Suicide

Noted (AI summary) Islington Council expresses condolences and provides background on the inquest hearing, including limitations on evidence presented, and includes details of their income and expenditure assessment process for housing applicants.

Noted (AI summary) Stockton on Tees Council will bring TEWV's Section 136 policy to the Mental Health Legislation Operational Group to consider further education for Cleveland Police. They will also recirculate the Section 136 Policy to relevant staff within Adult Social Care. Middlesbrough Council will ensure their mental health service receives refreshed communication regarding section 136 guidance, and the circumstances relating to the Regulation 28 report. This will be flagged within the Multi-Agency Mental Health Legislation Operational Group to determine the need for further awareness and training among wider partners. Redcar and Cleveland Borough Council will recirculate the Section 136 Policy to relevant staff within Adult Social Care and make them aware of the concerns identified through Mr Bradley’s inquest. They reiterate the use of the Crisis Assessment Suite at Roseberry Park as the appropriate place of safety. Hartlepool Council will give consideration to further education and awareness raising within Cleveland Police regarding the use of Section 136 powers. They will also recirculate the Section 136 Policy to relevant staff within Adult Social Care and make them aware of the inquest's concerns. The ICB acknowledges the concerns regarding mental health safeguarding for intoxicated individuals, explains existing crisis services, and states they have no plans for a specific holding facility. They note that the crisis team was not contacted in this specific case, so they can't comment on the potential outcome. Tees, Esk and Wear Valley NHS shared learning with the police via the Multi-Agency Mental Health Legislation Operational Group on the 11 July 2025 to ensure awareness of the Report and best practice. This report has also been shared with Crisis Teams. The Department of Health and Social Care liaised with the NHS North East and Cumbria Integrated Care Board (NENC ICB) who will be responding directly. They also mentioned Cleveland Police began to implement the Right Care Right Person approach in 2024, and committed £26 million in capital investment to support people in mental health crisis.

Noted (AI summary) Durham Constabulary's Deputy Chief Constable states that a full review of the case and police actions was undertaken, with the outcome and actions attached to the response. The Police and Crime Commissioner expressed condolences and noted that a review by Durham Constabulary didn't highlight significant failings but resulted in two points of organisational learning and recommendations. The commissioner will monitor the 'Right Care Right Person' model. The College of Policing has contacted Durham Constabulary, who have reviewed their policies and procedures in line with the College of Policing toolkit and Approved Professional Practice. The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. Durham Constabulary will implement recommendations aligned with the National Toolkit for Right Care, Right Person (RCRP), aiming for full implementation by mid-July 2025. These include a review of police systems for further intelligence, supervisor review, and immediate escalation to the Supervisor on a second call about the same person within a 12 hour period.

Noted (AI summary) The Trust acknowledges bed availability challenges and mentions ongoing work to improve bed management and reduce out-of-area placements. They plan to prioritise inpatient strategy development with the Integrated Care Board and ensure adequate access to inpatient care is acknowledged through the Contract Management Board. The DHSC acknowledges the concerns, notes actions ICBs are required to take, refers to funding and initiatives to support mental health crisis care, and describes broader government commitments to suicide prevention.

Noted (AI summary) NHS England acknowledges concerns about menopausal care and highlights increased awareness and demand. They describe training programmes, awareness sessions and e-learning packages that have been launched, some since Anne's death, to improve resources for healthcare practitioners. Somerset NHS Foundation Trust has developed supportive guidance for families regarding Section 17 leave from inpatient units, which is currently out for feedback and will be shared at an operational meeting for approval. They also describe planned training for mental health staff on menopause. NICE expresses condolences and states that the concerns raised are not directly attributable to NICE but are addressed to other organizations. They reference existing NICE guidance and quality standards related to suicide prevention and menopause, and indicate that the menopause guideline was recently updated and will remain under surveillance. The RCOG extends condolences and recognises the concerns raised, highlighting that management of the menopause is covered in the core training curriculum for Obstetricians and Gynaecologists, including a Special Interest Training Module and the Diploma of the Royal College of Obstetricians and Gynaecologists. Kenny & Murphy Ltd sold the incident site in March 2024 and has no influence over tenants there. However, they have discussed electrical safety with tenants at their other sites and provided them with relevant leaflets and documents.