Rachel Garrett

Ms Penelope Schofield 
HM Coroner West Sussex 
Record Office 
Orchard Street 
Chichester  
PO19 1DD  

Dear Ms Schofield 

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

18 August 2023 

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 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
  
 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. 

Yours sincerely, 

Medical Director for Professional Leadership and Clinical Effectiveness  
NHS England

NHS Sussex 
Wicker House 
High Street 
Worthing 
BN11 1DJ 

Ms Penelope Schofield 
Senior Coroner 
County Records Office 
HM Coroners Office 
Orchard Street 
Chichester 
West Sussex 
PO19 1DD 

22 08 2023 

Dear Ms Schofield 

I write in response to your Regulation 28 report and the covering letter dated 29.06.23, 
addressed to our Chair, 
after hearing evidence at the Inquest touching on the death of Rachel Garrett. 

, in respect of the concerns you have highlighted 

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. 

Yours sincerely, 

Chief Nursing Officer 

On behalf of NHS Sussex