Jagjeet Singh

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

39 Victoria Street   
London  SW1H 0EU   

23 December 2024  

Our Ref: 

Melanie Sarah Lee  
Assistant Coroner  
Inner North London St 
Pancras Coroner’s Court  
Camley Street  
London   
N1C 4PP  

Dear Ms Lee  

Thank you for your Regulation 28 report to prevent future deaths dated 4 November 
2024 about the death of Jagjeet Singh. 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 Jagjeet’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.   

I understand your concerns about a bed on the mental health ward not being available 
for Mr Singh when he was discharged from the medical wards. I note that you have 
also  addressed  these matters of  concern  to the  Chief Executive  of  NHS  England.  I 
look  forward  to  seeing  her  response  and  working  with  NHS  England  where 
appropriate, to avoid a repetition of the tragic events of this case.  

I recognise the impact that a suitable bed not being available can have on a patient’s 
care, as exemplified in Jagjeet’s case.  

I am sure you will appreciate that 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  people  to  stay  well  in  the  community,  therefore  reducing  the 
likelihood of an inpatient admission being necessary.  

I expect individual trusts and local health systems to effectively assess and manage 
bed capacity, the ‘flow’ of patients being discharged or moving to another setting and 
the  availability  of  specialist  personality  disorder  rehabilitation  units.  I  recognise  that 
mental health services have been under significant strain in recent years due to the 
rise in demand.   

  
    
  
  
  
   
  
  
  
  
  
  
  
  
 Over the past few years, the NHS has been developing the community mental health 
framework with the aim of improving community support for people with severe mental 
illness, thus avoiding the need for an inpatient admission where possible and freeing 
up more beds.   

NHS  England’s  2024/25  priorities  and operational planning guidance  reinforces  this 
focus on improving patient flow as a key priority – with local health systems directed 
to reduce the average length of stay in adult acute mental health wards to deliver more 
timely access to local beds. And in areas where there is a clear need for more beds, 
this has been addressed in part through investment in new units.  

It  is  also  important  that  when  people  are  discharged,  this  happens  in  a  way  that 
considers their needs on discharge and any risks to their safety.  To help support safe 
and timely discharge decisions, the Department published statutory guidance on  
Discharge from mental health inpatient settings in January 2024 and which is available 
at: Discharge from mental health inpatient settings - GOV.UK  
(www.gov.uk).   This  sets  out  how  health  and  care  systems  should  work  together  to 
support  safe  discharge  from  all  mental  health  and  learning  disability  and  autism 
inpatient settings for children, young people and adults.   

As part of our mission to build an NHS fit for the future, we will make sure more mental 
health  care  is  delivered  in  the  community,  close  to  people’s  homes,  through  new 
models of care and support, so that fewer people need to go into hospital.  

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

Yours sincerely,

Ms Melanie Sarah Lee 
Assistant Coroner 
Inner North London 
St Pancras Coroner’s Court  
Camley Street 
London 
N1C 4PP 

Dear Coroner, 

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

24 December 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Jagjeet Singh who died 
on 8 March 2024  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  4 
November 2024 concerning the death of Jagjeet Singh on 8 March 2024. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my deep condolences to Jagjeet’s family and loved ones. NHS England are keen to 
assure the family and the Coroner that the concerns raised about Jagjeet’s care have 
been listened to and reflected upon.   

Your Report raises concerns over a chronic shortage of inpatient mental health beds, 
both within the London region and nationally. In relation to Jagjeet’s care, you have 
raised that a bed on the mental health ward should have been available for him when 
he was discharged from the medical ward. 

The number of mental health 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 people to stay well in the 
community, therefore reducing the likelihood of an admission being necessary.  

In  some  local  areas  there  is  a  need  for  more  beds,  this  is  being  addressed  in  part 
through  investment  in  new  units  and  additionally  as  part  of  a  whole  system 
transformation  approach.  This  was  supported  by  the  NHS  Long  Term  Plan  (LTP), 
which saw an additional £2.3 billion funding invested in mental health services from 
2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and 
acute mental health services to help people get quicker access to the care they need 
and prevent avoidable deterioration and hospital admission.  NHS England’s 2024/25 
priorities and operational planning guidance reinforces this focus on improving patient 
flow as a key priority – with systems directed to reduce the average length of stay in 
adult acute mental health wards in order to deliver more timely access to local beds.  

To  address  the  wider  system  issues  that  impact  on  health  services,  a  further  £1.6 
billion has been made available via the Better Care Fund from 2023-25. This funding 
can be used to support mental health inpatient services as well as the wider system 
which should help to reduce pressures on local inpatient services, so that those who 
need to access beds can do so quickly and locally. 

                                                                                                                       
 
 
 
 
 
 
  
 
 
  
 This is being supplemented by a further £42 million recurrent investment from 2024/25 
for all Integrated Care Boards (ICBs) in the country to recommission inpatient care, in 
line with local models that provide the best evidence of therapeutic support. 

My  Clinical  Quality  regional  colleagues  in  London  are  engaging  with  North  East 
London  Integrated  Care  Board  on  the  concerns  raised  in  your  Report  and  system 
arrangements for mental health inpatient beds.  

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 
Jagjeet, 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,  

Professor Sir Stephen Powis   
National Medical Director