Lauren Bridges

From Maria Caulfield MP 
Parliamentary Under Secretary of State 
Department of Health & Social Care 

39 Victoria Street 
London 
SW1H 0EU 

9 May 2024  

Andrew Bridgman  
Assistant Coroner  
South Coroner's Office  
1 Mount Tabor Street  
Stockport  
SK1 3AG  

Dear Mr Bridgman,  

Thank you for your Regulation 28 report to prevent future deaths dated 19 September 2023 
about the death of Lauren Elizabeth Bridges.  I am replying as the Minister with 
responsibility for mental health and patient safety.       

Firstly, I would like to say how saddened I was to read of the circumstances of Lauren’s 
death and I offer my sincere condolences to her family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention. Please accept my sincere apologies for the significant delay in responding to 
this matter.  

Your report raises concerns about delayed discharges from out of area placements in 
independent mental health inpatient settings.   

In preparing this response, Departmental officials have made enquiries with NHS England 
and I understand that NHS England and Dorset Healthcare University NHS Foundation 
Trust have each already carefully considered the matters of concern in your report and 
have provided you with comprehensive responses setting out the actions being taken to 
improve care quality and patient safety.  

The Department recognises that it is important that those who require inpatient care are 
treated as close to home as possible, which is why we publicly committed to eliminating all 
inappropriate acute out of area placements by 2020/21.  Unfortunately, COVID-19-related 
pressures contributed to services missing that target. These pressures were caused by a 
number of factors, including bed closures due to the need for infection control; reduced 
community networks; staff absences; and higher levels of demand for NHS mental health 
services. However, I would like to assure you that that we remain committed to eliminating 
all inappropriate acute out of area placements for adults aged 18 and over.    

All systems that still have inappropriate out of area placements have been required to 
refresh their local plans to ensure these placements are eliminated everywhere as soon as 
reasonably possible. NHS England continues to work with the worst performing areas and 
support them to improve and we are working with NHS England to ensure that systems 
prioritise this, including a focus on discharge and flow.    

 
 
 
 
  
   
  
  
  
  
  
  
   
 To support adult social care and discharges across the NHS, including from mental health 
inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 
2024/25, reducing bed occupancy.   

The Department has also worked with NHS England and other system partners to develop 
statutory guidance for discharge from all mental health inpatient settings, which was 
published in January 2024. This sets out how NHS bodies and local authorities can work 
together to support the discharge process, improving flow and ensuring the right support in 
the community.  The guidance is available at: Hospital discharge and community support 
guidance - GOV.UK (www.gov.uk)  

More widely, through the NHS Long Term Plan, we have invested almost £1 billion extra in 
community mental health care for adults by March 2024, expanding community mental 
health services to reduce reliance on inpatient treatment, so that patients are supported to 
stay well in their communities. This major expansion in funding for community mental health 
services commenced in all areas in 2021/22 and has been key to managing pressures on 
beds.   

Turning to your concerns around an over-reliance by the NHS on independent providers for 
mental health beds, private companies have always played a role in the NHS and patients 
should expect a safe and good quality service regardless of whether their care is delivered 
by independent sector or public sector providers.  As set out in NHS England’s response to 
your report, all integrated care boards have been tasked with developing 3-year plans to 
localise and realign inpatient mental health care, including care provided by the 
Independent Sector, as part of NHS England’s mental health, learning disability and autism 
inpatient quality transformation programme.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely, 

MARIA CAULFIELD

Andrew Bridgman 
Assistant Coroner 
South Manchester area 

Corporate Office  
Sentinel House 
Nuffield Industrial Estate 
4-6 Nuffield Road 
Poole, Dorset 
BH17 0RB 

Dear Mr Bridgman,  

Re Regulation 28 Report following the inquest touching on the death of Lauren Bridges   

We acknowledge receipt of the Regulation 28 Report issued to Dorset HealthCare University NHS 
Foundation Trust following the inquest touching on the death of Lauren Bridges. The report, dated 
19th September 2023, was received by Dorset HealthCare on 24th November 2023, following contact 
with your office.  

Our thoughts are with Lauren’s family following their loss and we are truly sorry for the circumstances 
in which Lauren died.  

After Lauren died, we undertook a review of the care and support offered and we have made changes 
to the way in which we support our patients who are receiving care out of area.  

In respect of the specific regulation 28 matters of concern notified to the Trust, I will respond to these 
in turn: 

a)  The omission to update the Hospital Overview timeously and correctly. 

In  respect  of  the  Hospital  Overview  document,  we  have  made  a  number  of  changes  and 
improvements to ensure that this is updated in a timely and correct way. The changes we have made 
are detailed below:  

1.  The  Trust  has  undertaken  a  comprehensive  review  to  ensure  that  all  patients  who  are 
receiving acute care funded by the Trust in Out of Area beds are accurately identified as such 
on our clinical system. 

2.  We have enhanced the daily Hospital Overview situation report which is accurate at the point 
it is sent, with the purpose of providing a summary at the start of the working day across the 
organisation  to  key  colleagues  including  senior  clinicians  and  managers.  The  information 
contained  in  the  daily  Hospital  Overview  template  is  updated  manually  by  the  night 
practitioners from data contained in the clinical system. It is then checked by both the Out of 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 Area Co-Ordinator and the Clinical Site Managers, who are clinicians who are overseeing 
bed flow decisions, to ensure that the information contained in this document is correct for 
that  point  in  time.  The  Hospital  Overview  is  then  emailed  to  key  colleagues  to  provide  a 
summary of the bed state every 24 hours.  

3.  In  addition,  the  Trust  has  also  added  a  specific  section  to  the  daily  Hospital  Overview 
template showing patients who are in out of area beds who require repatriation to a local bed. 
This ensures that Clinical Site Managers are taking these patients into account when making 
daily decisions on bed allocations. 

4.  We  have  also  made  improvements  to  our  automated  reporting.  We  have  updated  the 
electronic  admission  form template  that  is  embedded  in  the  patient record  system  so that 
when a patient requires admission, we capture more robust information, which is then also 
reportable  in  a  bed  state  automated  report.  This  automated  report  provides  additional 
information in respect of patients in excess of the Hospital Overview document, for example 
a list of names and length of stay for every patient admitted to hospital, to an out of area bed, 
and those awaiting admission. This more detailed information is used by clinicians directly 
involved in bed flow and inpatient care to support their daily work.  

b)  It can be inferred from the absence of any documentation regarding discussions about 

Lauren’s repatriation to an available bed that no such discussion took place. 

In respect of this matter of concern, I have focused our response on actions we have taken to 
improve the oversight, routine review, and documentation in respect of admission and / or 
repatriation decisions including for patients whose inpatient care is provided out of area: 

1.  The  Trust  has  implemented  a  new  Standard  Operating  Procedure  (SOP)  for  Enabling 
Purposeful Admissions. This clearly sets out the required process, roles and responsibilities 
of key staff and the required recording in respect of inpatient flow decisions. This SOP has 
been communicated to staff and included on our staff intranet.   

2.  We have reviewed our daily clinical meeting that takes place in respect of bed flow and set 
out requirements in the meeting's terms of reference, including standard items for discussion 
and  recording  standards.  These  terms  of  reference  are  included  within  the  Enabling 
Purposeful Admissions SOP.  

3.  As referred to during the inquest, we have appointed a dedicated Out of Area Coordinator 
post, which is a clinical post. We have also written and implemented a SOP for the ‘Use of 
Out  of  Area  Acute  and  Psychiatric  Intensive  Care  (PICU)  Mental  Health  Inpatient  beds: 
Therapeutic inpatient care and proactive discharge planning’. The SOP includes standards 
to be met in respect of regular contact and recording of that contact with patients who are out 
of area, and their families / carers, as well as with clinicians working in out of area providers 
overseeing that care.  

4.  Clinical Site Managers now use a live Microsoft Teams channel for communicating updates 
between them on requirements around bed flow, which is linked to patient electronic records. 
This replaces previous paper handover records and ensures that there is documentation of 
bed  flow  discussions  and  decisions,  for  example,  if  there  are  moves  of  patients  between 
wards in order to create bed capacity in a specific ward to facilitate an admission, that this is 

2 

 
 
 
 
 
 
 
 
 
 appropriately communicated between Clinical Site Managers. This supports better handover 
between Clinical Site Managers coming onto a shift, so they can understand the status of 
pending  admissions  and  decisions  taken  in  the  previous  shift.    In  addition,  discussions 
regarding individual patients are also recorded in the patient's own electronic patient record 
(known as RiO) to ensure a complete up to date record for each individual patient.  

5.  A  regular  audit  takes  place  every  month  involving  reviewing  the  records  of  all  patients 
receiving their care out of area against the standards set out within the SOP. This audit is 
undertaken by our Nursing and Quality Directorate and will remain ongoing. Audit standards 
include evidence of OOA coordinator input, date of last input, that the patient has an allocated 
Care Coordinator, date of last input from them, date of last contact with patient and family, 
date  of  Care  Programme  Approach  meeting,  date  of  last  clinician  attendance  at  a  multi-
disciplinary team review, and whether there is a discharge / repatriation plan. 

I can confirm that all of the actions detailed have been completed and ongoing assurance where 
required  is  monitored  via  the  monthly  audit.  We  hope  we  have  provided  assurances  that  Dorset 
HealthCare has addressed the areas identified in the Regulation 28 Report and that we have taken 
the matter extremely seriously. The DHC Board are sighted on the significance of the Regulation 28 
Report. We will continue to report our progress to both our Board and NHS Dorset Integrated Care 
Board so there is clear visibility of the service improvements being made.   

We are now confident that the circumstances for Lauren would not be repeated, which we hope will 
bring some comfort to Lauren’s family. We are also keen to reiterate our sorrow for the circumstances 
in which Lauren sadly died. 

Yours sincerely 

Chief Executive 

3

Andrew Bridgman  
Manchester South Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Dear Coroner, 

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

9 November 2023  

Re: Regulation 28 Report to Prevent Future Deaths – Lauren Elizabeth Bridges 
who died on 26 February 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  19 
September 2023 concerning the death of Lauren Elizabeth Bridges on 26 February 
2022.  In advance of responding to the specific concerns raised in your Report, I would 
like to express my deep condolences to Lauren’s family and loved ones. NHS England 
are keen to assure the family and the coroner that the concerns raised about Lauren’s 
care have been listened to and reflected upon.  

In your Report you raised concerns over underfunding of local mental health beds and 
the mental health impact of Out of Area (OAP) placements and an over-reliance by 
the  NHS  on  independent  providers.  You  also  raised  the  issue  of  inadequate  and 
insufficient  communication  between  the  Trust,  independent  provider  and  other 
relevant  parties,  the  challenges  that  can  be  posed  by  having  separate  NHS 
commissioning bodies, and the need for protocols/standardised operating procedures 
to avoid delayed discharge from OAPs/Psychiatric Intensive Care Units (PICUs).  

The  NHS  remains  committed  to  eliminating  the  practice  of  adult  acute  Out  of  Area 
Placements.  All  Integrated  Care  Boards  (ICBs)  were  asked  to  work  towards 
eliminating the practice in NHS England’s 2023/24 Priorities and Operational Planning 
Guidance. An ICB is a 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 within a given geographical area. They 
replace clinical commissioning groups (CCGs), taking on the NHS planning functions 
previously  held  by  CCGs,  as  well  as  absorbing  some  planning  roles  from  NHS 
England.  

While good progress was being made ahead of the Covid-19 pandemic in eliminating 
the  practice  of  OAPs,  the  subsequent  increase  in  prevalence  of  mental  health 
problems against the backdrop of an existing treatment gap has made this even more 
difficult.  

Further,  while  the  level  of  NHS  investment  in  mental  health  services  is  higher  than 
ever  before  and  investment  targets  are  being  met  nationally,  pressures  on  both 
community and inpatient services remain very high. 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
  
 In July 2023 NHS England published renewed guidance to support the commissioning 
and delivery of timely access to high quality therapeutic inpatient care, close to home 
and in the least restrictive setting possible. Key to this are the principles of: timely and 
purposeful admissions that are local, timely discharge, joined-up care and continuous 
improvement. 

To implement this, all ICBs have been tasked with developing 3-year plans to localise 
and realign inpatient mental health care, including care provided by the Independent 
Sector,  as  part  of  the  mental  health,  learning  disability  and  autism  inpatient  quality 
transformation  programme  launched  in  2022.  Health  and  Care  systems  across 
England are currently being supported to operationalise the guidance via 3-year plans 
with direct support from regional and national teams. The transformation programme 
is underpinned by a £36 million investment.  

NHS England recognises the critical importance of strong commissioner oversight and 
joint working in inpatient mental health care, and as such has made it a requirement 
that  these 3-year  plans  be  co-produced  –  including  with  patients,  families  and  their 
carers.  

We  are  also  currently  engaging  on  how  the  roles  and  responsibilities  for 
commissioning  and  assuring  the  quality  of  mental  health,  learning  disabilities  and 
autism  inpatient  care  across  the  NHS  and  the  independent  sector  can  be 
strengthened,  with  a  view  to  embed  learnings  and  best  practice  in  National  Quality 
Board policy and governance frameworks from 2024 onwards. 

My  regional  colleagues  in  charge  of  quality  of  care  in  the  South  West  have  also 
engaged with Dorset Healthcare University NHS Foundation Trust (‘the Trust’) on the 
matters raised in your Report. The Trust have acknowledged that there were missed 
opportunities  in  Lauren’s  care,  and  I  understand  have  written  to  Lauren’s  family 
separately  to  express  their  regret.  They  have  also  provided  NHS  England  with 
assurances that actions have been taken to address the identified learnings. These 
actions have included:  

•  Reviewing all standard operating procedures  
• 
Improving the way we engage and communicate with providers and families  
•  Better  care  co-ordination  and  involvement  of  local  teams  to  address  our 

patient’s clinical needs and plans for repatriation.   
• 
Improved data and oversight including regular auditing of care arrangements. 
•  Appointment  of  an  out  of  area  co-ordinator  and  a  programme  of  quality 

assurance of providers used by the Trust.  

The Trust advises that the work is resulting in improvements and a reduction in the 
time patients are receiving care outside of area, where there is no clinical need. They 
have also secured planning permission to rebuild some of their mental health inpatient 
facilities and increase the availability of PICU for adults and younger people. Subject 
to business cases and plans being agreed, they hope to have new facilities in 2026. 
In  the  shorter  term  they  have  also  taken  the  opportunity  of  using  winter  monies  to 
create  a  discharge  and  flow  team  for  mental  health  and  have  recently  appointed  a 
Consultant Psychiatrist to provide clinical leadership to this team. 

 
 
 The Trust now has a formal arrangement with Marchwood Priority in Southampton, for 
those occasions where an OAP may still be required based on clinical need and due 
to capacity. Marchwood Priory is geographically one of the closest providers to Dorset, 
which  hopefully  improves  the  chances  of  families  being  able  to  visit  and  maintain 
contact.  

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, 

National Medical Director