Juan Martin

Parliamentary Under Secretary of State   
For Patient Safety, Women’s Health  
and Mental Health.  

39 Victoria Street  
London  
SW1H 0EU  

020 7210 4850  

12 August 2024  

Our Ref: 

Priya Malhotra  
Assistant Coroner  
Inner West London Coroner’s Court  
33 Tachbrook Street  
London   
SW1V 2JR  

By email: 

Dear Mrs Malhotra,  

Thank you for your Regulation 28 report to prevent future deaths dated 11 June 
2024, about the death of Juan David Martin.  I am replying as the recently-appointed 
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 Juan’s 
death and I offer my sincere condolences to his family and loved ones. The 
circumstances your report describes are concerning and I am grateful to you for 
bringing these matters to my attention.   

Your report raises concerns over the adequacy of mental health bed capacity across 
London and I recognise the impact that a suitable bed not being available can have 
on patients, as exemplified in this case.  

This government believes that the whole mental health system needs to work 
together, with efficiency, to reduce the likelihood of inpatient admission. In turn, this 
will improve bed availability.   

I recognise how important it is that people with mental ill health get the level of care 
that is appropriate for their needs, and we want to ensure that people have access to 
the right mental health support, in the right place, and at the right time.   

 
  
  
  
  
  
   
  
  
  
  
  
  
  
  
  
  
 1  

At national level, as part of our mission to build an NHS fit for the future, we will make 
sure mental health care is delivered in the community wherever possible - through 
new models of care and support available for those who are struggling - so that more 
people are prevented from needing to go into hospital.  

The suicide prevention strategy for England, published in 2023, is a five-year 
strategy which sets out the national ambition for suicide prevention. As part of our 
commitment to reduce the lives lost to suicide, the 8,500 new mental health workers 
we will be recruiting across children’s and adult services will be specially trained to 
support people at risk.  

I understand that South West London and St George’s Mental Health NHS Trust and 
NHS South West London Integrated Care Board will respond to your concerns about 
local mental health bed capacity directly, reflecting their responsibility to assess bed 
capacity and the ‘flow’ of patients being discharged or moving to another setting.   

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

Yours sincerely,

Chief Executive’s Office 
South West London and St George’s Mental Health NHS Trust 
Elizabeth Newton Building 

Springfield University Hospital   
15 Springfield Drive   
London SW17 0YG 

Direct Line: 

            E-Mail: 

Chief Executive’s Office 
NHS South West London Integrated Care Board  
120 The Broadway 
London 
SW19 1RH 

29 July 2024 

Private & Confidential 
Priya Malhotra 
Assistant Coroner for Inner West London 
Inner West London Coroner’s Court 
33 Tachbrook Street 
London  
SW1V 2JR 

Dear Madam 

Our internal Reference: 

Re: Regulation 28 Report to Prevent Future Deaths – Mr Juan David Martin 

We are writing to you following receipt of the Regulation 28: Report to Prevent Future Deaths 
(PFD)  dated  11  June  2024 (received  on  13  June  2024),  regarding the  sad  death  of  Mr Juan 
David Martin.    

You  have  requested  that  South  West  London  and  St  George’s  Mental  Health  NHS  Trust 
(SWLStG)  and  NHS  South  West  London  Integrated  Care  Board  (SWL  ICB)  respond  to  the 
matters of concern that you have detailed in your correspondence.  

We have taken a joint approach exploring the matters of concern and provided responses below 
including actions we are taking and how we will work together to improve.  

We thank  you for your  consideration  and  commitment to  the  prevention  of  future  deaths  and 
helping us to learn.    
We would like to express our deep sympathy to the family and friends of Mr Martin for their loss. 
While we seek to make improvements within the Trust and local system to help ensure we are 
able to provide the necessary bed provision, we recognise that this cannot diminish their pain 
and anguish.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Trust and ICB remains committed to continuous learning and improvement and we are very 
grateful for all those involved in the Inquest.   

Sincerely  

Chief Executive Officer 
South West London and St George’s  
Mental Health NHS Trust 

Chief Executive Officer 
South West London ICB  

2 

 
 
 
 
    
                                                  
                                        
 
 
                                                          
 
 
 
       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Bed capacity: Matter of Concerns and Actions 

The MATTERS OF CONCERN are as follows:  

(1)  Juan  Martin  was  held  informally  on  7  April  2022  and  following  a  mental  health 
assessment  on  11  April  subsequently  became  liable  for  detention.  He  therefore  spent  6 
days  in  the  Lotus  Assessment  Suite.  Witnesses  confirmed  that  no  suitable  bed  was 
identified until approximately after 15:00 on 12 April 2022, which then became unavailable.  

(2)  The  Matron  in  Acute  and  Urgent  Care  confirmed  bed  capacity  remains  an  ongoing 
problem  and  has  not  been  resolved.  The  Matron  provided  one  recent  example  where  a 
patient waited for 7 days in the Accident and Emergency Department for a mental health 
bed. 

(3)  The  Matron  added  there  was  an  exceptional  process  which  required  a  considered 
decision  at  a  high  level  to  make  a  bed  available  through  identifying  someone  currently 
occupying a bed space to be discharged and that the ‘flow’ of patients being discharged or 
moving to another setting amplified the bed capacity issue.  

Based on the evidence heard, my principal concern is that bed capacity in London remains 
inadequate. Whilst some action may have been taken by the Trust to better triage the need 
for beds it is insufficient to resolve the problem. It follows there is a genuine risk of future 
deaths  directly  connected  to  a  shortage  of  mental  health  bed  spaces  in  London  unless 
further action is taken.  

South West London and St George's Mental Health NHS Trust - Response  

The  Trust  (SWLStG)  fully  acknowledges  the  concern  regarding  insufficient  bed  capacity  in 
London and the reason why the Coroner has cause to raise these concerns.  

SWLStG recognises this as a key risk to patient safety, which is fully captured and articulated 
within  our  Board  Assurance  Framework,  and  we  are  working  to  mitigate  the  risk  as  far  as 
possible.    We  note,  as  has  the  Coroner,  that  this  is  not  fully  within  our  control  due  to  the 
increasing complexity and level of demand for acute mental health services and the constraints 
on  funding  and  resources  to  provide  acute  mental  health  beds.      Where  appropriate  and 
available, we seek acute mental health beds in the private sector, but with a recognition that this 
is  not  always  in  the  best  interest  of  the  patient  as  these  admissions  can  be  remote  from  a 
patient’s local support networks and disconnected from their broader NHS care. 

As part of our integrated transformation programme, we have implemented a range of projects 
aimed to improve acute mental health patient flow and bed access, including: 

-  Discharge  planning  best  practice  implementation  in  line  with  NHS  guidance  (100-day 

discharge challenge; 10 high impact interventions; ward workflows project). 

-  Collaborative discharge and flow work with Local Authority partners through the Strategic 

Operational Interface Programme. 

3 

 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 -  Revised and strengthened our Bed Management Policy, including additional actions at 
higher levels of escalation, and moved to real-time electronic bed status and waiting list 
management. 

-  Embedded a clinical prioritisation tool into our acute flow management process to ensure 
that patient safety and risk is foremost in allocating limited bed capacity. This tool has 
subsequently formed the basis of a London-wide prioritisation scoring tool commissioned 
by NHSE London and to be adopted by all mental health trusts in 2024. 

-  Commissioned additional, unfunded private sector acute mental health beds from a local 

- 

provider, and stepdown hostel beds to support flow. 
Invested significantly into community and crisis prevention services to support patients 
to remain well in the community and avoid the need for an acute admission, thus helping 
to also provide more available beds. 

Despite this, we appreciate there is still a risk around patients awaiting admission due to  the 
lack of beds and we are undertaking further work in the following areas: 

- 

Intensive support to our acute ward teams to identify barriers to flow and enhance best 
practice ways of working, with swift but safe discharges. 

-  Further  transformation  of  our  mental  health  crisis  offer,  including  developing  mental 
health triage and rapid access services to support our local Emergency departments with 
patients presenting with mental health needs. 

-  Review of our rehabilitation and mental health supported living settings in partnership 
with Local Authorities and the South London Partnership for mental health complex care 
programme, to support improved access to onward care settings. 

We  would  support  any  further review  of  the  sufficiency  of  acute mental  health beds  in  South 
West  London  and  London-wide  to  meet  the  increased  and  more  complex  demand  for  these 
services.  

South West London Integrated Care Board – Response 

SWL ICB recognises the demands and pressures on acute mental health inpatient beds. 
There are a range of reasons including increased demand, increased acuity of patients and 
delays caused by people who are clinically ready for discharge but are delayed accessing their 
onward accommodation.  

The ICB is working with SWLSTG and other healthcare providers in South West London to 
address situations where patients experience delay in all parts of the care pathway. This 
includes work focused on reducing length of stay and minimising the use of out of area 
placements. As part of the 2024/25 planning process, ongoing investment was made into 
commissioning additional beds in the private sector to mitigate the current bed pressures while 
longer term work on improved patient flow continues. 

4

Chief Executive’s Office 
South West London and St George’s Mental Health NHS Trust 
Elizabeth Newton Building 

Springfield University Hospital   
15 Springfield Drive   
London SW17 0YG 

Direct Line: 

 E-Mail: 

29 July 2024 

Private & Confidential 

Priya Malhotra 
Assistant Coroner for Inner West London 
Inner West London Coroner’s Court 
33 Tachbrook Street 
London  
SW1V 2JR 

Our internal Reference: 

Dear Madam 

Re: Regulation 28 Report to Prevent Future Deaths – Mr Juan David Martin 

I  am  writing  to  you  following  receipt  of the  Regulation 28:  Report to  Prevent  Future Deaths 
dated 11 June 2024 (received on 13 June 2024), regarding the sad death of Mr Juan David 
Martin.  

You  have  requested  that  South  West  London  and  St  George’s  Mental  Health  NHS  Trust 
(SWLStG) respond to the matters of concern that you have detailed in your correspondence.  

In  order  to  examine  all  of  the  concerns  raised,  the  Prevention  of  Future  Death  Report  was 
shared with the clinical leadership team responsible for  Mr Martin’s care and treatment and 
our Trust board quality committee to help the Trust respond to the points of concern you have 
raised. 

I have provided a response to each of your concerns and direction as they were raised in your 
correspondence: 

Fire safety / evacuation  

The MATTERS OF CONCERN are as follows: 

Chief Executive, 

                 Chair, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (1) There was no policy in place at the time to evacuate those liable for detention and/or at 
risk  of  absconding  in the  fire evacuation  policy  at  the time  Juan  Martin absconded  on  12 
April 2022. Witnesses confirmed that the local operational policy was updated on 14 April 
2022. The fire evacuation policy was updated in February or March 2024. Notwithstanding 
the now updated fire evacuation policy, a Health Care Assistant who still works in the Lotus 
Assessment Unit, confirmed he had not seen the evacuation plans, which form part of the 
policy. 

Based  on  the  evidence  heard,  my  principal  concern  is  that  there  is  a  lack  of  knowledge 
around the fire evacuation policy on the Lotus Assessment Suite. Whilst some action may 
have been taken by the Trust to update the policy belatedly and deliver training locally by 
clinicians; the Health Care Assistant was not familiar with the evacuation plans. It follows 
there is a genuine risk of future deaths directly connected to a lack of training on the fire 
evacuation policy and embedded learning and familiarisation around it. 

(2) The Fire Safety Advisor in  evidence confirmed the findings of the Trust’s Root Cause 
Analysis (RCA) report were not shared with him, despite the RCA being completed on 18 
July 2022. Further the nurse in charge was not made aware of the findings of the report that 
“it  would have been  best  practice for  Lotus staff  to  consider  removing  valuable items  i.e. 
bank card and any cash from the patient particularly after he met the criteria for detention”. 
It  is  surprising  findings  from  the  Trust’s  own  RCA  report  were  not  shared  with  key  staff 
members, namely the Fire Safety Advisor and the Nurse in Charge on the day Juan Martin 
absconded from the unit. 

As  captured  during  the  Inquest,  both  the  Lotus  operational  policy  and  fire  evacuation 
procedures  had  been  updated  with  clear  guidance  for  the  variance  in  procedure  of  the 
evacuation of sectioned/detained patients. While this should this have been done sooner, it is 
now clear that such detained patients should follow the section 136 evacuation procedure and 
route to ensure they are not able to leave the unit.  

Since the Inquest, we have: 

▪  Updated  the  fire  training  provided  as  part  of  the  Trust’s  corporate  induction  (for  all  new 
staff) to include the consideration to the risk of patients potentially absconding during a fire 
alarm activation and the importance of consideration of detention status and risk status. 
▪  Likewise,  the  local/team  induction  information  and  a  focus  on  the  revised  evacuation 

procedures has been established for all inpatient areas and Lotus 

▪  Specifically with Lotus, to provide additional assurance, all staff have confirmed they are 
aware and understand the evacuation procedures and how to legally hold someone under 
the Mental Health Capacity Act/Common Law.  This includes those individuals awaiting a 
Mental Health Act (MHA) Assessment, or those liable to be detained under the MHA, where 
staff have material safety concerns considering risk of possible imminent absconding.   All 
Lotus staff (apart from those on leave) have confirmed and signed a local induction sheet 
to confirm their understanding of the different evacuation procedures.  There are plans in 
place to ensure all staff who are on leave and all new joiners do the same. 
▪  Fire warden training has also been updated to cover the same information. 

Chief Executive, 

                 Chair, 

 
 
 
 
 
 
 
 
 
 
 
 
 ▪  A  real  time  fire  evacuation  drill  has  taken  place  on  Lotus  and  the  Fire  Safety  Officer 
confirmed  this  was  very  successful  and  staff  were  aware  of  the  different  evacuation 
procedures. The Fire Safety Officer produced a written summary of the drill.  Further drills 
will take place and be designed into the routine arrangements for fire drills that will focus 
on the specific variations to evacuation. 

▪  The  learning  from  this  situation  will  be  shared  and  published  via  our  internal  Monthly 

Learning Bulletin (MLB) by September 2024. 

Investigation learning  

The MATTERS OF CONCERN are as follows: 

Based on the evidence heard, my principal concern is that critical learnings from the RCA 
have not been shared with key individuals. Whilst some action may have been taken by the 
Fire  Safety  Advisor  following  a  request  for  evidence  during  my  investigation,  such  as 
updating the fire evacuation policy earlier this year, it is insufficient to resolve the problem of 
failing to share learning. It follows there is a genuine risk of future deaths directly connected 
to a failure to share learning from the RCA unless further action is taken. 

Since the Inquest, we have: 

▪  Provided  briefings  to  the  central  investigation  team  to  review  the  process  for  sharing 
investigation  reports  and  their  key  findings  and  actions  at  the  various  stages  of  the 
investigation.  

▪  Updated  our  Patient  Safety  Incident  Response  Plan  (PSIRP)  document,  adding  a  new 
specific  section  on  ‘sharing  learning’.  This  includes  the  process  and  guiding  principles 
around  engaging  and  sharing  learning  with  both  staff,  patients  and  families.  This  also 
recognises that such engagement, following what are often traumatic events can be very 
upsetting for staff involved, hence the need for a tailored approach (via the key principles) 
to ensure that the most suitable person engages with the staff involved and best able to 
provide the necessary pastoral support.  

▪  Reviewed the patient safety  investigation template to make actions more thoughtful and 
meaningful.  For example, we now include the focus on  ‘What does the action intend to 
achieve’  and  ‘How  will  it  be  implemented  /  delivered’.      In  addition  to  a  firmer  focus  on 
assurance and monitoring. 

▪  Strengthened  the  process  for  capturing  actions  from  investigations  into  our  incident 

management system, to enable better allocation of actions. 

▪  Added more focus on the formal issuing of the final report to the relevant service line with 
better  clarity  on  the  expectations  that  they  properly  review  within  their  governance  and 
business meetings to assurance themselves learning is shared and embedded.  

▪  Due  to  national  NHS  changes that  require  ‘draft’  investigation  reports to be  shared  with 
patients  and  families  (as  part  of meaningful  engagement  around  patient safety),  we are 
reviewing our internal review and sign-off processes which includes the key roles of specific 
groups and committees.  In turn, this will help ensure we have the right learning, with a 
focus on sharing and improvement. 

Chief Executive, 

                 Chair, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Absent without leave (AWOL) and missing persons 

The MATTERS OF CONCERN are as follows: 

(3) The absent without leave (AWOL) and missing person policy. 

(a) The policy in force at the time of Juan Martin’s death and currently in force, confirm the 
necessity for the engagement of the Security team following a patient absconding and that 
the hospital and grounds should be searched. This did not happen on 12 April 2022. The 
Nurse in Charge who still works for the Trust, accepted she did not contact security, nor was 
there a search. Juan Martin was a high-risk patient. 

(b) Furthermore, Trust policy dictates that the police should be called immediately. Despite 
being in possession of a radio during the fire evacuation, the Nurse in Charge nor any other 
staff member present telephoned nor asked for the police to be contacted until 11 mins after 
Juan Martin absconded. CCTV confirmed he was in the vicinity of the hospital grounds for 
up to 8 mins after absconding. 

(c) The London Mental Health Trusts Joint policy dated November 2023 concerning patients 
who are AWOL or abscond is not in line with the Trust’s current policy dated 22 March 2023, 
nor does the pan-London policy contain a flow chart for dealing with patients who are high-
risk. 

Based on the evidence heard, my concerns are that (i) there is a lack of understanding of 
the AWOL and missing person policy by senior staff; (ii) the pan-London and local policies 
do not align. Whilst some action may be taken by the Trust to better align the policies and 
improve knowledge and compliance amongst clinicians of their duties under the policy; this 
has not yet been undertaken, nor has a clear proposal been provided, such that in my view 
it is sufficient to resolve the problem. It follows there is a genuine risk of future deaths unless 
further action is taken, directly connected to (i) a lack of knowledge of procedures following 
a patient absconding or AWOL and (ii) inconsistency between policy documents. 

Prior to the Inquest (and what was then covered during the  Inquest proceedings), the Trust 
had  both  policies  in  circulation,  although  the  intention  was  to  have  a  single  policy  in  place, 
being the London Mental Health Trust Joint Policy Pan London (‘pan London’).  Inevitably this 
led to a lack of consistency and a lack of alignment, and this was reflective of what was relayed 
to the Inquest.      

The Trust had since removed our internal AWOL policy, replacing with the joint pan-London 
policy,  however the  Inquest  helped the  Trust  to  identify  that  there  was  also  key  information 
within our old policy around procedures for missing / AWOL service users that was not reflected 
in the pan-London policy document. 

Chief Executive, 

                 Chair, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Since the inquest, we have: 

▪  Reviewed both polices to check what may need to be added into an updated pan-London 

policy.  

▪  As  aforementioned,  this  included  adding  the  flow  chart  regarding  the  missing  /  AWOL 

procedure to the pan-London policy as an appendix.    

▪  Liaised with the pan-London policy owners on the changes we have made, with a view of 
working together during the formal revision period (July 2024), as other trusts may wish to 
include a version of what we have since added.  
▪  Published the revised policy for all staff to be aware.  
▪ 

Issued  the  revised  policy  to  the  clinical  service  lines  and  specifically  Lotus  service  and 
sought assurance that management to ensure staff are aware and understand the policy 
requirements and procedures. 

▪  Walk-through AWOL drills have been undertaken in Lotus to ensure that staff are aware of 

▪ 

the procedure which has resulting in a reassuring understanding and response. 
In addition, we will be creating a short  scenario video on AWOL and fire,  to boaster the 
awareness and this will be incorporated into both local and corporate induction over the 
autumn period. 

▪  The  learning  from  this  situation  will  be  shared  and  published  via  our  internal  Monthly 

Learning Bulletin (MLB) by September 2024. 

A separate letter will follow from the Integrated Care Board (ICB) and myself in connection to 
the other PFD related to this sad case.  

We thank you for your consideration and commitment to the prevention of future deaths and 
helping us to learn, and I would like to express our deep sympathy to the family and friends of 
Mr Martin for their loss. While we seek to make significant efforts to ensure that we prevent 
any similar deaths in the future, I recognise that this cannot diminish their pain and anguish.  

The Trust remains committed to continuous learning and improvement and we are very grateful 
for all those involved in the Inquest.   

Yours faithfully 

Chief Executive  

Chief Executive, 

                 Chair,