Nathan Scantlebury

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1 Department for Health and Social Care
2 Department for Education
3 NHS England

1

CORONER

I am Charlotte KEIGHLEY, Assistant Coroner for the coroner area of Cheshire

2

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3

INVESTIGATION and INQUEST

On 02 October 2019 I commenced an investigation into the death of Nathan Tesla George
SCANTLEBURY aged 16. The investigation concluded at the end of the inquest on 15 July
2024. The conclusion of the inquest was that:

Nathan Tesla George Scantlebury died as a consequence of asphyxia following a
The
intended the outcome to be fatal.

event was a deliberate act but it cannot be established on the evidence that he

.

Nate’s death was contributed to by:-

i.

ii.

A failure to take appropriate steps to ensure Nate’s safety when the
was first observed and whilst it was still loose; and
Neglect

Nate’s death was possibly contributed to by:-

i.

ii.

iii.

iv.

The lack of availability generally of suitable placements for children with
complex mental health needs.
Failures by the Local Authority and the Clinical Commissioning Group to
adequately assess the suitability of the placement to meet Nate’s needs;
A lack of understanding by the local authority and the clinical commissioning
group of the way in which the model of care used in the placement worked in
practice and whether this would meet Nate’s needs.
Failings by the clinical commissioning group and the local authority to ensure
that a s117 after-care plan was in place to ensure that all professionals involved
in Nate’s care were aware of their respective role and responsibilities

4

CIRCUMSTANCES OF THE DEATH

Nathan Scantlebury was just 16 years old at the time of his death. He had a complex
mental health needs and was a looked after child, having been so since December 2013.

Nate had a significant history of self-harm and spent several periods detained under the
Mental Health Act. Nate had previously been placed at a placement in Wales, specialising in
providing care to Young People with high risk self-harming behaviours. Following a serious
incident in August 2018, Nate was detained under the Mental Health Act with the placement

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

 considering they could no longer keep him safe.

Following a period of detention, the only placement available for Nate was in a mainly adult
service, with a least restrictive approach adopting a therapeutic risk-taking and recovery-
based approach. The service provided care for those aged between 16 and 25.

During the course of Nate’s placement, a number of concerns were raised in respect of the
suitability of the service for Nate, with a number of self-harming incidents taking place
which required hospital treatment.

On the 25th September 2019, Nate tied a

around his neck, initially the

was loose and Nate was left whilst advice was obtained. Nate was later found laid

on his bed, blue in colour and unresponsive with the

tight around his neck. The

was removed and Nate’s physical observations taken with further advice being
sought and observations taken prior to an ambulance being called. Nate was taken to
hospital and pronounced deceased a short time later.

5

CORONER’S CONCERNS

During the course of the investigation my inquiries revealed matters giving rise to concern.
In my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:

The lack of availability of suitable placements for high risk children with complex mental
health needs which is both a local and a national issue which has been ongoing for a
number of years.

6

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe your
organisations have the power to take such action.

7

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by September 17, 2024. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.

8

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons

Liverpool City Council

Cheshire and Merseyside Integrated Care Board (Liverpool)

I have also sent it to

Child Safeguarding Practice Review Panel

who may find it useful or of interest.

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

 I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.

I may also send a copy of your response to any person who I believe may find it useful or
of interest.

The Chief Coroner may publish either or both in a complete or redacted or summary form.
He may send a copy of this report to any person who he believes may find it useful or of
interest.

You may make representations to me, the coroner, at the time of your response about the
release or the publication of your response by the Chief Coroner.

9

Dated: 23/07/2024

Charlotte KEIGHLEY
Assistant Coroner for
Cheshire

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

From 

Parliamentary Under-Secretary of State for    
Patient Safety, Women’s Health and Mental Health  

39 Victoria Street   
London   
SW1H 0EU   

17th September 2024  

Our ref: 

Mrs Charlotte Keighley  
Assistant Coroner  
Cheshire Coroner’s Court 
Museum Street 
Warrington  
Cheshire  
WA1 1JX  

By email: 

Dear Mrs Keighley,   

Thank you for the Regulation 28 report of 23 July 2024 sent to the Department of Health and 
Social  Care  about  the  death  of  Nathan  Tesla  George  Scantlebury.  I  am  replying  as  the 
Minister with responsibility for Patient Safety and Mental Health.        

Firstly,  I  would  like  to  say  how  saddened  I  was  to  read  of  the  circumstances  of  Nathan’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  lack  of  suitable  placements  available  for  high  risk 
children with complex mental health needs.   

In  preparing  this  response,  my  Departmental  officials  have  made  enquiries  with  NHS 
England and Cheshire and Merseyside Integrated Care Board and I understand that NHS 
England  will  address  your  concerns  in  more  detail  in  its  response.  We  will  work  with 
colleagues at NHS England to ensure the appropriate steps are taken to avoid a repetition 
of this tragedy.  

As your report highlights, the number of mental health inpatient beds required to support a 
local population is dependent on both local mental health need and the effectiveness of the 
whole local mental health system in providing timely access to care and supporting children 
with  complex  mental  health  needs  like  Nathan  to  stay  well  in  the  community,  therefore 
reducing the likelihood of an admission being necessary. I am committed to ensuring this 
Government acts to ensure patients have access to community services and instances like 
this one can be prevented.   

The model of inpatient mental health care is being re-designed to enable the move to a  
more  community-based  provision  of  care,  where  children  and  young  people  can  access 
appropriate mental health support in a timely, effective, and person-centred way, at home or 
close to home and in the least restrictive environment.   

 
    
  
   
  
  
  
 
  
  
  
   
   
  
   
  
  
 As part of our mission to build an NHS that is fit for the future, we will recruit an additional 
8,500 mental health workers to reduce delays and provide faster treatment which will also 
help ease pressure on busy mental health services. To help reduce the lives lost to suicide, 
these new workers will be specially trained to support people at risk. More broadly, we will 
modernise  the  Mental  Health Act  to  give  greater  choice,  autonomy,  enhanced  rights  and 
support, and ensure everyone is treated with dignity and respect throughout treatment.  

I am advised by colleagues in NHS England and Cheshire and Merseyside (Integrated Care 
Board that the local provision of suitable placements for children with complex mental health 
needs  remains  a  key  focus  for  the  ICB.  Its  intentions  to  design  and  develop Appropriate 
Places of Care where there are gaps in its current support offer for children and young people 
with the most complex needs are set out in its Children and Young People’s Mental Health 
Plan for 2024-26 - NHS Cheshire and Merseyside, published in August 2024, and which is 
available at: Children and Young People’s Mental Health Plan for 2024-26 - NHS Cheshire 
and Merseyside.  

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

Yours sincerely,

Ms Charlotte Keighley 
Assistant Coroner for Cheshire  
The West Annexe 
Town Hall 
Sankey Street 
Warrington 
Cheshire  
WA1 1UH 

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

12 September 2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Nathan Tesla George 
Scantlebury who died on 25 September 2019 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 23 July 
2024  concerning  the  death  of  Nathan  Tesla  George  on  25  September  2019.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Nathan’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Nathan’s 
care have been listened to and reflected upon.   

Your Report raised the concern over the lack of availability of suitable placements for 
high risk children with complex mental health needs, both at a local and national level.  

Significant improvements are underway nationally to develop the Children and Young 
People’s Mental Health (CYPMH) inpatient pathways. Care being provided close to 
home has seen a reduction in the number of young people placed inappropriately out 
of their local area. Natural clinical flows (NCF) aim to ensure that a young person is 
only  placed  away  from  their  local  area  when  this  can  provide  the  right  therapeutic 
outcome. For Children and Young People (CYP), it is important that every step is taken 
to avoid this given the impact on families, carers, links to school and social networks. 
In March 2022, there were 145 CYP outside of NCF and, in March 2023, there were 
128 CYP outside of NCF.  

NHS  England  has  sought  to  improve  the  availability  of  local  inpatient  care  for  CYP 
through a number of actions:   

•  The introduction of NHS-Led Provider Collaboratives which are key enablers 

• 

for bringing the care of CYP closer to home.    
Investing capital and revenue funding into localised inpatient and alternative to 
inpatient provision over a three-year period.  

•  The NHS Operational Planning Guidance 2022/23 outlined the need for Mental 
Health Provider Collaboratives and Integrated Care Systems (ICSs) to ensure 
the  provision  of  General  Adolescent  and  Psychiatric  Intensive  Care  Units  to 
meet the needs of their local population.   

                                                                                                                       
 
 
 
 
 
 
  
 
 
  
 The  CYPMH  Clinical  Reference  Group  has  developed  an  inpatient  strategy  which 
provides  an  evidence  base  to  support  services  when  considering  their  workforce 
challenges and team composition. A new Youth Intensive Psychological Practitioner 
pilot (YIPP) is now entering its third year and in partnership with Exeter University has 
established  roles  in  inpatient  Multi-Disciplinary  Teams  (MDTs)  to  complement  the 
team.  There  has  been  a  refresh  of  the  Care  (Education)  and  Treatment  Review 
(CETR) policy, and an escalation policy has been agreed with all  NHS-Led Provider 
Collaboratives and regional teams.   

In addition to steps taken to localise care and reduce reliance on inpatient care, we 
have  seen  the  establishment  of  many  intensive  alternative  to  admission  models 
introduced by NHS-Led Provider Collaboratives and Integrated Care Boards (ICBs), 
which support CYP to be cared for in the least restrictive environment and close to 
home.  Examples  include  the  establishment  of  day  units,  strengthened  intensive 
support and outreach teams, paediatric liaison and improved thresholds for admission 
and gatekeeping to actively avoid admissions.   

The CYP’s National Quality Improvement Taskforce has delivered improvements to 
mental health, learning disability and autism inpatient services for CYP, with a wide 
range of initiatives that co-designed and co-delivered 39 change projects across CYP 
inpatient services to support local improvements.  

In 2022, NHS England (NHSE) commissioned a new Quality Improvement Programme 
and  one  of  its  priorities  was  to  undertake  a  review  of  the  CYP’s  inpatient  model, 
recognising the continued pathway pressures and quality and safety challenges. The 
review included how our English model compares internationally, the views of children, 
young  people  and  their  families  and  requests  from  local  teams  to  work  together  to 
improve  the  model  of  care.  The  findings  of  the  evidence  review  presented  and 
consolidated a future vision for CYPMH inpatient care, and now forms the cornerstone 
of  the  CYPMH  Transformation  Programme,  which  has  resulted  in  a  review  of  the 
service specification and the development of a new clinical model, which considers 
the needs of  a  young person  across  the  whole  pathway  of  care. Support has been 
provided  to  local  systems  and  Provider  Collaboratives  to  plan  a  timeline  for 
implementing the change, coupled with implementation support as requested.    

Children  and  young  people’s  mental  health  interventions  can  take  place  in  many 
contexts and will depend on the clinical needs of the child as to whether interventions 
are delivered in the community, whilst the child is in a placement, or in an inpatient 
setting. NHSE are working with the Department for Health and Social Care (DHSC) 
and Department for Education (DfE) to ensure that the needs of children in different 
settings are met fairly and equitably.   

The NHSE strategy is to reduce reliance on mental health inpatient beds and to have 
fewer young people being detained under the Mental Health Act (MHA). To support 
this, the model of inpatient care is being re-designed to enable the move to a more 
community-based provision of care, where CYP can access appropriate mental health 
support in a timely, effective, and person-centred way, at home or close to home and 

  
 https://digital.nhs.uk/services/national-care-records-servicein 
environment.    

the 

least 

restrictive 

It  is  also  recognised  that  for  some  CYP,  admission  to  hospital  will  not  be  the  most 
appropriate way to meet their needs. This has been a focus of the transformation of 
CYPMH and continues to be a priority in the NHS Long Term Plan.    

A guidance document for CYP has been co-written with multi-agency partners, which 
specifically includes the role of the Approved Mental Health Professional (AMHP) and 
the legal requirements of the Mental Health Act process, and whether it is clinically 
appropriate for the young person to be admitted for assessment and treatment. This 
aims to ensure that any use of the MHA in crisis is reviewed before detaining a young 
person. 

My regional colleagues in the North West have also been engaging with NHS Cheshire 
& Merseyside (CM) ICB on the concerns raised in your Report. We are advised that 
the  local  provision  of  suitable  placements  for  children  with  complex  mental  health 
needs remains a key focus for the ICB. Its intentions are set out here: Children and 
Young People’s Mental Health Plan for 2024-26 - NHS Cheshire and Merseyside. 

The new model of care includes: 

•  Place  Based  Gateway  meetings  to  ensure  appropriate  support  when  needs 
change  or  escalations  to  prevent  admission  to  care,  custody  or  inpatient 
settings.  

•  Development of a Complex Needs Escalation Tool.  
•  A THRIVE framework focused on getting advice, help and risk support. This is 
needs-led  by  CYP  and  families  alongside professionals  (see  page  7  of  the 
plan). 

•  System  wide  priorities  for  the  ICB  for  timely  access,  crisis  response, 

appropriate places of care and specialist mental health.  

•  Development of cross organisational data set to explore the rising prevalence 

of complex mental health.  

•  System wide stakeholders to develop appropriate places of care.  
•  Support and development for mobilisation of appropriate places of care.  

My North West colleagues have requested further information from CM ICB regarding 
the actions taken following the death of Nathan, as part of their assurance purposes.  

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 
Nathan, 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