinary teams based in the acute hospital which include Registered Mental Health Nurses and Consultant Psychiatrists.

The person’s ongoing psychiatric assessment and treatment is coordinated by PLS, through the use of a High Risk Care Plan. This includes where a person is awaiting onward transfer to a mental health bed, as was the case with Ms Petit. The High Risk Care Plan is a shared document that is placed in the medical notes and on the electronic record. It highlights the actual and potential risks, as well as plans to minimise the outlined risks. It is a live document and reviewed regularly.

While at Royal Surrey County Hospital, Ms Petit was assessed by a Consultant Psychiatrist who carried out a review of her medication. She was provided with support from a Psychiatric Liaison Team and received 1:1 observation by a Registered Mental Health nurse. While optimisation of treatment in a mental health hospital would have been the preferred option, the unavailability of an inpatient mental health bed meant that this was not possible and, instead, Ms Petit was provided with treatment for her mental health needs at the acute hospital.

The Mental Health Act can be used to authorise detention and provide mental health assessment and treatment to a person admitted to an acute hospital setting. It is currently only the Emergency Department where the Mental Health Act cannot be used. This is recognised as a gap in the legislation.

Therefore, where a person is admitted to the acute hospital and does not consent to remain there on a voluntary basis, steps are taken to detain the person under the Mental Health Act to a bed at the acute hospital wherever possible. This action can only be taken with the agreement of the acute Trust. The section under the Mental Health Act is commenced at the acute hospital and transfer to an inpatient mental health setting will take place as soon as a bed is available. Anyone detained under the Mental Health Act in an acute hospital would have a Responsible Clinician, who is a Consultant Psychiatrist. This ensures that medication can be introduced, where appropriate, and their response to treatment monitored. They also continue to benefit from the multi-disciplinary assessment and treatment of the Psychiatric Liaison Services while an inpatient mental health bed is awaited.

Since Charne’s sad death in May 2023, the Trust has embarked on collaborative improvement work with our acute care partners through the Mind and Body Transformation as part of the Trust Provider Collaborative (which consists of SaBP, Ashford and St Peter’s, Royal Surrey County Hospital and also includes East Surrey Hospital, Epsom General and Frimley Park Hospital). This work is in recognition of the challenges the system faces to support people safely whilst they may be awaiting a mental health bed or be in the acute hospital with both physical and mental health needs. The programme has been designed to better integrate physical and mental healthcare, and support for people attending acute hospitals with a combination of needs, by improving outcomes, flow and experience of those with mental health needs, their carers and families. Each Trust now has a mental health senior lead whose role is to oversee the appropriate care and support for a person with mental health needs in their acute Trust through the deployment of the Enhanced Care Framework working collaboratively with SaBP PLS. As one of the Trust’s partners within the Mind & Body Provider Collaborative, Royal Surrey County

Hospital now has a Head of Nursing for Mental Health providing senior oversight of the collaboration across mental health and physical healthcare.

While working within a legal framework acknowledged by the Government to be in need of reform, we and our partners within the health and care system must also react to increasing numbers of people presenting in crisis. I remain committed to continually improving the way in which we provide mental health care to those served by the Trust despite the bed availability difficulties faced and would very much welcome the resolution of this issue at a national level. I note that the PFD report has also been sent to NHS England who are most appropriately placed to address this issue nationally.

On behalf of the Trust, I would like to offer our sincere condolences to Ms Petit’s family for their loss.

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Charne Nikita Petit who died on 12 May 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26 September 2024 concerning the death of Charne Nikita Petit on 12 May 2023, sent to the Chair of NHS England. I am responding on behalf of the organisation in my capacity as National Medical Director but would like to assure you that the Chair has also been sighted on this response and has reviewed your Report. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Charne’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Charne’s care have been listened to and reflected upon. Your Report raises concerns over a national shortage of mental health beds. 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 approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn 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 continues 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 and in order to deliver more timely access to local beds. To address the wider system issues that impact on health services, a further £1.6bn 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

21 November 2024

This is being supplemented by a further £42m recurrent investment from 2024/25 for all ICBs in the country to recommission inpatient care in line with local models that provide the best evidence of therapeutic support It is appropriate that Surrey and Borders Partnership Trust respond to your first concern regarding Charne not being properly medicalised or observed, as well as their inpatient mental health provision. I note that your Report was also addressed to the Trust and NHS England has asked to be sighted on their response to the Coroner. We have also engaged with Surrey Heartlands Integrated Care System, who we are aware are working with and monitoring improvements with the provider.

I would also like to provide further assurances on 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 Charne, 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.