Matthew Sheldrick

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

39 Victoria Street  
London  
SW1H 0EU  
020 7210 4850  

Our Ref: 

Penelope Schofield  
Senior Coroner for West Sussex, Brighton and Hove  
County Records Office,   
Orchard Street,   
Chichester,   
PO19 1DD 

Dear Ms Schofield  

 04 March 2025  

Thank you for your Regulation 28 report to prevent future deaths dated 16 December 
2024 about the death of Matthew Zak Sheldrick (Matty). 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 Matty’s 
death  and  I  offer  my  sincere  condolences  to  their  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 lack of inpatient beds leading to unacceptable wait 
times in A&E for those experiencing mental ill health. In Matty’s case, this meant that 
a bed was not found for them within a 26-day period. You also expressed concerns 
that the environment  in A&E  as  a holding  place  is not  conducive  for those  who are 
neurodiverse, including autistic people, and can exacerbate their mental health issues.  
I also understand your concerns regarding a gap in services for those who do not meet 
the criteria for detention under the Mental Health Act but who are too high a risk to be 
sent home.  

In  preparing  this  response,  my  officials  have  made  enquiries  with  NHS  England  to 
ensure we adequately address your concerns.   

I am sure you will appreciate that the number of mental health inpatient beds required 
to  support  a  local  population,  including  people  who  are  also  neurodiverse  and  non 
binary/transgender,  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.   

 
 
  
 
   
  
  
  
  
  
  
  
  
 2025-26 Planning Guidance contains fewer targets across the board to focus on the 
fundamentals of good care. It sets a requirement for Integrated Care Boards to take 
action to reduce the average length of stay in adult acute mental health beds, improving 
local bed availability and reducing the need for inappropriate out of area placement, 
and to reduce waits longer than 12 hours in A&E through making use of alternatives 
described below.   

•  Reducing  avoidable  ambulance  dispatches  and  conveyances,  and  reduce 
handover  delays  by  working  towards  delivering  hospital  handovers  within  15 
minutes, with joint working arrangements that ensure that no handover takes longer 
than 45 minutes and improving access to urgent care services at home or in the 
community  including  urgent  community  response  (UCR)  and  virtual  ward  (also 
known as hospital at home) services  
Improve  and  standardise  urgent  care  at  the  front  door  of  the  hospital  by 
increasing the proportion of patients seen, treated and discharged in 1 day or less 
using the principles of same day emergency care (SDEC) and optimising the urgent 
care offer to meet the needs of their local population, including the use of urgent 
treatment centres (UTCs)  

• 

•  Reduce length of stay in hospital and ensure that patients are cared for in 
the most appropriate setting by increasing the percentage of patients discharged 
by  or  on  day  7  of  their  admission  in  line  with  existing  guidance. Additionally,  by 
working across the NHS and local authority partners to reduce average length of 
discharge  delay  in  line  with  the  Better Care Fund  (BCF) policy  framework.  ICBs 
should  review  BCF  commitments  to  ensure  they  represent  the  best  use  of 
resources,  and  plan  sufficient  intermediate  care  capacity  to  meet  demand, 
including through surge periods across the year  

As part of our mission to build an NHS fit for the future , we need to focus treatment 
away  from  hospital  and  inpatient  care  and  improve  community  and  crisis  services, 
making  sure  more  mental  health  crisis  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.  NHS England is already piloting the 24/7 Neighbourhood Mental 
Health Centre model in England, building on learning from international exemplars. 6 
early  implementors  are  bringing  together  their  community,  crisis,  and  inpatient 
functions into one open access neighbourhood team which is available 24 hours a day, 
7 days a week. This means people with mental health needs can walk in or selfrefer 
as can their loved ones and system partners.  

Anyone in England experiencing a mental health crisis can now to speak to a trained  
NHS professional at any time of the day through a new mental health option on NHS 
111. Trained NHS staff will assess patients over the phone and guide callers with next 
steps  such  organising  face-to-face  community  support  or  facilitating  access  to 
alternatives services, such as crisis cafés or safe havens which provide a place for 
people to stay as an alternative to A&E or a hospital admission. The new integrated 
service can give patients of all ages, including children, the chance to be listened to 
by a trained member of staff who can help direct them to the right place. These crisis 
lines currently take around 200,000 calls a month.  

As announced in the Budget, we are committing £26 million in capital investment to 
open new mental health crisis centres, reducing pressure on busy A&E services and 
ensuring people have the support they need when they need it.  

  
  
  
  
 Mental Health Response Vehicles have also been established in order to see and treat 
patients away from Accident  and  Emergency.  New  integrated operational pressures 
escalation  levels  (OPEL)  scoring  systems  have  also  been  established  for  mental 
health,  enabling  greater  transparency  and  escalation  of  risks  across  mental  health 
pathways. We have committed £26 million in capital investment to open new mental 
health crisis centres, reducing pressure on busy emergency mental health and A&E 
services and ensuring people have the support they need when they need it.  

I also note your concerns about the sensory environment of A&E departments for those 
who  are  autistic  and  regarding  significant  wait  times  for  referral to  assessment  and 
treatment services. 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.   

In November 2023, NHS England also published guidance on ‘Meeting the needs of 
autistic adults in mental health services’, which sets out 10 principles to help mental 
health  services, 
including  crisis  services,  provide  high-quality  assessment, 
intervention and support to autistic adults who have any mental health symptoms or 
conditions  and  provides  practical  examples  of  how  this  may  be  achieved.  This 
guidance highlights that local services should recognise that emergency departments 
can be intrinsically overwhelming and distressing for autistic people.   

We are also taking action to increase awareness and understanding of autism amongst 
healthcare  professionals.  Under  the  Health  and  Care  Act  2022,  service  providers 
registered with the Care Quality Commission (CQC) are required to ensure their staff 
receive learning disability and autism training appropriate to their role. To support this, 
we are rolling out the Oliver McGowan Mandatory Training on Learning Disability and 
Autism. Over 2 million people have now completed the e-learning module, which is the 
first part of the training.   

NHS  England  is  also  rolling  out  further  training  for  staff  working  in  mental  health 
services to upskill staff in supporting autistic people in contact with those services. This 
includes a National Autism Trainer Programme which is co-designed, coproduced and 
co-delivered  with  experts  by  experience,  based  on  a  ‘train-the-trainer’  model  and 
promotes  an  experience-sensitive,  trauma-informed  approach.  This  training  is 
progressing across a range of children and adult mental health services. In addition, 
NHS  England  has  commissioned  the  Royal  College  of  Psychiatrists  to  deliver 
foundation and enhanced autism training for psychiatrists, which is aimed at upskilling 
psychiatrists  across  both  specialist  and  mainstream  settings  to  improve  health 
outcomes for autistic people.  

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.   

  
  
  
  
  
  
 I note that you have also addressed your matters of concern to NHS England and I 
look forward to seeing its response and working with NHS England where appropriate, 
to avoid a repetition of the tragic events of this case.  

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

Yours sincerely,

Penelope Schofield 
HM Senior Coroner,  
West Sussex, Brighton & Hove 
Record Office,  
Orchard Street 
Chichester 
PO19 1DD 

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

24 February 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Matthew Zak Sheldrick 
who died on 4 November 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  16 
December 2024 concerning the death of Matthew Zak Sheldrick (known as Matty) on 
4 November 2022. In advance of responding to the specific concerns raised in your 
Report, I would like to express my deep condolences to Matty’s family and loved ones. 
NHS England are keen to assure the family and the Coroner that the concerns raised 
about Matty’s care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to respond to your Report, and I 
apologise for any anguish this delay may have caused to Matthew’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 Report raises concerns about the service provision and availability of services 
for  patients  suffering  with  their  mental  health,  and  the  appropriateness  of  the 
Emergency  Department  as  an  environment  for  people  who  are  autistic  and/or 
neurodiverse to be held as they await a mental health bed. My response to the Coroner 
addresses  the  issues  raised  that  sit  within  NHS  England’s  national  policy  and 
programme remit.  

Shortage  of  mental  health  inpatient  beds  and  unacceptable  waiting  times  in 
Accident and Emergency (A&E) for patients suffering with their mental health 
and for onward referrals. 

Increased waiting times for inpatient beds have been contributed to by longer stays in 
hospital and the length of time required to discharge patients who are clinically ready 
to  leave  hospital.  This,  alongside  a  48%  increase  in  referrals  to  community  crisis 
services since the pandemic, and despite the NHS Long Term Plan’s (LTP) expansion 
and transformation of these services, has affected how quickly patients can access 
local beds.  

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 The number of mental health beds required to support a local population is dependent 
on local mental health needs and the effectiveness of the whole local mental health 
system in providing timely access and care and supporting people to stay well in the 
community, therefore reducing the likelihood of a hospital 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, however, this should be considered as part of a whole 
system transformation approach. 

The  NHS  LTP  saw  an  additional  £2.3  billion  of  funding  invested  in  mental  health 
services  from  2019/20  to  2023/24,  around  £1.3  billion  of  which  was  for  adult 
community, crisis and acute mental health services to allow people to get faster access 
to  the  care  they  need  and  prevent  deterioration  and  hospital  admission  where  it  is 
avoidable. The NHS 111 mental health call option has also been established around 
the  country  to  support  reductions  in  A&E  attendance  and  Mental  Health  Response 
Vehicles  have  also  been  established  to  see  and  treat  patients  away  from  an  A&E 
setting.  New  integrated  operational  pressures  escalation  levels  (OPEL)  scoring 
systems have also been established for mental health, enabling greater transparency 
and escalation of risks across mental health pathways.  

NHS  England’s  2024/25  priorities  and  operational  planning guidance  continues  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.  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. 

Existing crisis services, such as liaison psychiatry services, local crisis resolution and 
home  treatment  (CRHT)  teams  are  also  in  place  to  help  support  people  suffering 
mental health crisis, but who do not meet the criteria for admission. Additionally, the 
Urgent and Emergency Care Recovery Plan has also set out that the NHS is investing 
an additional  £150 million  capital  funding  for  new  projects to  support  urgent mental 
health care and crisis response. This will also help to support people to be provided 
with  the  care  and  support  they  need  closer  to  home  and  reduce  the  number  of 
admissions to hospital. 

A&E is an unsuitable environment for autistic and/or neurodiverse people to be 
held  when  waiting  for  a  mental  health  bed.  There  is  a  lack  of  inpatient  bed 
provision for informal patients, in particular for those who are autistic and those 
who are transgender, requiring a mixed ward. 

Patients  attending  A&E  suffering  with  a  mental  health  crisis  remain  there  until  a 
suitable mental health bed can be found. Since the introduction of the Mental Health 
Crisis Care Concordat, investment was secured to provide 24-hour access to Liaison 
Psychiatry Services in 70% of hospitals in England by the end of 2023/24. On arrival, 
patients should receive a mental health triage assessment to determine the level of 
observation  they  require  and  where  they  should  be  placed  within  the  A&E 
department.   

 
 
 
 
 
 
 NHS  England’s  guidance  (NHS  England  »  Meeting  the  needs  of  autistic  adults  in 
mental  health  services),  which  is  aimed at  ICBs,  health  organisations  and  wider 
system partners, was published in December 2023. The guidance includes information 
in relation to accommodating people's sensory reactivity, which would also apply to 
acute healthcare settings, including:    

•  Helping people to self-manage their needs by providing information in advance 
about the layout and sensory environment of clinical spaces. This could be in 
the form of a video made available on the clinic website of the route from the 
car park to the treatment room. 

•  Offering  waiting  environments  that are  considerate  to  sensory  reactivity.  The 
NHS England sensory resource pack may be relevant. This includes the Green 
Light Toolkit which was designed to support service improvement. 

•  Providing resources to help autistic people cope with the sensory environment, 

such as sensory care bags in waiting rooms or on hospital wards. 

•  Assessing autistic adults’ sensory needs and recording identified adjustments 

in their health/communication passport. 

• 

If  a  waiting  room  environment  is  distressing  for  an  autistic  adult,  the  service 
should  offer  a  different  waiting  area  where  autistic  adults  have  more  control 
over the sound, light, temperature or smells, or it should arrange with the person 
where they would rather wait.  

Reasonable  adjustments  as  described  in  the  Equality  Act  2010 also  require  public 
sector  organisations  to  make  changes  in  their  approach or  provision  to  ensure  that 
services are accessible to all. 

Mixed 'sex' ward accommodation was eradicated in the NHS in 2010 and, in Matty's 
case, the Royal Sussex County Hospital would have deferred to their internal policy / 
guidance to admit Matty. NHS England cannot comment on the availability of inpatient 
accommodation at a local provider level.   

Local information 

NHS England’s South East regional colleagues have also engaged with NHS Sussex 
ICB, the responsible commissioner for the services described, on the concerns raised.  
We are advised that they have identified actions which include the provision of leaflets 
to  patients  and  carers  explaining  delays  in  access  to  mental  health  beds,  with   
information  and  signposting  to  support  lines  and  apps.  There  are  also  now 
arrangements in place to support escalation and clinical discussion of patient flow and 
referral reviews. The ICB have requested an update from the Trust on their action plan, 
following Matty’s death.  

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 Matty, 
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