Heather Findlay

Office of the Chief Medical Officer 
Trust Headquarters 
5th Floor 
9 Alie Street 
London E1 8DE 

Private & Confidential 

Ms Mary Hassell 
HM Senior Coroner 

7 August 2023 

Dear Madam 

RE: Regulation 28 Response – Heather Findlay 

I am writing on behalf of East London NHS Foundation Trust (‘the Trust’) to provide a 
formal response to the Regulation 28 Report that you issued on 12 June 2023 following 
the inquest touching the death of Ms Heather Findlay.  

I would like to offer sincere condolences to Ms Findlay’s family from me, and also on 
behalf of the Trust.  

The Trust has carefully considered your Regulation 28 Report at the most senior clinical 
levels. Your Report raised six matters of concern, and I have set out below details of the 
actions which the Trust has taken (or will take) in relation to them, or alternatively why the 
Trust does not consider that action is practically feasible. 

In relation to your first concern, I note you received written evidence that ‘it was expected 
practice for [the Healthcare Assistant] to return to the ward in the way she did rather than 
to try to chase after Ms Findlay, who was running at speed and who crossed a busy road. 
Pursuit could have put Ms Thomas at risk, and could have put Ms Findlay at further risk if 
she for example tried to cross other roads to evade her.’ 

Although this was the practice in operation at the time, the Trust has taken action to 
review the relevant part of its Missing and Absent Without Leave (AWOL) Policy to reflect 
this practice. The updated version will read as below: 

Where possible staff must always try to prevent people from absconding from 
escorted leave, whilst bearing in mind the safety of the individual, staff and public, 
and take into account: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                       
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Use of non-physical interventions – e.g. asking the patient to return, 

• 
providing reassurance etc.  

• 
Staff may follow from a distance maintaining line of sight whilst requesting 
assistance via mobile telephone from other members of staff, hospital security or 
when appropriate the Police.  

Staff member to maintain line of sight of the patient until assistance arrives 

• 
if it is safe for staff and the patient.  

It may not be possible to keep patients in sight as for instance they may use public 
transport/ board a private vehicle or taxi/ or run at speed. In such circumstances 
staff should return to the ward as soon as possible to notify the appropriate staff 
and external agencies. 

If the patient is out of sight or a long way from the hospital, the member of staff 
may consider to abandon the escort and return to the ward where they will need to 
access the grab pack for AWOL patient and seek assistance from the police 
especially if the risk is immediate. 

The Trust intends to incorporate scenarios involving patients going AWOL on escorted 
leave into its induction training for new staff in the relevant services. In addition there will 
be a 2-yearly refresher for Section 17 and Escort training. The scenario training will 
incorporate such situations and include reference to the information that needs to be 
considered by the escorting staff and fed back to staff on the wards to help in making a 
decision around risk and level of escalation needed. The Trust expects this to be in place 
in the next 3-6 months. 

In relation to your second concern, the Trust believes that the appropriate response from 
a senior nurse in the envisaged ‘line of sight’ advice-giving scenario should be driven by 
that senior nurse’s clinical judgement at the time of the event, and that attempting to 
prescribe a response in advance in a policy document would be unhelpful given the 
number of dynamic factors that could be relevant.  

The Trust would like to emphasise the general principles espoused in the existing practice 
(to be consolidated in a written policy as above) namely that staff must attempt to prevent 
patients on escorted from absconding and may follow them if it is safe and feasible to do 
so, while liaising with suitable sources of support as necessary. 

In relation to your third and fourth concerns, the Trust respectfully notes that it is an 
oversimplification to say that hospital staff have the same powers as the Police via section 
18 of the Mental Health Act. Although s18 does confer legal authority on Trust staff to 
return a sectioned patient to hospital, it does not endow them with any authority to divert 
members of the public away who might attempt to intervene (on either a malevolent or 
well-intentioned basis) in the process of taking a patient into custody and returning them 
to a ward. The absence of such wider powers could put patients, members of the public 
and staff at risk if Trust staff were to exercise s18 MHA powers.  

Furthermore, it should be noted that healthcare staff do not have the range of mechanical 
restraints (e.g. handcuffs) or personal protective equipment (e.g. stab vests) available to 
the MPS, which are occasionally needed. The Trust would find it contrary to its values as 
a healthcare provider to adopt such equipment.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Furthermore, it should be noted that mobilising a group of staff to travel off-site to take a 
patient into custody and return them to the ward would have significant resource 
implications and could impinge on the safety of patients on the ward.   

The Trust notes that you are aware of the Affinity protocol which is already in place 
between the Metropolitan Police Service (MPS) and the Trust.  

A meeting between senior ELFT and MPS staff (plus other local health stakeholders) took 
place on 24 July 2023. One relevant point discussed was the work of a pan-London group 
who will set standards for scenarios where patients are absent without leave, in order to 
move away from discreet Trust policies which may be inconsistent. Discussions about 
joint working and the roles of respective organisations will continue through these 
partnerships, with relevant implementation and monitoring of agreed arrangements arising 
from there too.  

In relation to your fifth and sixth concerns, risk assessment and prediction in relation to 
suicide are complex areas that the Trust is determined to address appropriately and 
robustly.  The National Institute for Health and Care Excellence (NICE) published 
guidance in 2022 suggesting that risk stratification (e.g. medium and high risk) should not 
be used to predict future suicide or self-harm, and that risk assessment tools and scales 
should not be used for those purposes either.  The emphasis should be on supporting the 
person’s immediate and long-term psychological and physical safety, and on risk 
formulation.  

ELFT intends to review its policy for Risk Assessment and will consider recent NICE 
guidance in so doing.  We will also be seeking an expert opinion from outside of the Trust 
about changes we then propose for our policy and procedures before a programme of 
work to implement changes is undertaken, with consideration given to the implications for 
other organisations at that point. The expected timescale for this programme of work is six 
months.  

The author of the AWOL policy has been tasked with reviewing how the Grab Pack aligns 
with local polices, including what information is included. The expected timescale for this 
is three months. 

Very respectfully, it is the  Trust’s understanding that the Serious Incident investigator’s 
evidence was that she could not answer your question in relation to the HCA’s telephone 
call to Police. This does not of course affect the Trust’s consideration of your broader 
points, as reflected by the programme of work described above. 

I hope I have provided reassurance to you and the family of Ms Findlay about the learning 
that has taken place as a consequence of her sad death.  

Yours sincerely,  

Chief Medical Officer

Rt Hon Chris Philp MP 
Minister of State for Crime, 
Policing and Fire 

2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

4 August 2023 

Mr M E Hassell 
Senior Coroner 
Inner North London 
St Pancras Coroner’s Court  
Camley Street 
London 
N1C 4PP 

Dear Mr Hassell,  

Thank you for your report of 13 June 2023 regarding the Regulation 28 Report to Prevent 
Future Deaths which was sent to the Home Secretary.  I am replying as the Minister of 
State for Crime, Policing and Fire.  

Firstly, I would like to express my sympathies to the family of Heather Findlay.  

The police are responding to an increasing number of mental health incidents which they 
say is detracting from their ability to respond to crime.  There will be cases where it is 
necessary for the police to be involved in incidents where there is real and immediate risk 
to life or serious harm, or where a crime or potential crime is involved.  However, often 
incidents involving mental health do not require the police to attend and patients’ needs 
are better met through a health-led approach.  

The Right Care Right Person (RCRP) approach sets out a threshold to assist police 
decision making on responding to incidents based on a duty of care.  The benefits of this 
are that the police should only be responding to health and social care incidents where 
they need to investigate a crime that has occurred or is occurring; or to protect people, 
when there is a real and immediate risk to the life of a person, or of a person being subject 
to or at risk of serious harm.  This ensures the public receives the right care from the right 
person and reduces unnecessary police involvement.   

People in mental health crisis need the right support from the right agency at the right time, 
often this will be a health response.  Police cannot act in the stead of professional health 
services although we recognise that there will always be some situations where a police 
response may be needed.  We are urging local health partners and police to work together 
to plan and implement RCRP in a way that delivers for their communities, to ensure that 
those in a mental health crisis receive the right support and that police officers can focus 
their efforts on investigating and preventing crime. 

Local partners should agree, at the local level, on how different types of incident are to be 
dealt with and by whom, with delivery plans in place to safely implement changes.  To 
support rollout and ensure that local implementation aligns with RCRP principles, the 
National Police Chiefs’ Council (NPCC) are developing toolkits and guidance products for 
police forces and health will be producing their own guidance. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Improving the response to people with mental ill health is a key priority, and we continue to 
work with health and policing partners to identify and expand good practice to better 
support individuals experiencing acute mental health crisis.  The RCRP approach will not 
change police involvement where crimes have been committed.  We will continue to work 
with cross-government colleagues, the police, as well as health and social care partners to 
reduce inappropriate police involvement and support access to appropriate mental health 
specialists through the rollout of RCRP. 

With regards to the response to the missing person report made by the East London 
Foundation Trust (ELFT) to the Metropolitan Police Service (MPS), the police investigation 
of a missing person report is an operational decision for individual police forces.  The 
Home Office has no authority to intervene in operational policing matters.  I cannot 
comment on the action and decisions taken by police officers in the course of their duties 
because operational matters are the responsibility of the Chief Officer of the force 
concerned.  However, my officials have consulted the MPS to gain assurance that the 
correct protocols are in place in order to prevent future incidents of this nature.  

The MPS response will set out details of its Affinity Protocol, a joint agreement between 
the MPS and ELFT, which aligns with the NPCC’s framework, published in October 2020, 
and accessible at https://www.gov.uk/government/publications/the-multi-agency-response-
for-adults-missing-from-health-and-care-settings-a-national-framework-for-england. 

This framework provides a blueprint that local partnerships should consider when 
developing their own joint local policies and procedures in response to those who go 
missing from health and care settings.  This framework is being rolled out across police 
forces in England through RCRP.  I am satisfied that the MPS Affinity Protocol reflects the 
NPCC framework, and I encourage other police forces to adopt this approach to 
developing joint agreements with health partners in their force area in relation to missing 
persons. 

I trust this response has demonstrated some of the measures in place to ensure 
appropriate responses to those who go missing from healthcare settings. 

Yours sincerely, 

Rt Hon Chris Philp MP

Coroner M E Hassell 

HM Senior Coroner 

Inner North London 

St Pancras Coroner’s Court 

Camley Street 

London N1C 4PP 

Dear Ms Hassell 

T/Assistant Commissioner 

Metropolitan Police Service 

New Scotland Yard 

Victoria Embankment 

London 

SW1A 2JL 

Date: 12th July 2023 

I am the Temporary Assistant Commissioner for the Met Ops Chief Officer Team in the Metropolitan 

Police Service (“MPS”). On behalf of the Commissioner of Police of the Metropolis, I write to 

provide the response to the matters of concern addressed to the MPS in your Report to Prevent Future 

Deaths dated the 12th June 2023. 

On behalf of the MPS may I first of all express my sincere condolences to the family and friends of 

Heather Findlay, our thoughts and sympathies are very much with them. 

The “MPS” has acknowledged and reviewed all the matters of concern raised in your Regulation 28 

Report and responds to points 3, 4 and 5 as follows: 

The Coroner’s “Matters of Concern” 

The Prevention of Future Deaths report records:- 

(3) Moreover, one of the MPS policy leads in this area gave evidence that in such a situation the 

police would not necessarily attend, even if called direct by a hospital staff member in the street 

following a patient about whom they are worried. I spent some time examining the police regarding 

this point, and I was left with the impression that a clinician calling the police in what the clinician 

perceived to be an emergency situation might not be assisted by the police.” 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 MPS Response 

The MPS currently has the Affinity Protocol in place and has done since September 2021.This is a 

collaborative partnership between local policing, NHS Trusts and mental health service providers, the 

aim of which is to achieve mutual understanding of each partner’s responsibilities in respect of those 

patients detained under the Mental Health Act and who may abscond. This could be from a health 

care professional whilst under s17 Mental Health Act escorted leave; by not returning from authorised 

leave or simply leaving the premises without permission. The Protocol relies on our commitment to 

existing policy rather than necessitating new policy. 

The Affinity Protocol utilises a Joint Responsibility Agreement outlining the key functions, roles and 

responsibilities of both the MPS and NHS Mental Health Providers. The ELFT have been signatories 

to that agreement since April 2022.  

The implementation of the national Right Care, Right Person model into the MPS is in line with the 

National Partnership Agreement being developed by the College of Policing, National Police Chiefs 

Council and NHS which is supported by the Home Office and Department of Health and Social Care. 

The model will formalise the principles in the Affinity Protocol and make clear the expectations of 

each agency in caring for those with mental ill-health. Right Care, Right Person will create a single 

interpretation of an emergency situation requiring police assistance for both police and mental health 

trusts.  Where there is an immediate threat to life to the patient or another, or the patient is restricted 

under Part III Mental Health Act the police will support mental health partners in re-taking a patient 

that is absent without leave. 

(4) I heard that Right Care, Right Person is an operational model developed by Humberside Police 

that changes the way the emergency services respond to calls involving concerns about mental health. 

I understand that it is in the process of being rolled out across the UK as part of ongoing work 

between police forces, health providers and government. I heard that the MPS has already created a 

similar model under the resource and demand team. The protocol is called Affinity. It attempts to 

target preventable demand from the mental health trusts.  

I was told that ELFT and the MPS work in partnership, so I asked the MPS what is meant to happen if 

an escort is following a patient who has run away and about whom the escort is worried. 

I was told that this is primarily a health problem. It was pointed out that doctors, nurses and other 

hospital staff have the same powers as the police under section 18 of the Mental Health Act. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Hospital employees have the legal authority to take a sectioned patient into custody and return them 

to hospital. 

However, I heard nothing of an ELFT protocol that would advise staff on the ward to come out to 

assist an escort who already following a patient. I heard nothing of a trust contingency plan that 

would allow a ward to function without the doctors and nurses needed to undertake such a task. I 

heard nothing of any training given to doctors and nurses in how to restrain a patient in the middle of 

the street and to transport them back to the ward. 

From the evidence I heard, the police / health trust partnership working allows each agency to regard 

such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a 

seriously ill patient who is meant to be inside a locked ward for their own safety. 

Whether this is a matter of policy or practice, the result is the same. If partner agency working is to 

be effective in caring for this extremely vulnerable cohort of patients, there needs to be crystal clear 

understanding by all those involved, from the highest policy maker to the most junior member of a 

team at the sharp end, of how to tackle these difficult situations and exactly who is meant to be doing 

what. 

MPS Response 

The core responsibilities of the police are to prevent and detect crime, protect life and property and 

maintain the Kings Peace. The retrieval of persons sectioned under the Mental Health Act, who have 

left the medical setting in which they reside, is a health care responsibility unless the need to locate 

them and/or take them into police custody, falls into one of the core policing duties. Involving the 

police in mental health issues where there is no crime or threat to life risks criminalisation of patients, 

and in London in particular, where there is a higher percentage of mental illness within some minority 

communities, has a disproportionate criminalising effect on them. 

The MPS and medical agency partners already work to an existing framework which sets out roles 

and responsibilities. They are: 

National Missing Adult Framework  

The National Missing Adult Framework was published in August 2020 by the Home Office. It sets 

out the need for joint working between Police and other agencies and has been signed up to by 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 National Police Chiefs Council, NHS England, Public Health England, HMICFRS and others. This 

document underpins the Affinity Protocol and the Joint Responsibility Agreements that the MPS 

Police have in place with the nine Mental Health Trusts including ELFT.  

Joint Responsibility Agreement - CM6 signed April 2022 by ELFT and MPS 

The MPS has, since September 2021, had in place a prevention and information sharing strategy for 

patients who are Absent Without Leave (AWOL) from a NHS Mental Health facility. This is named 

the Affinity Protocol and is underpinned by a Joint Responsibility Agreement (JRA) between the 

MPS and NHS Mental Health Service providers. This JRA allows both partners to identify their own 

areas of responsibility, areas of joint responsibility and for each agency to have a mutual 

understanding of the others area of responsibility. 

The Joint Responsibility Agreement sets out that where possible prevention of a person becoming 

Absent Without Leave (AWOL) is the optimal response. However this is not always achievable and 

therefore planning for that eventuality should take place by the NHS Mental Health provider for all 

patients granted leave under section 17 Mental Health Act 1983. This planning should allow for any 

critical concern for safety to be effectively communicated to the police, should a patient abscond. By 

sharing this information with police, it allows for a risk assessment to be made and targeted enquiries 

to be undertaken where appropriate to locate the missing person as quickly as possible. Information 

provided should include an up-to-date clinical risk assessment and an information pack that includes 

known risks, relevant history and prescribed medication. 

The Joint Responsibility Agreement sets out where police should always and immediately be called 

by health partners under the Mental Health Act 1983: Code of Practice – 

  Patients subject to Part III MHA 1983 – this means patients connected to criminal 

proceedings, either before or after trial or conviction 

  Patients who are dangerous 

  Patients who are particularly vulnerable 

The JRA asks the NHS to set out rationale to the police where the above is not met to assist the police 

in assessing the risk and determining the level of response. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The police response on receipt of this information is determined by the Approved Professional 

Practice set by the College of Policing for Missing People. For this reason the information provided 

by NHS partners is critical to ensuring the most appropriate response is undertaken. 

In instances where police do respond, unless the patient is subject to criminal proceedings (e.g. Part 

III MHA 1983), or S18 MHA applies, then police will generally not provide transport for the purpose 

of returning patients from the location they are found. This is clearly set out in the National Missing 

Adult Framework and is therefore a position which makes clear with which partner the responsibility 

sits. The National Missing Adult Framework also highlights that for many patients, being transported 

in a police vehicle is a traumatic experience and the most appropriate professional should return the 

patient. 

In cases where risk is mitigated on locating and speaking with the patient (e.g. at home), then police 

will inform Clinical staff of the patient’s location and police involvement will end. Requests for 

police to assist further (e.g. attending a S135 (2) warrant) will be dealt with outside of the MPS 

Missing Persons Process. 

The need for clarity of expectation, roles and responsibilities is at the core of the Right Care, Right 

Person approach and seeks to ensure that patients receive the right care, from the right person rather 

than police officers who are not trained specialists in dealing with mental health being used 

inappropriately. This furthers clarifies and supports the agreements and guidance already in place. 

Right Care, Right Person (RCRP) 

In February 2023 the Home Secretary wrote to Chief Constables and Police and Crime 

Commissioners to ask them to work with health partners to implement Right Care, Right Person in 

their area. To underpin this model, a National Partnership Agreement is being drafted between the 

Home Office, Department of Health and Social Care, National Police Chiefs Council and NHS 

England and is expected to be signed by all parties this summer. 

The Commissioner of the Metropolitan Police, 

, wrote to Health and Social Care 

Partners on 24th May 2023, to set out the Met Police’s intention to implement the national Right Care, 

Right Person approach. Under Assistant Commissioner 

 a team is now working to put this 

in place, and an initial senior board has taken place with senior health and social care providers to 

work towards RCRP implementation. This is also in parallel with the work being done by health care 

providers on the London mental health concordat. A key aspect of this is working with all of the  

 
 
 
 
 
 
 
 
 
 
 
 
 
 Mental Health Trusts to ensure that all agencies understand their responsibilities. The Police 

nationally under the NPCC lead, are developing the policies that sit behind Right Care, Right Person 

and the MPS is heavily engaged in this development. 

The preparatory work being done on implementing Right Care, Right Person provides the Mental 

Health Trusts with the opportunity to refresh their policies and training to allow them to meet their 

legal obligations under s18 Mental Health Act and Article 2 and 3 ECHR, in respect of someone who 

has absconded. In many cases this will be about asking trusts to implement in practise policies that 

currently exist. The MPS will be meeting with Health and Social Care partners from July to establish 

a RCRP External Partner Delivery Group to allow all parties to be clear on roles and responsibilities 

and for health and social care partners to develop their contingency plans to respond to patients who 

are Absent Without Leave from Mental Health facilities and the other pillars of Right Care, Right 

Person. 

(5) Evidence was given that the police classify a person at high risk as: the risk is immediate and 

there are substantial grounds for believing immediate risk of self-harm. 

I was told by the MPS that, at the time of reporting to the MPS, trusts should volunteer their own 

grading of the patient’s risk. The police said that they will not necessarily following the trust grading, 

but they regard it as a significant factor and it should form part of the MPS thinking. ELFT witnesses 

told me that if the police did not ask for the trust’s grading then the trust would not offer it. 

I was told that, until April 2022 the grab pack prepared by ELFT for the MPS in such a situation was 

printed out and handed to police if & when the police attended the ward. It is now filled out on a 

portal as part of the reporting procedure. However, it is not clear to me how far the grab pack aligns 

with local policies, whether all useful information (including the trust’s grading of risk) is recorded 

as a matter of routine, and how far the police and the trust are using the same terminology with the 

same definitions. It seems that this would benefit from consideration. 

MPS Response 

It would appear this concern is focused primarily on the information sharing practice and policy the 

ELFT have with the MPS – what information is considered important and whether the assessment of 

importance and language to communicate that is common between both partners. 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 The work that the MPS, National Police Chiefs Council and Health and Social Care partners will be 

undertaking as part of the implementation of the Right Care, Right Person will ensure that the policies 

of all parties align and there is a clear understanding of definitions and terminology used within these. 

It will also provide an opportunity for the police and Trust to work together to clarify what 

information is required within the grab pack to allow the police to make an effective risk assessment 

and understand whether there is a real and immediate threat to life to the patient or others. A clear 

understanding of when police will support the Trust in locating and potentially re-taking the patient is 

an important objective for both partners.   

Please do not hesitate to contact me should you have any queries. 

Yours sincerely 

T/Assistant Commissioner Met Operations and Performance

Coroner M E Hassell  
Inner North London  
St Pancras Coroner’s Court 
Camley Street 
London 
N1C 4PP 

Dear Coroner, 

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

26 July 2023  

Re: Regulation 28 Report to Prevent Future Deaths – Heather Findlay who died 
on 11 June 2020.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  12 
June 2023 concerning the death of Heather Findlay on 11 June 2020. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep  condolences  to  Heather’s  family  and  loved  ones.  NHS  England  are  keen  to 
assure the family and the coroner that the concerns raised about Heather’s care have 
been listened to and reflected upon.  

The concerns in your Report relate to organisational policy at East London Foundation 
Trust  as  well  as  policy  within  the  Metropolitan  Police  Service.  NHS  England  is  not 
therefore the appropriate organisation to respond to many of the concerns raised. 

I do however take the concerns raised seriously, and I thank you for bringing them to 
my attention, together with the other Reports to Prevent Future Deaths you highlight 
concerning the care of other patients at the Trust. I have asked that NHS England is 
sighted on the Trust’s response to your Report, as well as the responses to the other 
cases and we will consider these carefully, to include whether any further action needs 
to be taken. I have already been sighted on the Trust’s Patient Safety Serious Incident 
Review Report on this matter and note that they have taken a learning to ensure that 
the  police  are  provided  with  a  direct  dial  number  whenever  reporting  a  patient 
absconding, which did not happen in this case.  

I have also been sighted on the draft Terms of Reference for a new Joint Mental Health 
and Policing Group in the London region and understand that the first meeting took 
place earlier in July. I am pleased to see that the group will consider how they work 
together  to  deliver  the  Right  Care,  Right  Person  (RCRP)  programme  (which  is  a 
programme to ensure that the right service provides support to people who call the 
police for mental health matters), together with other mental health programmes and 
work within the region, and to deliver improvements to ensure safe and effective care 
for those in mental health crisis, as well as better coordination between the services.  

I also draw your attention to NHS England’s national Mental Health, Learning Disability 
and  Autism  Inpatient  Quality  Transformation  Programme,  which  was  established  in 
2022  to  support  cultural  change  and  a  new  model  of  care  across  all  mental  health 
inpatient settings. The programme seeks to:   

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 1.  Explore and accelerate different therapeutic offers, including community-based 

alternatives to admission and a culture within inpatient care that is safe, 
personalised and enables patients and staff to flourish. 

2.  Have a clear oversight and support structure that is sustainable and 

transparent, where issues are identified early. Services that are challenged will 
have timely, effective, and coordinated recovery support. 

Your Report has been shared with the team responsible for delivering this programme.  

I would also like to provide further assurances on national NHSE 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. 

Yours sincerely, 

National Medical Director