Matthew Sheldrick

Ms Penelope Schofield 
Senior Coroner 
County Records Office 
HM Coroners Office 
Orchard Street 
Chichester 
West Sussex 
PO19 1DD 

10 February 2025 

Dear Mrs Schofield 

NHS Sussex 
Sackville House 
Brooks Close 
Lewes 
East Sussex 
BN7 2FZ 

Tel: 0800 433 4545 

E-mail: 

Website: www.sussex.ics.nhs.uk  

I write in response to your Regulation 28 report dated  16.12.2024 setting out your concerns after 
hearing evidence at the Inquest relating to the death of Matthew Zack Sheldrick. 

I  wish  to  begin  by  extending  my  sincere  condolences  to  Matty’s  family  and  friends.  The  inquest 
proceedings  must  have  been  an  extremely  difficult  time  for  them,  and  I  hope  that  my  response 
provides them and you with assurances that NHS Sussex Integrated Care Board (ICB) has taken 
action to address the issues set out in your Regulation 28 report. 

I address your concerns as follows: 

The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering 
with their mental health who are awaiting beds. In Matty’s case a bed was not found for them 
within a 26-day period.    

The role of the NHS Sussex is to commission services based on local needs, working with partners 
within the NHS, councils and voluntary sectors to deliver high quality care. NHS Sussex commissions 
Sussex Partnership NHS Foundation Trust (SPFT) to provide most of the mental health services for 
Sussex.  NHS Sussex commissions a comprehensive range of mental health and learning disability 
services from SPFT for all ages. This includes inpatient beds for children, adults and older people.  
Nationally,  there  has  been  an  increased  demand  on  mental  health  services  since  the  end  of  the 
COVID 19 pandemic and NHS Sussex recognises this demand locally.   

There are 493 adult inpatient mental health beds commissioned in Sussex (note, this relates only to 
adult  inpatient  beds,  and  it  should  be  noted  that  Sussex  Partnership  Foundation  NHS  Trust  also 
provide other inpatient beds such as forensic beds and child and adolescent mental health beds). 

This includes 453 delivered by Sussex Partnership and 40 beds in the independent sector. Of these 
453 beds, 302 are acute care beds, 91 are rehabilitation beds, 50 are dementia care beds and 10 
are specialist learning disability beds.  

By the end of March 2025, this will increase, including 27 acute beds (net increase 17). A business 
case for further beds in 2025-26, to ensure timely access to inpatient care when required, is being 
developed. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 To note, Sussex benchmarks above average for the number of beds in acute mental health wards 
for  benchmarked  areas  nationally  (as  of  31st  March  2023).  There  are  25  beds  per  100,000 
population in Sussex, compared to a national mean of 23, where the upper quartile is 27 and the 
lower quartile 17.4. This position does not change when looking at weighted population whereby in 
Sussex the beds per 100,000 weighted population is 23.3. compared to a national mean of 18.9. 

In Matty’s case it appears there was a lack of appreciation by the ICB of their extensive length 
of stay in A&E.  It appears that this information (and others who had lengthy stays) was not 
at that time being collected, monitored and acted on by the ICB.   

In 2021, NHS Sussex did not routinely capture information on the numbers of mental health patients 
waiting in emergency departments.  Since then, we  have improved our oversight of patients who 
have increased waits within A&E’s.  

Since 2023 high-level data (numbers not patient details) is now provided to NHS Sussex through a 
‘live’  reporting  system  called  SHREWD.  This  information  includes  patients  who  are  waiting  for  a 
mental health bed. The patient data is available across the system for use by Providers, ICBs and 
regional NHS England colleagues. 

All patients waiting for an inpatient mental health bed both within the community and hospital settings 
are clinically assessed by SPFT and are prioritise in accordance with their level of clinical risk. SPFT 
sets the criteria used to prioritise patients.  

Since  June  2024,  NHS  Sussex  has  received  improved  oversight  of  the  total  number  of  patients 
waiting for over 24 hours within the A&E Departments across Sussex. These individual high-level 
patient details are reviewed by a multi-disciplinary group at NHS Sussex who support an escalated 
conversation between the provider and the commissioners to support improvement and to support 
the  movement  of  patients  between  services  in  order  to  help  to  reduce  the  waiting  times  in  the 
Emergency Departments. From January 2025, there is an escalated Executive led system call with 
University Hospitals Sussex NHS Foundation Trust and other health and social care organisations 
on a twice weekly basis to support individual patient level escalations. The system will evaluate the 
effectiveness of this during Quarter 4, 2024/25.  NHS Sussex would therefore be aware of any patient 
experiencing an extensive stay in A&E in  2024 because that data is now captured and there is a 
clear system in place for escalation, monitoring and action. 

There being a shortage of beds for Autistic patients (both informal and detained) within the 
private  sector  that  are  being  funded  by  the  ICB.  Evidence  was  heard  that  those  providing 
beds  within  the  public  sector  very  often  refused  to  accept  autistic  patients  due  to  their 
additional risks.   

Providers are funded to deliver care to all patients including patients with protected characteristics.  
Protected characteristics include people with a learning disability and people with autism.  

There is no separate funding in Sussex for mental health beds for autistic people.  

SPFT, as the lead provider for mental health services across Sussex, manages the totality of the 
mental health inpatient bed capacity and commission additional independent providers to provide 
capacity. Each provider admits patients to the most appropriate bed to meet their need.  

In addition, NHS Sussex commissions the Transforming Care Autism Team (TCAT) to support with 
admission  avoidance,  discharges  facilitation,  care  and  treatment  review  and  clinical  advice  for 
autistic people at risk. They undertake assessments of individuals and their families, and develop 
care plans alongside the service user, their family and clinical team to manage ongoing risks. There 
is  regular  review  of  these  plans.  They  ensure  that  best  practice  is  embedded  in  care  and  that 
reasonable adjustments have been considered 

NHS Sussex has not had any formal reports that providers within the public or private sector are 
refusing  autistic  patients  due  to  their  additional  risks.  As  a  result  of  the  feedback  shared  during 

 
 
 Matty’s inquest, NHS Sussex will formally request a review of the use of all SPFT inpatient beds and 
subcontracted  inpatient  beds  to  provide  oversight  to  ensure  patients’  needs  are  accommodated 
appropriately,  including  autistic  patients.  This  will  be  formally  requested  at  the  Quality  Review 
Meeting in April 2025, which is a regular assurance meeting that takes place each month between 
NHS Sussex and each of the statutory providers in Sussex.  

There being a shortage of beds for transgender patients who are in need of a mixed ward.   

SPFT as the lead provider manages the inpatient bed capacity to best support the needs of all mental 
health patients in Sussex and they clinically prioritise accordingly. SPFT can flex their capacity on a 
gender basis within their overall number of beds.  

SPFT  offer  mixed  sex  beds  within  their  bed  base.  As  the  commissioners,  we  do  not  specify  the 
numbers of mixed sex beds as this is dependent on demand and capacity. NHS Sussex funds SPFT 
to also commission 40 additional independent sector beds, with an additional 12 interim independent 
sector beds commissioned for 2024/25.  

In  2011,  the  Department  of  Health  wrote  to  all  NHS  Chief  Executives  to  eliminate  mixed  sex 
accommodation  with  further  National  Guidance  in  2019  regarding  the  delivery  of  same-sex 
accommodation  to  prioritise  the  safety,  privacy  and  dignity  of  all  patients  with  a  move  to  ensure 
people  are  treated  where  possible  in  single  sex  wards.  Care  Quality  Commission  report  Sexual 
Safety on Mental Health Wards 2018 national guidance on reducing mixed sex accommodation on 
mental health wards in conjunction with other initiatives such as staff management of the physical 
environment and the use of therapeutic engagement. 

SPFT  where  possible  offer  single  sex  accommodation  to  safeguard  people’s  privacy  and  dignity. 
Where mixed sex accommodation is available men and women are in separate bays or rooms and 
have access to gender specific toilet and washing facilities. 

SPFT have a Mixed Sex Accommodation Policy Maximising Individual Dignity, which states where 
possible transgender patients are accommodated according to their preference (this may consider 
the pronouns that they currently use), with all transgender patients cared for in single rooms. NHS 
Sussex to undertake a review of the availability of mixed sex beds during quarter 1 2025/26 at the 
SPFT Quality Review Meeting.   

The unsuitability of the environment of A&E as a holding place for those in need of a mental 
health bed. The evidence was that the environment in A&E as a holding place is not conducive 
for those suffering with Autism and/or who are neurodiverse. The environment in A&E can 
exacerbate and cause further deterioration in their mental health.   

We  recognise  a  busy  A&E  is  a  challenging  environment  for  mental  health  and/or  neurodiverse 
patients. Reasonable adjustments can be made and alternative services to A&E are available for 
people in crisis. The escalation calls now in place should result in people with mental health needs 
who  may  also  be  neurodiverse  waiting  less  time  in A&E  so  that  it  is  not used as  a  holding  place 
although at times of increased demand it may still mean that some people have to remain in A&E for 
longer than we would like.  

NHS Sussex has no role in the set up or environment of an NHS Provider, however, updates are 
required for any new construction projects. For existing environments, it is the responsibility of NHS 
provider  organisations  to  ensure  they  follow  national  guidance  on  the  built  environment  and 
undertake national risk assessments.  

University Hospitals Sussex NHS Foundation Trust has an urgent and emergency care plan for each 
site where it delivers Emergency Department services. This includes investment, improvement, and 
innovations  that  will  help  provide  better  access  to  emergency  and  urgent  care  for  patients.    The 
Royal  Sussex  County  Hospital,  Brighton  has  started  a  £50  million  acute  floor  reconfiguration 
programme with support from patient engagement group, involving community organisation leaders 

 
 
 
 representing different demographics including neurodivergence, non-English speaking and physical 
disability, along with Healthwatch. 

There is a gap in services for those who are not ill enough to be detained but who are too 
high risk to be sent home. 

A number of community services are provided across Sussex to support people who require mental 
health crisis support which include Text Sussex (24 hrs support), Crisis Resolution Team and staying 
well services. These services have been developed over recent years based on national guidance. 

The Havens is an additional service provided across Sussex which provides a dedicated  24-hour 
mental health crisis assessment facility for people over age of 18 years.  

Following clinical assessment, a patient who is not detained under the Mental Health Act but remains 
high  risk  to  be  sent  home with community  services  support  could  be  recommended  for  voluntary 
admission to an inpatient bed.  

NHS  Sussex  will  ensure  SPFT  undertake  an  audit  of  potential  voluntary  admission  to  test  the 
pathway of services available. This will be delivered through quarter 1 2024/25. 

There  is  a  significant  wait  time  for  referral  to  the  Assessment  and  Treatment  Service. 
Therefore, any therapeutic input is delayed, and this results in repetitive attendances at A&E 
when in crisis.  

NHS  Sussex  has  oversight  of  all  performance  targets  and  waiting  times  and  has  assurance 
conversations monthly with SPFT. NHS Sussex has the overarching commissioning responsibility 
for  the  totality  of  the  contract  with  the  SPFT,  however  the  flexibility  within  the  services  is  the 
responsibility  of  the  Trust.  The  Trust  report  to  NHS  Sussex  on  performance  both  internally  and 
publicly and manage the risks within their services.  

NHS Sussex has not received a formal report from providers that there is a significant risk for referral 
to the Assessment and Treatment Service.  

NHS  Sussex  will  monitor the  waiting  times for  the Assessment  and  Treatment  Service  to  identify 
delays and manage improvement through the Quality Review meeting with SPFT. A monthly Quality 
Review  Meeting  is  held  with  the  SPFT  to  review  the  overall  safety,  experience,  and  clinical 
effectiveness of SPFT services as part of the NHS Contract. 

Current  gaps  in  service  around  psychosocial  support  for  transgender,  non-binary  and 
intersex adults have been provided by third party charitable organisations.  It is understood 
that  much  of  their  funding  has  recently  been  withdrawn  by  the  ICB.    This  is  of  particular 
concern  as  Brighton  is  recognised  as  having  one  of  the  largest  trans  communities  in  the 
Country  

NHS Sussex has funded specific engagement projects to hear from and listen to the Trans, Non-
Binary, or Intersex (TNBI) community via voluntary, community and social enterprise organisations. 
Through national health inequalities funding, there was specific funding for engagement to support 
Lived Experience insight for a Trans Healthcare Board in 2023-24.  The Board included members 
from  the  transgender  community.  This  was  so  that  NHS  Sussex  could  hear  from  the  community 
about their experiences of healthcare in Sussex. This was limited one-year national funding. 

NHS  Sussex  has  continued  funding  some  work  with  local  community  organisations  who  support 
TNBI  people  and  their  families,  to  make  sure  we  continue  to  listen  to  and  embed  the  lived 
experiences of this community into the services we offer. NHS Sussex has funded The Clare Project 
to  support  an  engagement  officer  role,  for  an  engagement  event  and  to  fund  some  targeted 
engagement for primary care materials  

 
 
 In 2022, we established a locally commissioned service (LCS) to ensure there was dedicated care 
and support in place.  Through this service, in the last year, more than 5,000 people received direct 
healthcare and prescribing support in its first year, and 1,000 of these also received further health 
checks, to ensure their specific health needs were being met by local services. Across Sussex, there 
are 101 GP practices signed up to provide this healthcare support and they will actively engage with 
their registered patients. The financial spend on activity for both parts of the LCS ‘prescribed and 
monitored’ and ‘annual review completed’ is increasing each year. 

Further to this, there is a Gender Identity Service and we have also continued funding to work with 
local community organisations who support TNBI people and their families, to make sure we continue 
to listen to and embed the lived experiences of this community into the services we offer. 

Thank you for bringing your concerns to my attention. I hope that we have provided you and Matty’s 
family with some assurance that NHS Sussex has taken steps to address the concerns outlined in 
your report and that we are continuing to take action to prioritise patient safety. 

Thank you for raising this matter with me and please contact me if I can be of any further assistance. 

Yours sincerely, 

Chief Nursing Officer  

On behalf of NHS Sussex