James Herbertson

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

Chief Executive 
Horsham District Council  
Chart Way  
Horsham  
West Sussex 
RH12 1RL 

1 

CORONER 

I am PENELOPE SCHOFIELD, senior coroner, for the coroner area of WEST SUSSEX 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQU EST 

On 23rd April 2019 I commenced an investigation into the death of in James Herbertson 
which concluded at the end of the inquest on 25th November 2020.   

At the end of the Inquest I concluded “James Kenneth Herbertson, who at the time of his 
death was under the care of the community mental health team, took his own life whilst 
the balance of his mind was disturbed. In the days leading up to his death there was a 
failure to recognise and act upon the clear signs of his mental health relapse and 
provide him with the additional support he needed.” 

Following the Inquest, I indicated that I was minded to make a Regulation 28 report but 
would like to hear submissions from the Interested Persons. Submissions have since 
been received from the family and those representing your Trust. 

I have fully considered these submissions prior to preparing this report and I apologise 
for the delay in finalising this Regulation 28 report. 

4 

CIRCUMSTANCES OF THE DEATH 

On the 10th April 2019 at 17:32 hours, James Kenneth Herbertson was struck by a train 
on the railway near to Crawley train station. His death was confirmed at scene. 

James had a history of mental health difficulties. He was first involved with the mental 
health services in 1998 following a mental health episode which resulted in him being 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 sectioned. However, he absconded and took off for Amsterdam. 

We heard that James returned home in April 1999 when he received treatment from the 
mental health services.  This resulted in a diagnosis and prognosis in 2000 of symptoms 
of schizophrenia with possible effects of substance misuse and depression.   

James left the UK again and moved to France. He then remained in France over the 
next 17 years although he did return home from time to time for short periods. 

The next key milestone was in January 2018 when the family became aware that his 
mental health had deteriorated again.  James eventually returned home to the UK on 
22nd March 2018.   

In June 2018 James was detained under the Mental Health Act and admitted to Langley 
Green Hospital where he remained before being discharged to the care of the 
Community Mental Health Team on 17th August 2018. 

His family felt he was ill prepared for discharge.   He declined the offer of a bed at a 
hostel and slept rough for several nights before eventually being found emergency 
accommodation at the Grange Hotel.  Both the initial accommodation offered and the 
accommodation at Grange Hotel were unsuitable for someone with the mental health 
and alcohol misuse issues that James had. 

James was allocated a Lead Practitioner to support him upon discharge. However, she 
had not been involved at the point of discharge. 

In the months leading up to James’ death his family had become increasingly concerned 
about him.  James fluctuated as to what involvement he would let his family have. At the 
beginning of April 2019 James started to discuss moving back to France however his 
Lead Practitioner told him that she did not think it was a good idea.  She did not think his 
mental health was stable enough.   

His Lead Practitioner then had a period of leave.  On her return on the 8th April she 
spoke to James.   On the phone James was incoherent.  He would start a conversation 
but would not finish it and he made mention that he wanted to go back to Hospital.  He 
was clearly showing signs of a relapse.   

On 9th April James’ presentation was discussed at a multi-disciplinary meeting.  Details 
of Lead Practitioner’s assessment of him from the previous day was shared with the 
team and a decision was made to put him on “Red Zone”. This meant he was to be 
monitored more closely.  However, it did not appear that the team had identified that 
James’ was becoming acutely unwell. Therefore, there was no referral made to the crisis 
team.  It was left for his Lead Practitioner to monitor him.  This was a missed opportunity 
to render care particularly as his Lead Practitioner would not have been available to 
contact him on the following day (10th April) as she had been allocated to be the duty 
worker. 

On 9th April James sent his lead practitioner a text message asking for return contact.  
This was sent after 5.00pm and was not seen by her that evening or the following day 

James took his own life the following day on 10th April at 17.32 hours. 

5 

CORONER’S CONCERNS 

During the inquest the evidence revealed matters giving rise to concern. In my opinion 
there is a risk that future deaths will occur unless action is taken. In the circumstances it 
is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows.  –  

2 

 
 
 
 
 
 
 
 
 
 
  Discharge from Langley Green Hospital – August 2018 -  Sussex Partnership 
Trust and Horsham District Council (in respect of the Housing issue) 

a)  The discharge arrangements from Langley Green Hospital did not include the 
Lead Practitioner who was going to be the primary contact responsible for 
providing the support to James following discharge. Although she had met him 
once no therapeutic relationship had been established and at the point of 
discharge, she was not aware that discharge had taken place. 

b)  Although James was vulnerable his parents were also not aware of his 

discharge at the point of discharge and therefore were unable to offer support.   

c)  The accommodation offered to James both on leaving hospital (and 

subsequently) was not a safe and therapeutic environment for a person who had 
recognised mental health difficulties with a history of alcohol and substance 
misuse.    Whilst accommodation is a matter for the Local Authority the Trust 
staff work with partner agencies in the planning for a S117 discharge.   

A separate regulation 28 report has been sent to Sussex Partnership Trust detail this 
and a number of other issues. 

       ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe your 
organisation have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 10th May 2021. I, the coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the Chief Coroner and to the following Interested 
Persons: - 

Sussex Partnership Trust. 

, parents of the deceased. 

I am also under a duty to send the Chief Coroner a copy of your response.  

The Chief Coroner may publish either or both in a complete or redacted or summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or of interest. You may make representations to me, the coroner, at the time of your 
response, about the release or the publication of your response by the Chief Coroner. 

9 

 Date  15th March 2021 

Penelope Schofield, Senior Coroner 

3

Sussex Partnership NHS Foundation Trust 
Trust HQ 
Swandean 
Arundel Road 
 Sussex 

4th June 2021 

Your Ref:  

Re: The Late Mr James Herbertson 

Dear Ms Schofield  

Thank  you  for  your  letter  of  15th  March  2021  under  cover  of  which  you  raised  several  matters  of 
concern under Paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulation 28 and 
29 of the Coroner's (Investigations) Regulations 2013, arising from the inquest of Mr James Herbertson 
concluded on 25 November 2020. 

I was very sorry to learn about Mr Herbertson’s tragic death and I wish to convey my deep and sincere 
condolences to his Family.  

In response to your Regulation 28 Report, I have carefully considered the concerns you raised, and 
considered whether Mr Herbertson’s death could have been avoided at the time it occurred. I have 
also considered potential of future deaths in similar circumstances and now provide our responses to 
your key concerns in tabular format overleaf. 

1 

 
 
 
 
 
 
 
 
 
 
 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

Involvement of Lead 
Practitioner in discharge 
process.  

a)  Lead  Practitioner  had  not 
had  the  opportunity  to 
establish  a 
therapeutic 
relationship before JH was 
discharged  from  hospital 
and was not aware he had 
been discharged.  

for 

the 

The  Trust  agrees  that  it  is  best 
practice 
Lead 
to  be  actively 
Practitioner 
involved 
the  acute  care 
in 
discharge process and to ensure 
that  contact  is  made  within  3 
days of discharge for follow up; 
as  per  the  Care  Programme 
Approach policy version 7 March 
2020  (current  policy  appendix. 
1).  At  the  time  of 
James' 
discharge,  the  policy  in  place 
(version 6 appendix 2 2017) was 
for a 7 day follow up, but due to 
the  requirement  to 
improve 
outcomes,  this  was  reduced  in 
2020 to a 3 day follow up.   

In  addition,  discharge  from  an 
inpatient Ward occurs as part of 
a  planned  process  and  includes 
professionals. 
all 
the 
Discharge 
responsibility of clinical decision 
making by the Multi-Disciplinary 

relevant 

remains 

NO ACTION 
INDICATED 

CLINICAL OPERATIONAL 
MANAGER 

COMPLETED  

Appendix 1: 

TPCL006 - Care 
Programme Approach P

Appendix 2: 

TPCL006 - Care 
Programme Approach P

Appendix 3: 

TPCLOP262 - Acute 
Inpatient Mental Health 

3 

 
 
 
 
 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

Team [MDT) which includes both 
the  patient  opinion  and  where 
possible, with family input. This 
is  described  in  the  Acute  Adult 
Inpatient Mental Health Service 
-  Langley 
Operational  policy 
Green  Hospital  (2018)  attached 
as per appendix 3. 

James’ 

confirm, 

Lead 
To 
Practitioner  was  aware  that  he 
was  to  be  discharged  (as  per 
statement, 
Lead  Practitioner 
Clinical  records  and  Serious 
Incident  report)  as  the  Lead 
Practitioner  had  attended  the 
Section  117  discharge  aftercare 
meeting on  the  02.08.2018  and 
on 
James 
attended,  alongside  his  Lead 
Practitioner.  

the  Ward  which 

On  17.08.2018,  a  discharge 
meeting 
aftercare 
where 
arrangements were agreed, took 

4 

 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

the 

place. James' Carenotes indicate 
that he was given contact details 
for  his  Lead  Practitioner.  His 
Lead  Practitioner  was  also 
notified of his discharge.  On the 
Lead 
that 
occasions 
Practitioner was not able to join 
the  discharge  meetings  due  to 
other  work 
commitments, 
evidence was given to the Court 
that  there  was  communication 
between  her  and  the  Ward  in 
James' 
the  weeks  prior 
discharge. The Lead Practitioner 
did, in the event, complete the 7 
day follow up on the 22.08.2018. 

to 

Involvement of family in 
discharge process.  

b)  Family 

unaware 

of 
discharge  at  the  point  of 
discharge 

Action Taken or Required 

the  hospital/  Trust 
Where 
communication  with 
agrees 
families/  carers 
is  central  to 
treatment and clinical decisions, 
it  also  has  to  maintain  patient 
an 
confidentiality 

where 

NO ACTION 
INDICATED 

-  

NO ACTION 
REQUIRED 

5 

CLINICAL OPERATIONAL 
MANAGER 

NO ACTION REQUIRED 

Appendix 4: 

TPCLOP262 - Acute 
Inpatient Mental Health 

 
 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

expresses 

individual 
the 
requirement  not  to  have  their 
shared. 
information 
clinical 
James gave sporadic consent to 
share details with his family, and 
there  is  evidence  that  where 
consent was available, the family 
were included where their views 
were  shared  in  Ward  reviews 
and  details  of  acute  inpatient 
care was given. However, there 
is  little  evidence  that  James’ 
family were  actively engaged  in 
discharge 
or 
whether consent at the time was 
as 
sought.  Good  practice 
outlined 
in  the  Acute  Adult 
Inpatient Mental Health Service 
Langley 
Operational  policy/ 
Green 
attached 
(appendix  4),  stipulates  that 
clear 
is 
develop 
necessary 
Care 
comprehensive 

communication 
to 

arrangements 

Hospital 

6 

 
 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

Programme Approach compliant 
discharge  care  plans.  There  is 
evidence that prior to discharge, 
and  with 
consent, 
attempts  to  contact  the  family 
occurred. 

James’ 

NO ACTION 
INDICATED  

-  

NO ACTION 
REQUIRED 

CLINICAL OPERATIONAL 
MANAGER 

NO ACTION REQUIRED 

NO ACTION REQUIRED 

J H Discharge 
notification 2018.pdf

Accommodation on 
discharge.  

c)  Accommodation 

on 
discharge was not safe or 
therapeutic  for  a  person 
who  had  a  recognised 
mental  health  difficulty. 
Whilst  accommodation  is 
a  matter  for  the  Local 
Authority  the  trust  staff 
work 
partner 
with 
agencies  in  planning  for 
117 discharge. 

The  Langley  Green  Housing 
officer  was  actively  engaged  in 
James  with  post 
assisting 
accommodation 
discharge 
options. 
  However,  despite 
efforts,  James  did  not  have 
recourse  to  public  funds  as  he 
had  recently  returned 
from 
France  after  living  there  for  10 
years. 
and 
accommodation  referrals  were 
completed  with  James  by  the 
team who also assisted him with 
the 
of 
attendance 
appointments. 

benefits 

Both 

As  there  was  no  recourse  to 
funds  and  James  no 
public 

7 

 
 
 
 
 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

longer had acute care needs, his 
accommodation  needs  fell  to 
the local authority for access to 
and the organisation of housing 
requirements.  

Inpatient 
Our  Acute  Adult 
Service 
Mental 
Health 
Operational  policy/ 
Langley 
Green  Hospital  states  –  ‘In  the 
event  of  a  service  user  being  of 
No  Fixed  Abode,  the  mental 
health  and  risk  assessment  will 
inform  how  best  to  arrange 
accommodation  on  discharge. 
This  may  include  referral  to  the 
Council’s  Homelessness  Persons 
Unit  or 
sector 
provider’. 

third 

local 

James’  issues  of  homelessness 
were fully assessed through the 
risk  assessment  process  (as  per 
clinical notes 17.08.2018) which 
note  that  the  MDT  ‘were  not 

8 

 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

able  to  associate  him  being 
homeless  with  any  escalated 
risks,  certainly  not  above  and 
beyond to those risks to which he 
has  been  exposed 
through 
circumstances  over  the  past  16 
years  of  being  of  No  Fixed 
Abode, James demonstrated full 
capacity to make decisions’. 

Since  2019  Sussex  Partnership 
NHS  Foundation  Trust  (SPFT) 
participates  in  monthly  Rough 
Sleepers Multi Agency meetings 
in  Horsham,  Crawley  and  Mid 
Sussex  to  enable  a  joined-up 
individuals  who 
approach  for 
have  housing,  health  and  social 
care needs. In addition to SPFT, 
the  police,  probation,  county 
council,  and  drug  and  alcohol 
services (Change Grow Live CGL) 
are  all  present.  An  information 
sharing agreement is in place to 

9 

 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

individual 

discuss 
provide relevant support. 

cases 

to 

Strategically, SPFT participate in 
a  regular  West  Sussex  Multi 
to 
Disadvantaged  meeting 
for 
improvements 
develop 
the 
in 
individuals 
homeless 
county. 
the 
to 
In  addition 
agencies  already  mentioned, 
SPFT  is  in  regular  contact  with 
the  CEOs  of  local  homelessness 
organisations.  

Action Taken or Required 

ONGOING AUDITS 

–  

NO ACTION 
REQUIRED 

CLINICAL OPERATIONAL 
MANAGER 

that 

Incident  report 
The  Serious 
highlights  the  Care  and  Service 
delivery  problem 
the 
service  ‘did  not  appear  to  have 
considered a referral to the crisis 
team  despite  clear  signs  of 
relapse  and  concerns  raised  by 
family’.  In  addition,  that  ‘there 
was no documented evidence of 
this  discussion’.  As  an  action 

10 

Actions following Red Zone 
including (i) risk assessment 
(ii) recording in medical 
records/ 

Lead Practitioner’s role on 
mental health deterioration 
including (i) managing risk (ii) 
referral to CRISIS team (iii) 
other escalation 

COMPLETED NOVEMBER 
2020 

PLEASE SEE ATTACHED 
AUDIT 

Sept 2020 - Snapshot 
Audit of Horsham ATS  

 
 
 
 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

a)  The  change 

in 

in 

not 

James’ 
mental  health  condition 
recorded 
was 
adequately 
the 
community MDT on the 9th 
April 2019. Clear evidence 
that  there  was  a  lack  of 
understanding 
by 
individual staff as to what 
actions  they  should  be 
taking when a service user 
was  placed 
in  the  ‘red 
zone’. 

b)  James’ 

risk  was  not 
adequately  assessed  or 
in  his  medical 
recorded 
records 
following  being 
placed in ‘red zone’. 

from  the  SI  investigation  the 
the 
reviewed 
Trust 
daily 
of 
documentation 
meetings,  and  completed  an 
audit of the Carenotes noted by 
the service to ensure adherence. 
The  documentation  had 
to 
include  the  identified  risk,  plan 
of 
and  who  was 
undertaking  the  action.  The 
updated  audit  of  November 
2020 
illustrated  above  97% 
compliance  to  the  specified 
requirements.  

action 

policy 

The  SI  report  appreciated  the 
Clinical  Risk  assessment  and 
Risk 
Safety 
Planning 
management 
and 
procedure  was  not  adhered  to. 
is  no  record  of  risk 
There 
assessment  being 
reviewed 
when  new  information  about 
potential  risk 
is  known.  The 
action  as  a  consequence  was 

COMPLETED 

CURRENT ONGOING 

HORSHAM ATS 

CLINICAL OPERATIONAL 
MANAGER 

11 

15 CLINICAL STAFF  

Evidence of clinical risk 
assessment and safety 
management on My 
Learning system 

80% 13-02-2020 

96% 06-11-2020 

 
 
 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

that  all  Horsham  ATS  staff 
received 
risk 
training. 

mandatory 

This  action  was  completed  in 
is 
November  2020  where 
it 
evidenced 
had 
team 
the 
recorded on the centralised data 
base 96% compliance.  

Evidence to 
demonstrate 
completion of the 
action 

Horsham ATS Staff 
Checklist MASTER.docx 

c)  His  lead  practitioner  was 
not  available  at  the  time 
and  nobody  appears  to 
have  taken  responsibility 
to  manage  James’  risk  or 
make  a  referral  to  the 
crisis team. 

Action Taken or Required 

COMPLETED 

CURRENT ONGOING 

SEE ATTACHED  

CLINICAL OPERATIONAL 
MANAGER 

the  SI 
As  an  outcome  of 
investigation, 
Trust 
the 
understood the requirement for 
to  have 
Lead  Practitioners 
induction, 
and 
supervision in order for them to 
be  able  to  identify  when  risk 
assessments should be updated 
and reviewed.  

training 

The  Horsham  ATS  induction  for 
new  staff  was  reviewed  to 
ensure inclusion of collaborative 
care  planning,  risk  assessments 

12 

HORSHAM ATS STAFF 
INDUCTION CHECKLIST 

Includes Carenotes 
module training 
(incorporating risk 
assessments and care 
planning) and 
mandatory training 
modules including 
clinical risk assessment 
and safety 
management. 

 
 
 
 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

a 

In 
suicide  prevention. 
and 
November 
new 
2020, 
induction  pack  was  in  place  for 
new  starters  with 
leadership 
support.  Ongoing  monitoring 
through  monthly  review  of  risk 
assessment  and  care  plans 
continues  to  provide  assurance 
of compliance.  

Within  James’  Careplan,  there 
the  Crisis  and 
were  also 
contact  details 
contingency 
which included the ATS, Mental 
Healthline,  MIND  and 
the 
CRHTT.  On  11.09.2018  James' 
Lead  Practitioner  met  with  him 
and 
gave  him  emergency 
contact numbers in the event he 
required immediate support. 

Response to text messaging 
when Lead Practitioner is not 
available/ does not see the 

Trusts 

Information 
The 
have 
Technology 
confirmed  that  the  Trust  does 
not  have  the  ability  to  send 

team 

NO ACTION 
INDICATED 

CLINICAL OPERATIONAL 
MANAGER 

COMPLETED 

13 

Evidence to 
demonstrate 
completion of the 
action 

Horsham ATS Staff 
Checklist MASTER.docx 

CRHTT Operational 
Policy 20201117 - final.

TPCO060 - 
Contacting Service Use 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

message. Mobile Phone and 
Test Messaging policy  

Phone 

responses 

and 
(attached) 

automatic 
to 
individuals  when  they  text  a 
member of staffs’ mobile phone. 
James  had  however  requested 
that  the  services  and  the  Lead 
Practitioner  use  text  messages 
as 
the  main  method  of 
communication  in  his  discharge 
meeting.  In  the  Trusts  Policy 
‘Contacting  Service  Users  By 
Text 
Mobile 
Messaging’ 
the 
patient is to be made aware that 
their  contact  may  not  be 
answered,  and  that  a  crisis  and 
contingency plan is agreed.  On 
James’  care  plan,  there  were 
agreed  crisis  and  contingency 
contact  details  which  included 
the  ATS,  Mental  Healthline, 
MIND  and  the  Crisis  Resolution 
and  Home  Treatment  Team 
(CRHTT).  On  11.09.2018  James' 
Lead  Practitioner  met  with  him 

14 

 
 Concern Raised   

Action Taken or Required 

Date completed or 
to be completed by 

Lead and Level of 
Responsibility 

Current status as at (date) 

Evidence to 
demonstrate 
completion of the 
action 

and 
gave  him  emergency 
contact numbers in the event he 
required immediate support. 

15 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Where  indicated  in  the  table  above,  the  Trust  has  taken  action  to  ensure  that  these  very  sad 
circumstances do not repeat again.  I believe this letter reassures you that the steps we have taken to 
improve the support that we provide to our patients at the point they are discharged from inpatient 
admission and back into the Community and throughout their pathway, is safe and fit for purpose.  

Yours sincerely   

Chief Executive 

16