Dear Ms Kearsley,

Thank you for your Regulation 28 report to prevent future deaths dated 15 May 2024, about the death of Benjamin Sulzbacher. I am replying as the newly appointed Minister with responsibility for mental health.

Firstly, I would like to say how saddened I was to read of the circumstances of Benjamin’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these matters to my attention. I am thankful to you for the extension granted to the Department to provide a response.

Your report raises concerns over a lack of clarity and understanding within mental health services as to whether a privately paying patient would be entitled to be referred to the discharge services offered by the NHS.

In preparing this response, departmental officials have made enquiries with NHS England.

In accordance with the principal duty under section 1 of the National Health Service Act 2006, the NHS must provide a comprehensive health service that is free of charge. Patients should not lose their right to access NHS services by accessing private services. The Department of Health guidance published in 2009 sets out the principles that apply to NHS patients who wish to access additional private care. Part 7 of this guidance makes particular reference to clinical governance which we would expect to be applied in the case of transfers between private and NHS care. The guidance can be found here:

priv-care.pdf

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We recognise how important it is that organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital, and that people and their chosen carers are fully involved in the process. The Department has worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. It also includes best practice on how patients and carers should be involved in discharge planning.

This guidance applies to NHS bodies and local authorities exercising health and social care functions for children and adults in England and should be used to inform local service planning and delivery. However, even though the statutory duty to have regard to this guidance applies to NHS bodies and local authorities, the guidance is applicable to independent providers. NHS commissioners of inpatient services should ensure that all mental health inpatient providers are aware of this guidance, including those in the independent sector. Commissioners are expected to have regard to this guidance when commissioning services from the independent sector. The guidance is available at:

I would expect the Greater Manchester Integrated Care Board to provide details about how this works from a local perspective in its response to you. However, the Department will consider, in collaboration with other partners, whether, in light of this tragic case, the guidance could be made clearer to ensure that all mental health commissioners and providers are aware of how it applies to the independent sector.

More widely, NHS England has advised that, while much progress has been made in implementing new models of care in community settings, further clarity is needed on some aspects of delivery within integrated community mental health services. To support systems in this work, NHS England intends to develop further national guidance to set out core standards for community mental health services, building upon the Community Mental Health Framework, to provide clarity on areas critical to delivering high quality and safe care. This includes clarifying roles and responsibilities at the interfaces between community mental health services and other services, as well as greater clarity on pathways of care for people with severe mental health problems. In addition, all integrated care boards have been tasked with developing 3-year plans to localise and realign inpatient mental health care, including care provided by the independent sector, as part of NHS England’s mental health, learning disability and autism inpatient quality transformation programme.

I hope this response is helpful and demonstrates my sincere desire to improve care for patients so we can avoid such tragedies from occurring. Thank you for bringing these important concerns to my attention.

All best wishes

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4th Floor, Piccadilly Place, Manchester M1 3BN E: Date: 16/07/2024 Dear Ms Kearsley Re: Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 3rd May 2024 regarding the sad death of Benjamin Sulzbacher. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Benjamin’s family for their loss. Thank you for highlighting your concerns during the inquest which concluded on the 2nd of May 2024. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services. During the inquest you identified the following cause for concern: - It was unclear to all services as to whether a private paying inpatient (who would have qualified for care under the NHS but due to bed availability went private) would be entitled to be referred to the discharge services offered by the NHS. The NHS provides more than the private sector in respect of community discharge packages and can be engaged with someone for longer. Importantly the face to face contact enables a better understanding of how a patient is actually presenting when considering their mental health. In relation to the referral process for private patients into NHS services- patients in private settings are not excluded from accessing usual NHS services. An example of this is a patient in a private care home needing a referral to a specialist would do so through their GP. All people living in the borough are registered with a GP who can provide services or refer on for any service not delivered in primary care
e.g. an x-ray or to see a specialist The principles of discharge from an NHS funded mental health setting would remain the same for a discharge where the care has been privately funded. In general, the provider would be expected to provide a safe discharge plan which might include for example: a Section 117 discharge meeting if appropriate, 72 hour follow up arrangements, appropriate referrals/appointments and communication with care teams and family/friends involved. Please not this is an example of what may be put in in Private & Confidential Ms Joanne Kearsley H M Senior Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG A5

4th Floor, Piccadilly Place, Manchester M1 3BN place, arrangements put in place depend on the individual patient and their needs. (A Section 117 discharge planning meeting is held before a person is discharged from hospital. The meeting involves all relevant professionals, the person, and their family as appropriate, to discuss and agree on what care is required and how their identified needs can be met. The meeting is arranged by the team that has supported the person on the ward and their Community Care Coordinator, who are representatives from the Clinical Commissioning Group (Health) and Local Authority (Social Care). The purpose of the meeting is to meet a need arising from or related to the persons mental disorder and reduce the risk of a deterioration of the persons mental health condition. Locally, Pennine Care NHS Foundation Trust (PCFT) now have an out of area placement team who help bridge the gap between the private hospitals and PCFT. We will be raising this case at our quality assurance visits to providers over the coming weeks, highlighting how private providers can refer all patients (both NHS and privately funded) into NHS services and the importance of robust discharge planning. We will also be sharing this learning at the Greater Manchester System Quality Group in July and at the Greater Manchester Mental Health Programme Board. Thank you for brining this matter to our attention. Best wishes A6

Registered Office: Priory, Fifth Floor, 80 Hammersmith Road, London, W14 8UD

Registered in England No. 09057543

10 July 2024

Ms Joanne Kearsley Senior Coroner Greater Manchester North Coroners

Via email:

Private and Confidential

Dear Ms Kearsley,

Mr Benjamin Sulzbacher - Response to Regulation 28 report

I write to you in response to the Regulation 28 report Priory received dated 15 May 2024. The report was issued following the Inquest touching the death of Mr Benjamin Sulzbacher.

You raised two matters of concern. The first was addressed to Priory:

i) There was a lack of understanding from the Priory witnesses as to what the NHS community services could offer a patient on discharge.

The second concern you raised was addressed to Priory, the Secretary of State for the Department of Health and Social Care and Greater Manchester Integrated Care Board:

ii) It was unclear whether a private paying patient would be entitled to be referred to the services offered by the NHS at the point of inpatient discharge.

Priory’s response to your first concern:

Following the inquest, e-mail communications have been shared with all Priory consultant psychiatrists by the Clinical Director of the Private and Wellbeing service network, to explain the importance and professional requirement for them to maintain up-to-date knowledge and understanding of the services local NHS mental health community teams are able to offer.

Additionally, in order to facilitate contact and communication with NHS mental health services, all Priory hospitals have been asked to create a local NHS Mental Health Services Directory. This will focus on (and clearly distinguish between) Crisis Teams, Home Treatment Teams, Community Mental Health Teams, specialist mental health services and any other relevant mental health services in the region/local area. This directory will be updated annually and shared with all relevant healthcare professionals at the hospital, including Visiting Consultants at the point of their induction and annually thereafter.

This learning point will be raised during Priory’s Service Network Discussion Forum, which is chaired by the Chief Medical Officer, . This meeting is next scheduled to occur on 11th July 2024. This learning point will also be raised during Priory’s Acute service network meeting and the Private & Wellbeing service network meeting (both scheduled to occur in August 2024). These meetings are chaired by the Network’s Clinical Directors ( and respectively) for A7

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discussion and noting by all in attendance (which includes service network representatives to include Hospital Directors, Consultant Psychiatrists, Director of Clinical Services, Ward Managers, Senior Nurses and other healthcare professionals).

Priory’s response to your second concern:

As a general principle, we consider that it is well-established that in the majority of cases, private mental health inpatients may access NHS services following discharge but we accept that it would be helpful if options could be explained more clearly to patients and families so that they can make informed choices about aftercare.

As such, Priory has created a Standard Operating Procedure (SOP) (Appendix 1) which makes the aftercare pathways clearer and includes provisions that:

i) All inpatients are to receive a follow-up contact within 72 hours of discharge (whether the contact is from Priory or the NHS)

ii) A referral into NHS mental health services should be considered for all inpatients regardless of funding arrangements when planning inpatient discharge: the SOP details the non-exhaustive criteria to support this clinical decision making.

Where private patients indicate that they want to re-engage with NHS services following discharge and they meet the referral criteria, referral letters will be sent not only to GP’s (as is standard practice) but also to NHS community treatment teams so they can follow up directly with the patient within 72 hours.

However, we acknowledge that there will be occasions when an NHS referral is not achievable such as:

i) The patient does not meet the criteria for referral into NHS community services, ii) The patient does not consent to such a referral, iii) Instances where a NHS community team receive but then refuse the referral, iv) Or there might be instances where a NHS community team have not yet confirmed the date and time of the initial contact

In these circumstances, a follow-up telephone call will be made to the patient by the Priory ward staff within 48 hours of their discharge. This reflects current practice as recorded in Priory policy (H02 Admission, Transfer and Discharge).

Should a concern be raised during the 48-hour phone call, this will be relayed promptly to the consultant psychiatrist who was responsible for the inpatient care for the consultant’s review and guidance on any required subsequent action.

Priory continue to work closely with NHS community teams to ensure safe inpatient discharge and we will carefully review the responses submitted by the Secretary of State for the Department of Health and Social Care and Greater Manchester Integrated Care Board to this Regulation 28 report to ensure our approaches align. Priory are committed to making any relevant changes to our approach across the Healthcare division as required in order to ensure robust discharge and aftercare arrangements between Priory and the NHS.

I trust that the actions outlined above will provide the assurances you seek in respect of this matter. A8

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