Morgan Betchley

Ms Lisa Milner  
Assistant 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 

27 February 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Morgan Rose Betchley 
who died on 9 March 2022 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  2 
January  2025  concerning  the  death  of  Morgan  Rose Betchley on 9  March  2023.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Morgan’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Morgan’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  Morgan’s  family  or  friends.  I  realise  that 
responses to Coroners’ Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them. 

Your  Report  raises  the  concern  that  there  is  no  policy  or  guidance  to  staff  for  the 
assessment of risk posed by fixtures and fittings to patients with acute mental health 
needs at Sussex Partnership NHS Foundation Trust (SPFT).  

NHS England’s Culture of Care Standards for inpatient mental health settings clearly 
set  out  the  importance  of  relationships  between  staff  and  patients  being  built  on 
openness and trust. Positive relationships between staff and the people they support 
are  fundamental  to  a  person-centred  care  environment,  and  we  know  that  trusting 
therapeutic  relationships  are  the  strongest  predictor  of  good  clinical  outcomes  for 
people receiving mental health care. 

NHS England’s Culture of Care Programme includes focused work on moving away 
from  risk  stratification  as  predictor  of  risk  and  supporting  organisations  to  use  a 
personalised  safety  planning  approach.  We  recognise  the  delicate  balance  of 
supporting people to stay safe from self-harm and suicide, whilst ensuring the least 
restrictive practices are used and people’s human rights are protected. In addition to 
this, we are planning some future work in response to the upcoming Health Services 
Safety Investigations Body (HSSIB) investigation into creating conditions for learning 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
  
 from deaths in mental health inpatient services that will further define what is meant 
by the therapeutic relationship and how to promote and harness this within services. 

NHS England has also engaged with NHS Sussex Integrated Care Board (ICB), the 
responsible commissioner for SPFT’s inpatient mental health services, regarding the 
concerns raised in your Report. We have been sighted on the Trust’s Serious Incident 
Report and note that a number of actions have been identified as a result of the review 
of  Morgan’s  care.  These  include  raising  awareness  with  staff  of  the  importance  of 
updating care plans and therapeutic observations, with care plan audits in place, and 
ensuring that care plans are updated promptly following any incidents. An action was 
also taken to develop a training package for urgent care pathway and inpatient teams 
to  increase  awareness  of  the  needs  and  risks  associated  with  care  experienced 
individuals. The ICB has provided assurance to NHS England that they are seeking 
updates from the Trust on all actions identified in the report. We note that you have 
also addressed your Report to SPFT and will consider their response to the Coroner 
once we have been sighted on this.   

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 
Morgan, 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

27 February 2025 

Ms Lisa Milner 
Assistant Coroner 
Coroner Service: West Sussex, Brighton and Hove 
Parkside Chart Way 
Horsham, RH12 1XH 

Office of the Chair & Chief Executive 
Trust Headquarters 
Portland House 
44 Richmond Road 
Worthing 
West Sussex 
BN11 1HS 

Sent Via Email: 

Dear Ms Milner 

I write in response to your Regulation 28 report dated 2 January 2025 raising your concern 
about  the  risk  posed  by  Trust  fixtures  and  fittings.  I  am  grateful  to  you  for  raising  your 
concern and sharing the particular evidence that you heard during the Inquest touching the 
sad death of Morgan Betchley.  

Firstly, I wish to extend my sincere condolences to Morgan's family and friends. I know that 
the  Inquest  into  Morgan's  death  lasted  two  weeks  which  must  have  been  an  extremely 
difficult experience for her family and friends. That said, I hope that the thoroughness of the 
Inquest, together with this response will provide them with answers as well as assurances 
as to the improvements made in the last two years. 

I understand you are concerned about the extent of the Trust's policy/guidance in relation to 
Trust fixtures and fittings because of the risk that they may pose if not removed from patients 
who may utilise them as a means of taking their own life. 

I am informed that you have already been confidentially provided with a copy of the Trust's 
Ligature Anchor Point Risk Reduction Policy (the 'Policy'), for your personal assurance. The 
Policy provides the Trust-wide guidance in relation to the elimination, reduction and control 
of  ligatures  and  anchor  points  in  in-patient  settings.  I  understand  that  you  have  been 
expressly advised that the Policy is not, and must not be, available on our public website 
due to the patient safety risks associated with it being in the public domain. I should also 
add  that  restricting  the  accessibility  of  the  Policy  is  in  accordance  with  NHS  England's 
National Patient Safety Alert 2020/01, publication of which is also restricted, but confirmation 
of its existence and general information about Patient Safety Alerts can be found here: NHS 
England » Our National Patient Safety Alerts. 

As you will have seen, the Policy covers the risk posed by fixtures and fittings and how that 
risk  is  managed,  with  emphasis  on  the  need  for  comprehensive  risk  assessment,  safety 
planning  and  therapeutic  observations.  I  understand  that  you  heard  evidence  during  the 
Inquest about how, in practical terms, clinicians dynamically risk assess and manage risk, 
yet are unable to completely remove all risk.  Notably, the Policy specifically states that: 

Chair: 

                                                                                   Chief Executive: 

Head office: Sussex Partnership NHS Foundation Trust, Portland House,  
44 Richmond Road, Worthing, West Sussex, BN11 1HS 

A teaching trust of Brighton 
and Sussex Medical School 

 
 
 
 
                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 'The  Trust  recognises  the  need  to  balance  clinical  risk  management  against  issues  of 
privacy, dignity and the need to take positive therapeutic risk'.  

I understand that bedding and curtains were of  particular concern to you during Morgan's 
Inquest. It must be recognised, that whilst these are items that could be used as a ligature, 
or cause other harm, they are also necessary for comfort, dignity and privacy and I agree 
with the evidence you heard at Inquest that it is not, and should not be, routine practice to 
remove these items. The expected practice, in line with the Policy, is that the potential risk 
posed  by  items  must  be  individually  and  dynamically  risk  assessed,  and  the  risk 
incorporated into the patient's individualised risk assessment. So, in response to a significant 
risk  of  harm from  ligature,  enhanced observations  can  be  put  in place,  or,  in exceptional 
cases,  following  comprehensive  risk  assessment,  anti-ligature  clothing  is  available. 
However,  these  are  restrictive  interventions  which  can  only  be  used  if  they  are  the  least 
restrictive practice. 

Whilst  the  Policy,  that  was  in  place  two  years  ago,  did,  and  does,  cover  assessing  and 
removing items, following receipt of your Regulation 28 report revisions to Appendix 6 of the 
Policy  have  been  made,  with  specific  inclusion  of  bedding  and  curtains.    The  revisions 
expressly reference bedding and curtains as items to be considered during the assessment 
of items in a patient's bedroom that could potentially be used as a ligature.  The Appendix 6 
revisions are currently progressing through the Trust's policy ratification processes and will 
be incorporated into the Policy once ratification is completed, expected to be by the end of 
March.  However, I enclose a draft copy of the revised Appendix 6 for your assurance; for 
the patient safety reasons set out above, this must not be more widely shared.  

As an immediate measure, following receipt of your Regulation 28 report, a Patient Safety 
Briefing was circulated to ward staff to highlight your concern and to reinforce compliance 
with the Policy, specifically, the necessity to undertake comprehensive risk assessment to 
ensure patients can safely be allowed access to items of risk including their own clothes, 
bedding,  towels,  curtains  etc.    I  enclose  a  copy  of  that  Patient  Safety  Briefing  for  your 
assurance and, again, for the patient safety reasons set out above, this must not be more 
widely shared.  

For  completeness,  I  confirm  that,  refreshed  ligature  risk,  assessment  and  awareness 
training was launched in July 2024.  I understand that you have already been provided with 
details of the training package and, further, I can now confirm that the training will become 
mandatory in April 2025. 

Regarding  other  fixtures  and  fittings,  I  understand  that  you  heard  significant  evidence  in 
relation to the new anti-ligature alarmed bedroom doors and I am pleased to confirm that 
installation  is now complete on  Rowan Ward,  with  work having now  also  commenced on 
Maple Ward.  As you will be aware, work on other Trust sites is dependent on the needs of 
the particular site and is also subject to funding being secured.   
For  ongoing  assurance,  I  confirm  that  the  Trust  has  a  Trust-wide  ligature  group  which 
oversees all ongoing improvement works relating to ligatures and ensures all ward staff are 

 
 
 
 
 
 
 
 
 fully aware of the ligature risks in their areas, through a consistent and standardised use of 
heat maps, photos and other resources to pinpoint ligature risks.  That group considers and 
learning  and  on-going 
responds 
improvement.  

to  enable  cross-organisational 

incident  data 

to 

Thank you for raising your concern and bringing it to my attention.  I hope that the contents 
of this response provide you and Morgan's family with assurance that action has been taken 
to  address  the  concern  and  that  the  Trust  has  procedures  in  place  to  continue  to  make 
ongoing  improvements  to  maintain  patient  safety.  However,  if  I  can  be  of  any  further 
assistance to you, please do not hesitate to contact me. 

Yours sincerely  

Chief Executive