Aaron Deeley

13 August 2024 

Private and Confidential - By Email Only   
Ms Sonia Hayes  
HM Area Coroner for Essex Coroner’s Office  
Seax House  
Victoria Road  
South Chelmsford  
Essex  
CM1 1QH 

Dear Ms Hayes 

Aaron James Deeley (RIP) 

Chief Executive Office 
The Lodge 
Lodge Approach 
Wickford 
Essex 
SS11 7XX 

Tel: 

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 
5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners 
(Investigations) Regulations 2013, dated 19th June 2024 in respect of the above, which was 
issued following the inquest into the death of Mr Deeley. 

I would like to begin by extending my deepest condolences to Mr Deeley’s family. The Trust 
sympathises with their very sad loss.  

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed 
and noted. I will now respond in full to these concerns in the hope that this provides both 
yourself and Aaron Deeley’s family with comprehensive assurance of changes that have been 
made at the Trust to address the concerns you have raised, whilst noting that some of the 
concerns raised are best answered by Mid & South Essex University Hospital (MSE / the 
Acute Trust) and / or NHSE. 

Concern a)  

While a patient is admitted to an acute Trust ward for treatment for physical health treatment 
and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment 
due to concerns the patient presents a risk to themselves or others with a mental disorder, it 
permits the patient to be held for a maximum period of 72 hours. 

Patients admitted into the Accident & Emergency department detained under various sections 
of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under 
section have access to the Mental Health Liaison Team. 

Response: 

In order for an application for detention under the Mental Health Act 1983 to be made the 
application needs to be addressed to the managers of the specific hospital where the person is 
being detained to for purpose of admission. The application then needs to be formally 
accepted by the hospital managers (or nominated person on behalf of) for the named specific 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 hospital stated on the application. Patients in Accident and Emergency departments are not 
formally admitted for treatment nor assessment within the hospital inpatient wards, therefore 
the use of detention under Mental Health Act 2007can not be applied in this setting. 

All patients above age 18 years old both in Accident & Emergency department and those 
admitted to Southend University Hospital who require support with their mental health needs 
and referred to Mental Health Liaison Team (MHLT) are supported by this team regardless of 
their legal status. In the event of a patient aged 18 years old or over admitted to Southend 
University Hospital requiring the allocation of a Responsible Clinician in order to execute 
duties under the Mental Health Act EPUT will allocate a nominated professional to fulfil this 
role, in general practise (but not exclusively) this tends to be allocated to a consultant 
psychiatrist of the MHLT based within Southend University Hospital. 

EPUT and MSE have a Service Level Agreement, ref number: MSE-558-A Mental Health Act 
Administration in place in order to support MSE in compliance with the Mental Health Act and 
achieve best practise for service uses in relation to Mental Health Act. The allocation of 
Responsible Clinician by EPUT is confirmed by point 3.5.2 page 15 of this document.  

Concern b)  

Patients admitted onto a ward at the acute Trust detained under various sections of the Mental 
Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, 
there is no Responsible Clinician allocated for a vulnerable patient being held pending 
assessment for consideration for detention under the Mental 
Health Act. 

Response: 

The Mental Health Act 1983 Code of Practice at paragraph 36.1 refers to the identification of 
Responsible Clinician for patients being assessed and treated under the Act (i.e. section 2 for 
assessment and treatment, section 3 for treatment).  There is no mention of the need for the 
identification of a Responsible Clinician requirement for patients who are subject to a holding 
power under section 5 (2).  It is therefore respectfully submitted that the Trust adhered to the 
above provisions when applying the requirements of the Mental Health Act 1983 to the care 
and treatment of Mr Deeley. 

As set out in evidence by EPUT during the course of this Inquest; a patient is placed on a 
section 5(2) MHA by the Acute Trust, there is a requirement for the mental health liaison team 
at EPUT to be informed to ensure that appropriate mental health support is in place. 

In order to strengthen collaborative working across the two Trusts, a project group for 
development of the ‘joint protocol’ is being put into place.  The first meeting with attendees 
from both Trusts has been arranged for 23rd September 2024 

Further, whilst the project group takes forward the joint protocol work, EPUT’s Mental Health 
Act office continues to deliver training to MSE which includes the support available and role of 
the Mental Health Liaison team.   

The service matron is currently review this training package in order to ensure there that clear 
and specific information is cascaded in relation to roles and responsibilities of the Acute Trust 
as well as the role of the Mental Health Liaison team. 

We are advised that MSE leads are in the process of reviewing the ‘Admission and treatment 
of Mental Health Patients with a Mental Health Disorder in an acute hospital setting’ policy.   

 
 
 
 
 
 
 
 
 
 
  
 In support of the collaborative approach that both Trusts are taking forward, the service matron 
has confirmed with MSE leads that EPUT will be supportive of an active role in the ratification 
of this policy. Further, the EPUT Mental Health Liaison Service Operational Policy has been 
updated to include the support and advice to acute providers regarding risk management of 
patient’s presenting as requiring assessment under the Mental Health Act 2007. A  Standard 
Operating Procedure (SOP) was presented at the Liaison Services steering group on the 30th 
July 2024, final copy for comments has been circulated for comments by 5th August 2024; the 
Policy is now due for final ratification.  

By way of information, this SOP contains the following provisions: 

-  Where a referral is made to the Mental Health Liaison Team; there is a requirement 

that they respond within the following timeframes:    
  Emergency: 1 hour 
  Urgent: 4 hours 
  Routine: 24 hours. 

The SOP will be shared with the Acute Trust once it has been ratified; and on request, with 
your Court.   

Concern c)  

During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute 
ward or make assessment of the presenting risks of self-harm. 

Response: 

In line with the above assurances, training has been tightened in respect of the awareness of 
the need for Mental Health Liaison to be promptly be made aware by the Acute Trust of all 
patients that have been placed on a section of the Mental Health Act to ensure appropriate 
support is in place for the patient as well as our Acute colleagues.  Where urgent immediate 
attendance is required this will be facilitated in line with the protocols detailed above. 

Further, as set out above a joint working protocol that clearly outlines the responsibilities of the 
Acute Trust when placing a person on a section of the Mental Health Act is being put into 
place.   

Concern d)  

The acute care healthcare professionals do not have specialist mental health training to 
conduct a mental health assessment and the consequential presenting harm. 

Response: 

Where there is a concern relating to a person’s mental health, Acute clinicians are required to 
ensure that there is a prompt referral made to Mental Health Liaison team, who will respond in 
line with the above provisions.  The Mental Health Liaison Team will duly attend to assess and 
provide support to the patient and Acute colleagues to ensure risks are managed within the 
environment that they are being treated.  

The above provision will be included with the MSE mental health lead is reviewing the 
Admission and Treatment of Patients with a Mental health Disorder in an Acute Hospital 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Setting again EPUT’s Senior Management Team will provide in-put and support in terms of the 
ratification of this Policy 

Concern e) 

There was confusion at the acute Trust as to what regime was required to ensure that a 
patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust 
policy was confusing and did not cover patients like Aaron Deeley. 

Response: 

With respect to the Learned Coroner, the answer to this particular concern will be for the Acute 
Trust to respond to.  However, by way of completeness, the planned updates to the Mental 
Health Liaison Service Operational Policy will include provisions around support and advice to 
Acute providers regarding care planning and risk management.  

Concern f) 

There is no joint protocol to cover the working between the two Trusts on this issue as the 
referral for Mental Health Act assessment goes outside of both organisations. There is a 
lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous 
physical healthcare when a significant risk has been identified such that a patient may require 
detention for their own safety 

Response: 

There is a Mental Health Act Service Level Agreement (SLA) is in place between EPUT and 
MSE.  EPUT provides an administration service that supports MSE in the administration of the 
Mental Health Act.  The SLA supports MSE by undertaking a robust scrutiny of the section 
documentation to ensure that the patients are detained lawfully and where amendments which 
can be amended under the Act are done so within the required timelines. The SLA supports 
the MSE staff when a patient appeals to the Mental Health Tribunal or Hospital Managers 
against detention under the Act to ensure appropriate reports are requested and submitted in 
a timely manner. The SLA provides each detained patient with a Responsible Clinician. 

Again a Joint Working Protocol is also being put into place. 

In light of this Regulation 28 Report, a review of the Mental Health Liaison SOP has been 
undertaken.  The SOP now provides a clearer direction for the Mental Health Liaison Team 
staff to support and assist patients and acute colleagues in the management of patients who 
are awaiting formal assessment under the Mental Health Act.  With Mental Health Liaison Staff 
particularly supporting in the identification and management of risk. The recent review of this 
SOP is being shared with all MHLT staff in order to ensure awareness and consistency 
throughout the service. 

The SLA between MSE and EPUT, as well as the management and responsibility of the 
Mental Health Act assessments is being addressed at a senior level – with all escalations and 
concerns now having the benefit of senior oversight.  

I hope that I have provided reassurances around the steps that we have taken to address the 
issues of concern contained within your report. We appreciate that there is an acute need to 
embed and effect change, hence we will monitor the above provisions to ensure these are 
contributing to our overall aim of keeping patents safe and delivering therapeutic care. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Please do let me know if you require any further information at this stage, including copies of 
any of the documents referred to above. 

We Trust that your Court will share, as standard, a copy of this reply with Mr Aaron Deeley’s 
family 

Yours sincerely 

Chief Executive

H.M Area Coroner 
Ms Sonia Hayes 
SEAX House 
Victoria Road South 
Chelmsford 
Essex 
CM1 1QH 

Our Ref: 

13 August 2024 

Dear Ms Hayes 

Regulation 28 Report to Prevent Future Deaths- Aaron Deeley 

I write further to your Regulation 28 Report to Prevent Future Deaths (PFDR) dated 19th 
June 2024, relating to the Inquest of Mr Aaron James Deeley 

Thank you for this opportunity to share the improvements we have made since the tragic 
death  of  Mr  Deeley.  We  know  that  sadly,  increasing  numbers  of  our  acutely  unwell 
patients also face mental health challenges, and this is an important area of focus for us.  

We  have  carefully  considered  the  specific  areas  of  concern  arising  from  Mr  Deeley’s 
Inquest and I have set out below our response to each matter raised. 

Matters of Concern 

While a patient is admitted to an acute Trust ward for treatment for physical health 
treatment  and  is  being  held  under  section  5  (2)  Mental  Health  Act  for  a  Mental 
Health Act assessment due to concerns the patient presents a risk to themselves 
or others with a mental disorder, it permits the patient to be held for a maximum 
period of 72 hours. 

a)  Patients admitted into the Accident & Emergency department detained under 
various  sections  of  the  Mental  Health  Act  have  a  Responsible  Clinician 
allocated.  Patients  who  are  not  under  section  have  access  to  the  Mental 
Health Liaison Team. 

If  a  clinician  is  concerned  about  a  patient's  mental  health  whilst  in  the  Emergency 
Department (ED), the Mental Health Liaison Team (MHLT) is available 24 hours a day 
and 7 days a week to provide support. The MHLT are responsible for prioritising referrals 
as they receive them, and there are escalation routes in place for the ED team if required. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We have recently reviewed our policy ‘MSEPO-21231 Admission & Treatment of Patients 
with a Mental Health Disorder in an Acute Hospital Setting’ which reinforces the mental 
health support available to patients whilst in ED and inpatient wards.  

The policy includes clear and practical guidance for staff setting out how to access the 
MHLT and when to escalate concerns. 

b)  Patients  admitted  onto  a  ward  at  the  acute  Trust  detained  under  various 
sections of the Mental Health Act have an allocated Responsible Clinician. 
As section 5 (2) is a holding power only, there is no Responsible Clinician 
allocated  for  a  vulnerable  patient  being  held  pending  assessment  for 
consideration for detention under the Mental Health Act. 

& 

c)  During the waiting period of up to 72 hours, Mental Health Liaison will not 

attend the acute  ward or  make  assessment  of  the  presenting risks  of self-
harm. 

We recognise the legislation does not require a patient to have a ‘responsible clinician’ 
allocated whilst they await assessment. During this time, it is the ward's responsibility 
to risk assess the patient and maintain their safety. We know this can be challenging, 
especially when both acuity and patient flow is high. 

The wards are advised to refer to the MHLT when they have concerns about a patient’s 
mental  health  and  associated  risk(s).  We  are  encouraging  staff  to  have  early 
conversations  with  the  MHLT,  and  where  possible,  a  discussion  with  a  psychiatrist 
before the application of a Section 5(2), working towards holistic and collaborative risk 
assessments. I am advised that the MHLT are routinely advising ward staff on how 
best to support patients. 

A key management tool for staff caring for acute patients with mental health needs is 
our  ‘MSEPO-21228  Policy  for  Enhanced  Supervision  and  Engagement’.  We  have 
therefore made several improvements to this policy to provide more practical guidance 
and support for staff during this important time while patents await assessment. We 
have also delivered training to nursing colleagues in relation to the updated policy and 
refreshers on record keeping standards so that staff are appropriately skilled in how 
to complete the supervision paperwork correctly. 

All ward managers are empowered to escalate to senior managers if a patient requires 
additional mental health support. We are accessing Registered Mental Health Nurses 
where  needed  to  maintain  patient  safety,  and  we  are  confident  that  managers  are 
escalating these patients appropriately. 

 
 
 
 
 
 
 
 We acknowledge that our pathway documentation for patients detained under Section 
5(2) needed reform. We have therefore added a new flowchart to our ‘Admission & 
Treatment  of  Patients  with  a  Mental  Health  Disorder  in  an  Acute  Hospital  Setting’ 
Policy. A copy of the flowchart is attached for reference.  

Our new training sessions cover the practical application of this flowchart with worked 
examples for staff to understand the correct route to treatment for patients. We are 
confident that staff attending the training are clear on the steps they should take to 
maintain patient wellbeing and safety, whilst awaiting formal assessment. 

We  share  your  concerns  that  the  MHLT  may  not  attend  the  acute  ward  or  make 
assessments of the presenting risks of self-harm. There may of course be instances 
where it would be inappropriate to attend upon an acutely unwell patient and conduct 
such formal mental health assessments. For example, when a patient is unconscious 
or intoxicated. However, there are instances when our team feel MHLT support would 
benefit the patient prior to them being ‘medically fit.’ 

We have listened to this concern, and we feel this is a key topic for us to take forward 
with EPUT in our future working arrangements. As you will be aware, the MHLT service 
is  commissioned  by  our  local  Integrated  Care  Board  (ICB),  and  there  exists  a 
contractual  arrangement  between  the  ICB  and  Essex  Partnership  University  Trust 
(EPUT). 

We have taken the lead with organising a joint working group with the ICB, EPUT and 
ourselves to discuss this issue as well as the mental health services provided to us, 
as a whole, to make sure we are getting this service right for our patients. 

The joint working group will meet for the first time on 23 September 2024, and senior 
colleagues will set out terms of reference including the sequencing of assessments for 
patients with both a mental and physical health need; a written service level agreement 
so that staff are clear on when to ask for support, and when to expect it; a document 
setting our clear roles and responsibilities for staff at both trusts. 

We  are  confident  we  have  the  right  colleagues  attending  this  meeting  to  make 
important decisions about improving the standard of mental health care for patients in 
our hospitals.  

d)  The acute care healthcare professionals do not have specialist mental health 
training  to  conduct  a  mental  health  assessment  and  the  consequential 
presenting harm. 

 
 
 
 
 
 
 
 
 
 
 
 
 As an acute trust we cannot expect all staff to be able to conduct comprehensive mental 
health assessments and associated risk assessments, this is a service  that EPUT are 
contracted  to  provide.  However,  staff  must  be  trained  to  identify  when  mental  health 
assessments are required, and all staff should know when a patient is at risk of harm, to 
themselves or others. 

We have therefore employed a Mental Health Lead Nurse tasked to review our current 
policies, processes, and training needs. They are already working closely with  partner 
agencies to strengthen current practice and increase staff knowledge.  

Training has been delivered to Heath Care Assistants by the Mental Health Lead Nurse 
targeted on enhanced supervision skills, how to gain greater awareness of mental health 
issues, and how to engage meaningfully with patients and offer support. 

We  have  also  recently  developed a  rolling  training  programme  with  EPUT  so  that our 
staff can learn from the experts, and develop their skills and confidence delivering de-
escalation techniques, therapeutic engagement, risk assessment, awareness of warning 
signs, triggers and environmental hazards and risk management. 

The training is delivered by EPUT on a three-weekly basis to cohorts of MSE staff and 
this will continue indefinitely. 

In  addition  to  staff  training,  improvements  have  already  been  made  to  policies  as 
discussed above, and we are keeping our training needs under review. 

e)  There was confusion at the acute Trust as to what regime was required to 
ensure  that a  patient  awaiting  Mental  Health  Act  assessment  could  be  put 
under  1:1  observation.  The  Trust  policy  was  confusing  and  did  not  cover 
patients like Aaron Deeley. 

Section 5 of our Policy for Enhanced Supervision and Engagement has been re-written 
in  collaboration  with  the  Mental  Health  Lead  Nurse  to  clearly  set  out  the  criteria  that 
should be met for a patient to trigger for enhanced supervision. 

Appendix 4 of our ‘Admission & Treatment of Patients with a Mental Health Disorder in 
an  Acute  Hospital  Setting’  provides  further  guidance  on  assessing  individuals  with  a 
decision-making flowchart included (attached). 

f)  There is no joint protocol to cover the working between the two Trusts on 
this issue as the referral for Mental Health Act assessment goes outside of 
both organisations. 

It is a key priority for us to develop a robust joint protocol with EPUT, and this will be the 
first order of business at our meeting in September 2024. 

 
 
 
 
 
 
 
 
 Our vision is that patients in our hospital should have access to appropriate and timely 
mental  health  care  in  parallel  with  their  acute  treatment;  many  patients  may  not  be 
medically fit, but they are well enough to receive mental health support, and we know the 
sooner they have this, the better. We are committed to working with EPUT to develop a 
collaborative patient centered approach. 

There  is  a  lacuna  for  patients  awaiting  Mental  Health  Act  assessment  and 
requiring  simultaneous  physical  healthcare  when  a  significant  risk  has  been 
identified such that a patient may require detention for their own safety. 

We have delivered training so that staff are able to identify patients such as this, and we 
have improved our policies and guidance to make sure patients are carefully supervised 
when needed. We would be happy to supply full copies of the new policies if this would 
provide further assurance. 

We  now  have  clear  escalation  routes  to  senior  colleagues  who  can  access  external 
support, for example Registered Mental Health Nurses, when the ward team are unable 
to meet the patient’s needs, or the risks mean that extra help is needed. I am aware these 
practices are happening, and we are appropriately managing and mitigating risks. 

Further, we have important work to do with our colleagues at EPUT to develop a clear 
joint working protocol. We have a plan, and the right colleagues involved in this project 
to make this happen. 

We hope that the action we have taken, and the plans we have in place have provided 
assurance  that  your  concerns  are  being  addressed.  However,  if  you  have  any  further 
concerns or you would like to discuss this case further, please do not hesitate to contact 
me. 

Yours sincerely 

on behalf of 
Chief Executive 
Mid and South Essex NHS Foundation Trust 

Enc  

 
 
 
 
 
 
 
 
 
 
 
 
 
                                                                             
 Section 5(2) process                           

On admission staff should: 
-Record a detailed description of the patient and maintain a record of their clothing. 
-Utilise the MSE Enhanced Supervision Policy to assist in decision-making regarding necessary supervision level.  
-Record past risk history and current concerns e.g., patient is voicing suicidal ideas.  
-Refer to Mental Health Liaison Team at earliest opportunity. Request support and review if risk increases; this may reduce further escalation and the need    
for Sec 5(2) 

For Section 5(2)  
Patient (Adults and 
Children) must be 
considered to:  

1.  Have a mental 
disorder.  

2.  Be at risk of harming 
self or others.  
3.  Patient must be 
unwilling to stay 
informally. 

4.  Does not apply to A&E 

or Outpatients 

If patient is identified as needing to be 
detained on a Section 5(2) and agreed by 
the Clinical team. The form H1 must be 
fully completed.  

The Doctor must complete Part 1 and 
Nursing staff must complete Part 2 of form 
H1. The specific date and time must be 
recorded within the clinical notes when 
this detention started.  

Matron/ward manager/Nurse in charge to 
develop appropriate care plan and arrange 
enhanced supervision.  

Within the first 2 hours of detention, the 
Mental Health Liaison Team must be 
notified: 
Broomfield: 

Basildon: 

Southend: 

Ward staff/Doctor are responsible to send 
H1 form to the Mental Health Act Office: 

This must be sent within 3 hours.  
A copy of the form must be retained in 
patients’ record. 

Ward staff must make every effort to 
ensure the patient is aware of their rights 
and provide the ‘rights leaflet’ and 
document in patients’ notes. 

The leaflet can be found here:  
RIGHTS AND RESPONSIBLITIES OF NEAREST 
RELATIVE UNDER THE MENTAL HEALTH 
ACT 1983 (nationalarchives.gov.uk) 

The Mental Health Liaison Team (within 72 hours of detention):  

➢  To review and decide if a full Mental Health Act assessment is required.  
➢  The Liaison Team Psychiatrist may review the patient and decide to 

discharge from Section 5(2). The patient is then “informal” (voluntary 
patient) again.  

During the detention of Section 
5(2) a patient requires physical 
health treatment: 

➢  Adult patients - seek consent.  
➢  Children - seek consent from 

patient/parent/ 
appointed keyworker. 

If there is any doubt of patients’ 
capacity (16 and over) complete a 
Mental Capacity Assessment. 

If under 16 arrange an urgent 
MDT.  

If lacks capacity, follow Trust’s 
MCA Policy MSEPO-21103/ 
seek advice from the Safeguarding 
Team/ 
Legal Team if necessary: 

In an urgent situation, 
to save a life or prevent 
serious harm to a patient 
if it is reasonably 
believed that a patient 
lacks capacity, treatment/ 
care must be provided. 

Appendix 1: MSEPO-21231 Mental Health Policy Section 5(2) Flowchart 23/05/2024

Ms Sonia Hayes 
Area Coroner for Essex 
Essex and Thurrock Coroner’s Service 
Essex County Council  
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH  

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

11 September 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Aaron James Deeley who 
died on 14 January 2022  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  19 
June  2024  concerning  the  death  of  Aaron  James  Deeley  on  14  January  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to  Aaron’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Aaron’s care 
have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  to  Aaron’s  family  or  friends.  I  realise  that 
responses to Coroner Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones and appreciate 
this will have been an incredibly difficult time for them. 

Your  Response  raised  the  concern  that  that  there  is  a  lacuna  for  patients  awaiting 
Mental Health Act assessment and requiring simultaneous physical healthcare when 
a significant risk has been identified, such that a patient may require detention for their 
own safety. My colleagues in the National Adult Mental Health Team at NHS England 
have reviewed your Report and concerns and they have input into this response.  

National guidance on urgent and emergency Liaison Mental Health Services for adults 
states that liaison mental health teams should “be proactively involved in the person’s 
treatment and be ready to provide mental health input as soon as the person is able 
to be seen. This should not be just a request to be notified when the person is declared 
medically cleared, which can often lead to undue delays in the pathway.” The guidance 
is also clear that within four hours of arriving in an Emergency Department (‘ED’) or 
being referred from a ward, it is recommended that the person should have received 
a full biopsychosocial assessment and have an urgent and emergency mental health 
care plan in place.  

Section 5(2) of the Mental Health Act 1983 gives relevant clinicians the ability to detain 
a  patient  in  hospital  for  up  to  72  hours,  during  which  time  they  should  receive  an 
assessment that decides if further detention under the Mental Health Act is necessary. 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
  
 The  fact  that  someone  is  subject  to  a  section  5(2)  detention  and  is  in  receipt  of 
treatment for a physical health condition, which means that they need to remain under 
the  care  of  the  acute  trust,  should  not  prevent  the  liaison  mental  health  team  from 
providing ongoing support for that individual and advice to wider ED staff on approach 
to care and treatment.  

Your  Report  also  raised  concerns  over  the  policy  at  Mid  &  South  Essex  NHS 
Foundation  Trust  (MSEFT)  for  observation  of  patients  awaiting  Mental  Health  Act 
assessments,  and  that  there  was  no  joint  protocol  between  MSEFT  and  Essex 
Partnership University NHS Foundation Trust (EPUT) addressing the issue of referrals 
for  Mental  Health  Act  assessments.  We  note  that  you  have  also  addressed  your 
Report to these Trusts, and we have been sighted on their responses. We note the 
actions  that  have  been  taken,  including  the  organisation  of  a  joint  Working  Group 
between MSEFT, EPUT and Mid and South Essex Integrated Care Board to address 
the concerns raised about joint protocol and ways of working.  

I  would  also  like  to  provide  further  assurances  on  the  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 events, such as the sad death of Aaron, 
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