Dean Crossman

Jo Wharton 
HM Coroner for Teesside & Hartlepool,  
The Coroner’s Service,  
Middlesbrough Town Hall,  
Albert Road,  
Middlesbrough,  
TS1 2QJ 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

29 September 2022 

Dear Ms Wharton 

Re: Regulation 28 Report to Prevent Future Deaths - Dean Ryan Crossman 
who died on 18 June 2019. 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 June 
2022 concerning the death of Dean Ryan Crossman on 18 June 2019. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Dean’s family and loved ones. NHS England are keen to assure 
the  family  and  the  Coroner  that  the  concerns  raised  about  Dean’s  care  have  been 
listened to and reflected upon.   

I am grateful for the further time granted to respond to the Repost, and I apologise to 
the family for the delay, as I appreciate this will have been an incredibly difficult time 
for them.  

 Following the inquest, you raised concerns in your Report regarding:  

1.  Evidence was given at the inquest that at the time of Dean’s passing, there were 
issues  accessing  second  (s.12)  doctors  out  of  office  hours  for  the  purpose  of 
carrying out a Mental Health Act (MHA) assessment, resulting in delays to MHA 
assessments being carried out. The Emergency Duty Team (EDT) explained that 
since Dean’s passing, a “s.12 Solutions” App has been introduced, and although 
this had made a significant improvement, issues still exist trying to access a second 
doctor  out  of  hours, as  the  EDT  is  still  wholly  reliant  on  second  doctors making 
themselves available after midnight (with no fixed rota). 

2.  Evidence was given at the inquest that at the time of Dean’s passing, there were 
issues  securing  the  timely  attendance  of  the  private  ambulance  service  (ERS 
Medical) to transport patients after a MHA assessment had taken place, potentially 
resulting  in  an  increased  risk  to  both  the  Approved  Mental  Health  Professional 
(AMHP) and the patient for MHA assessments in the community. The EDT advised 
that since Dean’s passing, despite spot purchasing of private ambulances being 
introduced, issues still exist trying to get the private ambulance to attend a MHA 
assessment in a timely manner. 

                                                                                                                 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 3.  Evidence was given at the inquest that both of the above matters of concern are 

on-going national issues. 

It is  critical  that  when  a  MHA  assessment  is  required  it  is  undertaken  in  a  timely 
manner. The issues regarding availability of s.12 doctors are widely recognised and, 
as a result, the Independent MHA Review (2018)   recommended that the Government 
review  and  address  the  factors  that  affect  the  timely  availability  of  these  clinicians. 
Section 12 doctors are approved by the Secretary of State under section 12(2) Mental 
Health  Act  1983  and,  in  recognition  of  the  national  staffing  issue,  the  Government 
confirmed in the White Paper, ‘Reforming the Mental Health Act' (August 2021), that it 
has  commissioned  research  to  explore  the  factors  promoting  and  inhibiting  the 
accessibility of s.12 approved doctors to participate in MHA assessments in England 
and Wales.  

The  Department  of  Health  and  Social  Care  commissioned  the  National  Institute  for 
Health and Care Research (NIHR) to carry out a study of the reasons for and nature 
of  reported  difficulties  in  accessing  s.12  doctors  for  MHA  assessments.  The  NIHR 
published the outcome of their study in September 2021 in the report “The availability 
of section 12 doctors for Mental Health Act assessments: Interview perceptions and 
analysis of the national MHA Approvals Register Database”. A link the report is : here   

The study had two main findings: 

•  Firstly, the main problem is the availability of s.12 doctors, rather than overall 
numbers. This suggests a need to focus on encouraging psychiatrists and other 
s.12 doctors to make themselves more available for doing MHA assessments. 
•  Secondly,  there  is  currently  no  real  way  to  tell  how  many  s.12  doctors  are 
needed  without  better  information  about  the  numbers  of  MHA  assessments 
attended by different doctors, in what circumstances.  

The Department is working with regional approval panels to increase the number of 
s.12 doctors and consider what more can be done to improve availability, alongside 
the Mental Health Act reforms.  

that  bring 

Integrated  care  systems  (ICSs)  are  partnerships 
together  NHS 
organisations, local authorities and others to take collective responsibility for planning 
services, improving health and reducing inequalities across geographical areas. Each 
local  system  has  responsibility  to  ensure  that  the  section  12  rota  for  their  area  is 
adequately  managed,  to  ensure  24/7  availability  of  s.12  doctors.  NHS  England 
recognise that, while doctors may indicate their availability for certain times and days 
on local rotas, this does not obligate them to accept a request to attend and undertake 
a MHA assessment. The National NHS England Mental Health Team will review this 
issue via our regional NHSE teams to understand if there are any local areas where 
this is a particular concern, and if there is anything further that can be done nationally 
to  help  mitigate  the  issues.  This  may  include  sharing  and  promoting  best  practice 
approaches  from  areas  that  are  successfully  ensuring  s.12  doctor  availability, 
including after midnight / out of hours. 

It  is  also  critical that  appropriate  transportation  is commissioned  and  is available to 
transport someone to the appropriate setting, to meet their needs in a timely manner. 

 
 
 
 
 
 
 
 This  is  particularly  important  after  a  MHA  assessment  has  taken  place,  and  is  the 
responsibility  of  Integrated  Care  Boards  (ICBs)  who  commission  services  for  their 
footprint. Integrated Care Boards replaced Clinical Commissioning Groups (CCGs) as 
the  statutory  NHS  organisation which  is  responsible  for  developing  a  plan  for 
meeting the health needs of the population, managing the NHS budget and arranging 
for the provision of health services in a geographical area. 

In  recognition  of  the  significant  role  the  ambulance  service  plays  in  responding  to 
mental health calls, the NHS Long Term Plan, published in January 2019, stated that 
“Ambulance  staff  will  be  trained  and  equipped  to  respond effectively to  people  in  a 
crisis”, alongside a programme of investment (£70 million by 2023/24) to improve the 
capacity of ambulance services to respond to urgent and emergency mental health 
needs. 

There  are  three  key  strands  to  the  NHS  Long  Term  Plan  work  programme  on 
improving the mental health response of ambulance services: 

1.  funding  of  mental  health  nurses  and  other  mental  health  professionals  working 
alongside colleagues in integrated urgent care clinical assessment services (CAS) 
and ambulance emergency operation centres (EOC) and providing on-the-scene 
response; 

2.  training  for  ambulance  staff  to  improve  skills  and  competencies  in  relation  to 

supporting patients with mental health needs; and 

3.  capital  funding  for  dedicated  mental  health  response  vehicles  to  increase 
capacity to respond in a more timely manner, in a more suitable vehicle. A vehicle 
specification has been developed with patients, clinicians and fleet experts. 

One of the aims of the Long Term Plan ambition is to provide timely assessment 
from  trained  mental health  staff.  For patients  detained  under Section  136 of  the 
Mental Health Act, ambulance services have committed to an average 30-minute 
response and this is reflected within ambulance quality indicators (AQIs). 

The NHS England Ambulance Quality Indicators (AQIs) were first introduced in 
2011 to drive strong performance and identify areas for improvement across the 
sector. The data includes, for example, call answer and response times, and 
clinical outcomes of patients treated by the ambulance services for a number of 
presentations. 

The AQI system indicators specification has recently been updated (and will 
apply to data from 1 October 2022) to support improvement in mental health 
response, and advises that services should aim to achieve the measure of a 
mean (average) Section 136 response time of 30 minutes or less. 

As set out above, this investment is largely intended to support emergency response 
and conveyance but, where appropriate locally, it may also help to alleviate pressure 
on  critical  transportation  requirements  after  planned  MHA  assessments,  as  in  this 
case. 

 
 
 
 
 
 
 
 I would also like to provide further assurances on the national NHSE work taking place 
around the Reports to Prevent Future Deaths. All reports received are discussed by a 
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  Dean  Crossman,  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. 

Yours sincerely, 

National Medical Director