Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Nathan Tesla George Scantlebury who died on 25 September 2019

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23 July 2024 concerning the death of Nathan Tesla George on 25 September 2019. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Nathan’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Nathan’s care have been listened to and reflected upon.

Your Report raised the concern over the lack of availability of suitable placements for high risk children with complex mental health needs, both at a local and national level. Significant improvements are underway nationally to develop the Children and Young People’s Mental Health (CYPMH) inpatient pathways. Care being provided close to home has seen a reduction in the number of young people placed inappropriately out of their local area. Natural clinical flows (NCF) aim to ensure that a young person is only placed away from their local area when this can provide the right therapeutic outcome. For Children and Young People (CYP), it is important that every step is taken to avoid this given the impact on families, carers, links to school and social networks. In March 2022, there were 145 CYP outside of NCF and, in March 2023, there were 128 CYP outside of NCF.  NHS England has sought to improve the availability of local inpatient care for CYP through a number of actions: 
• The introduction of NHS-Led Provider Collaboratives which are key enablers for bringing the care of CYP closer to home.  
• Investing capital and revenue funding into localised inpatient and alternative to inpatient provision over a three-year period. 
• The NHS Operational Planning Guidance 2022/23 outlined the need for Mental Health Provider Collaboratives and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive Care Units to meet the needs of their local population.  National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

12 September 2024

The CYPMH Clinical Reference Group has developed an inpatient strategy which provides an evidence base to support services when considering their workforce challenges and team composition. A new Youth Intensive Psychological Practitioner pilot (YIPP) is now entering its third year and in partnership with Exeter University has established roles in inpatient Multi-Disciplinary Teams (MDTs) to complement the team. There has been a refresh of the Care (Education) and Treatment Review (CETR) policy, and an escalation policy has been agreed with all NHS-Led Provider Collaboratives and regional teams.  In addition to steps taken to localise care and reduce reliance on inpatient care, we have seen the establishment of many intensive alternative to admission models introduced by NHS-Led Provider Collaboratives and Integrated Care Boards (ICBs), which support CYP to be cared for in the least restrictive environment and close to home. Examples include the establishment of day units, strengthened intensive support and outreach teams, paediatric liaison and improved thresholds for admission and gatekeeping to actively avoid admissions.  The CYP’s National Quality Improvement Taskforce has delivered improvements to mental health, learning disability and autism inpatient services for CYP, with a wide range of initiatives that co-designed and co-delivered 39 change projects across CYP inpatient services to support local improvements. In 2022, NHS England (NHSE) commissioned a new Quality Improvement Programme and one of its priorities was to undertake a review of the CYP’s inpatient model, recognising the continued pathway pressures and quality and safety challenges. The review included how our English model compares internationally, the views of children, young people and their families and requests from local teams to work together to improve the model of care. The findings of the evidence review presented and consolidated a future vision for CYPMH inpatient care, and now forms the cornerstone of the CYPMH Transformation Programme, which has resulted in a review of the service specification and the development of a new clinical model, which considers the needs of a young person across the whole pathway of care. Support has been provided to local systems and Provider Collaboratives to plan a timeline for implementing the change, coupled with implementation support as requested.   Children and young people’s mental health interventions can take place in many contexts and will depend on the clinical needs of the child as to whether interventions are delivered in the community, whilst the child is in a placement, or in an inpatient setting. NHSE are working with the Department for Health and Social Care (DHSC) and Department for Education (DfE) to ensure that the needs of children in different settings are met fairly and equitably.  The NHSE strategy is to reduce reliance on mental health inpatient beds and to have fewer young people being detained under the Mental Health Act (MHA). To support this, the model of inpatient care is being re-designed to enable the move to a more community-based provision of care, where CYP can access appropriate mental health support in a timely, effective, and person-centred way, at home or close to home and

environment.   It is also recognised that for some CYP, admission to hospital will not be the most appropriate way to meet their needs. This has been a focus of the transformation of CYPMH and continues to be a priority in the NHS Long Term Plan.   A guidance document for CYP has been co-written with multi-agency partners, which specifically includes the role of the Approved Mental Health Professional (AMHP) and the legal requirements of the Mental Health Act process, and whether it is clinically appropriate for the young person to be admitted for assessment and treatment. This aims to ensure that any use of the MHA in crisis is reviewed before detaining a young person. My regional colleagues in the North West have also been engaging with NHS Cheshire & Merseyside (CM) ICB on the concerns raised in your Report. We are advised that the local provision of suitable placements for children with complex mental health needs remains a key focus for the ICB. Its intentions are set out here: Children and Young People’s Mental Health Plan for 2024-26 - NHS Cheshire and Merseyside. The new model of care includes:
• Place Based Gateway meetings to ensure appropriate support when needs change or escalations to prevent admission to care, custody or inpatient settings.
• Development of a Complex Needs Escalation Tool.
• A THRIVE framework focused on getting advice, help and risk support. This is needs-led by CYP and families alongside professionals (see page 7 of the plan).
• System wide priorities for the ICB for timely access, crisis response, appropriate places of care and specialist mental health.
• Development of cross organisational data set to explore the rising prevalence of complex mental health.
• System wide stakeholders to develop appropriate places of care.
• Support and development for mobilisation of appropriate places of care. My North West colleagues have requested further information from CM ICB regarding the actions taken following the death of Nathan, as part of their assurance purposes. 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 Nathan, 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 Mrs Keighley,

Thank you for the Regulation 28 report of 23 July 2024 sent to the Department of Health and Social Care about the death of Nathan Tesla George Scantlebury. I am replying as the Minister with responsibility for Patient Safety and Mental Health.

Firstly, I would like to say how saddened I was to read of the circumstances of Nathan’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.

Your report raises concerns over the lack of suitable placements available for high risk children with complex mental health needs.

In preparing this response, my Departmental officials have made enquiries with NHS England and Cheshire and Merseyside Integrated Care Board and I understand that NHS England will address your concerns in more detail in its response. We will work with colleagues at NHS England to ensure the appropriate steps are taken to avoid a repetition of this tragedy.

As your report highlights, 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 children with complex mental health needs like Nathan to stay well in the community, therefore reducing the likelihood of an admission being necessary. I am committed to ensuring this Government acts to ensure patients have access to community services and instances like this one can be prevented.

The model of inpatient mental health care is being re-designed to enable the move to a more community-based provision of care, where children and young people can access appropriate mental health support in a timely, effective, and person-centred way, at home or close to home and in the least restrictive environment. 

As part of our mission to build an NHS that is fit for the future, we will recruit an additional 8,500 mental health workers to reduce delays and provide faster treatment which will also help ease pressure on busy mental health services. To help reduce the lives lost to suicide, these new workers will be specially trained to support people at risk. More broadly, we will modernise the Mental Health Act to give greater choice, autonomy, enhanced rights and support, and ensure everyone is treated with dignity and respect throughout treatment.

I am advised by colleagues in NHS England and Cheshire and Merseyside (Integrated Care Board that the local provision of suitable placements for children with complex mental health needs remains a key focus for the ICB. Its intentions to design and develop Appropriate Places of Care where there are gaps in its current support offer for children and young people with the most complex needs are set out in its Children and Young People’s Mental Health Plan for 2024-26 - NHS Cheshire and Merseyside, published in August 2024, and which is available at: Children and Young People’s Mental Health Plan for 2024-26 - NHS Cheshire and Merseyside.

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