Dear Ms Schofield

Re: Regulation 28 Report to Prevent Future Deaths – Rachel Kathleen Garrett who died on 29 July 2020.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 27 June 2023 concerning the death of Rachel Garrett on 29 July 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Rachel’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Rachel’s care have been listened to and reflected upon.

In your Report you raised the concern that the Mental Health Liaison team involved in Rachel’s care could not detain her under Sections 5(2) or 5(4) of the Mental Health Act (MHA) 1983 (Doctors’ and Nurses’ holding powers), when she attended the Accident & Emergency Department (ED) at Royal County Sussex Hospital during a mental health crisis. This was because the Mental Health Liaison team were employed by Sussex Partnership Foundation Trust (SPFT), while Royal County Sussex Hospital is under the responsibility of an Acute Trust, the University Sussex Hospital NHS Foundation Trust (UHSx). You raised that the Mental Health Liaison team will often have the best knowledge of the patient’s health and that the delay in having a busy A&E doctor, with no prior knowledge of the patient’s health, act to detain a patient could put future patients at risk.

All systems (partnerships that bring together NHS organisations, local authorities and others to take collective responsibility for health services across geographical areas) must ensure that there are clear pathways for mental health patients who are accessing care via EDs and who need to remain in acute hospital settings until their care can be transferred. This should be supported by access to 24/7 mental health liaison teams (or other age-appropriate equivalents for children and young people), both in Accident & Emergency settings, and on the wards. The NHS is on track to deliver on its commitment, set out in in the NHS Mental Health Implementation Plan 2019/20 – 2023/24, that all general hospitals will have mental health liaison services by April 2023/24, with 70% meeting the ‘Core 24’ service standard for adults and older adults or an approved alternative model. The Plan also set out requirements for all acute hospitals to have mental health liaison services that can meet the specific needs people for all ages. For the first time, in 2023, all ED sites National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

18 August 2023

are now offering access to a liaison service or access to local crisis support (via in- reach) on a 24/7 basis. This is up from 66% at 2018, and only 39% back in 2016. It is not within the remit of NHS England to manage how MHA powers are administered or delegated within Trusts or systems. Some Acute Trusts will provide mental health liaison teams with honorary contracts, to ensure that they can exercise holding powers outside of their substantive Trust. While I note that this arrangement was not in place in Rachel's case, NHS England has engaged with NHS Sussex Integrated Care Board (ICB) on this matter, who have advised that the following actions are being undertaken:

• Pathway review at place and system level is being undertaken.
• SPFT are in the planning stages of putting together a business case for direct employment of Mental Health Staff by the acute providers.
• Sussex ICB are investigating the issues raised your Report with SPFT and considering any improvements that can be made to the safety of patients who are brought to A&E in the acute sector and who need to be detained under s5(2) and s5(4) of the MHA in response to HM Coroner’s concerns.
• The ICB has also approached the Mental Health Team Commissioners for their input.

NHS England will also be raising this case with the Department for Health and Social Education who have responsibility for Mental Health Act legislation, for their consideration of the issues raised.

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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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 I write in response to your Regulation 28 report and the covering letter dated 29.06.23, addressed to our Chair, , in respect of the concerns you have highlighted after hearing evidence at the Inquest touching on the death of Rachel Garrett. I would like to begin by extending my sincere condolences to Rachel Garretts family. This must have been an extremely difficult time for them, and I hope that my response provides them and you with assurances that NHS Sussex is taking action to address the issues set out in your report. Your matters of concern below have been reviewed and NHS Sussex’ response is also outlined below: Concerns Patients who attend a Hospital A&E Department with mental health difficulties are in most Hospitals seen by a Mental Health Liaison Team (made up of Consultant Psychiatrists and Mental Health Nurses). These staff are not employed by the acute Hospital Trust but are employed by a local Mental Health Trust (in this case I was Sussex Partnership NHS Foundation Trust). As a result of their employment status, the Mental Health Liaison Team (who have the best knowledge of the patient having been caring for them) cannot invoke the Doctors or Nurses holding powers under Section 5(2) Mental Health Act (Section 5(4) for nurses). If a patient decides to abscond from the Acute Trust Hospital the Mental Health staff cannot detain/hold the patient. They would have to ask a Doctor within the Acute Hospital to do so. This Doctor may not have any knowledge of the patient and would be unlikely to act immediately in a busy A&E. By this time the patient would be long gone. Due to this technical issue around the employment status of the Mental Health Team, those suffering with a deteriorating mental health in an acute setting are at risk in these circumstances. The response

As Commissioners of NHS services, NHS Sussex does not usually have a role in relation to the employment model of staff for particular services. However, if NHS Sussex, are made aware of an issue that is creating a risk for patients then we recognise that as the Commissioners, we do have a duty to raise the issue with the Provider/s concerned and to ensure that the issue is addressed. Since Sussex Partnership NHS Foundation Trust were interested persons and were represented at the inquest touching on the death of Rachel Garrett, they were already aware of the concerns that had been raised by HM Coroner and were also aware of the issue of the PFD report. We have therefore asked them for their input, and they have provided the following information: Mental Health Liaison Team (MHLT) staff are employed by partner specialist Mental Health Trusts for reason of professional supervision & management as is the arrangement in the majority of instances around England's 184 hospitals with an emergency department. In the case of an admitted patient, Mental Health Liaison Teams are not the ‘admitting team’. The admitting team will be typically medical or surgical with the MHLT staff there to advise. Rachel Garrett had been admitted to the short stay ward. The volume of work in Emergency Departments and delays to finding beds for people with Mental Health needs, admitted or not admitted, are a related but separate issue and there is a system improvement plan to address these. They are not the commissioned work of a MHLT service which is about the first 24hours of care. We have also contacted University Hospitals Sussex NHS Foundation Trust and they have advised us that they are in the process of recruiting for a Head of Mental Health Nursing. We are also aware that they have recently advertised for a Head of Nursing - Mental Health. The advertisement states that University Hospitals Sussex is seeking a highly experienced and motivated Senior to lead the strategic and operational development of mental health pathways within our Trust. We have investigated HM Coroner’s concerns with the Mental Health Commissioning Leads and have also raised them with the Chief Medical Officer for NHS Sussex. With regards the steps that NHS Sussex have already taken, we can report that in June 2023 the patient safety collaborative (PSC) were commissioned by NHS Sussex ICB to conduct a 4 week independent review of the Mental Health crisis pathways for adults, children and young people in West Sussex and Brighton and Hove. The PSC were asked to identify the significant challenges in these pathways and to make recommendations for partners across the system to improve service delivery. The partners included Sussex Partnership NHS Foundation Trust (SPFT), University Hospitals Sussex NHS Foundation Trust (UHS), the Local Authorities and NHS Sussex ICB. The independent review identified the challenges to the system across the various partners and some of those challenges related to the Mental Health Liaison Team (MHLT). One of the long term goals identified for SPFT, UHS, the Local Authority and NHS Sussex ICB is to draw from best practice from within and outside Sussex to agree a vision for the future shared model of crisis care across the system.

The report was published in June 2023 and work is ongoing to improve the provision of Mental Health support services across the systems in Sussex in order to improve the outcomes for patients suffering from Mental Health crisis. The issue of how the MHLT provides advice and support in A&E is therefore a matter that we will take up again with NHSE and with our partners, Sussex Partnership NHS Foundation Trust and University Hospitals Sussex NHS Foundation Trust. Two of the actions that we will take forwards as a matter of some urgency are to make contact with other ICBs to explore how they are addressing the employment of Mental Health Liaison Teams within the Acute Care Hospitals and also to look at workforce and practices with our Providers to try to resolve these issues on a local level. Whilst we are still trying to resolve the concerns that have been raised, this is a recognised National issue and as such we therefore do not yet have a local solution. We note that NHSE are also due to respond to HM Coroner on the issue in any case and we will liaise with NHSE so that they are made aware of the steps that we are taking and can offer any further advice. I hope that we have provided you with some assurance that NHS Sussex ICB is taking steps to address the concerns outlined in your report and that we are continuing to take action to prioritise patient safety. Thank you for raising this matter with NHS Sussex. If I can be of any further assistance or if HM Coroner would like a further update on how the above steps are being progressed, I would be happy to provide a further update.

I look forward to hearing from you.