Mark-Anthony Summersett

Our Ref: GF 

3 March 2025 

Mr J Turner 
Area Coroner for West Sussex, Brighton and Hove 

Dear Mr Turner 

Worthing Hospital 
Trust HQ 
Lyndhurst Road 
Worthing 
West Sussex 
BN11 2DH 
Tel: 01903 205111 
www.uhsussex.nhs.uk 

RE: Regulation 28: Report to Prevent Future Deaths:  Mark SUMMERSETT 

I write to formally acknowledge receipt of the Regulation 28 report to prevent future deaths and to 
respond to your matters of concern.  Please be assured that the report has been considered by the 
Medicine Division Leadership and operational team (Worthing, St. Richards and Southlands), and also 
Trust wide across the four main UHSx hospital sites with the Medicine, Specialist, Surgical, and 
Cancer Divisions who manage all the wards and Emergency Departments (EDs).  

Please find below the response to your concerns raised, which I hope will give the assurance required 
that the Trust has fully reviewed and communicated the current processes to be followed following 
absence of a patient to reduce the likelihood of a similar incident occurring again.   

There was a lack of information sufficiency, flow and sharing across the agencies whilst he 
was present in, and at and after the point he left the ED, which might have enabled greater 
efforts to locate, contact and more urgently treat him.  

Following the investigation report into Mr Summersett’s attendance and suicide in February 2024, I 
would firstly confirm that the two key actions in the action plan (support for triage at times of high 
demand and handover from police to Trust staff) have been addressed. 

Since this incident in February 2024, the Trust has undertaken a large amount of work in relation to its 
processes around missing persons from wards or EDs.  This has also been as a response to the Right 
Care and Right Person National Programme (RCRP) and changes to the Police response to following 
up Welfare checks (Phase 1), and Missing Persons (phase 2), and also later phases (3 & 4) of 
reduction to conveyances and time spent in hospital with those under s136. 

Over the past 12 months (January 24 – January 25) Worthing ED has had 199 patients recorded on 
their electronic system who have absconded from the department (range between 6 – 22 per month).  
Of these from the electronic records we are aware that 51% (102 patients) were referred for police 
follow up.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Prior to May 25th when the RCRP missing persons became live across Sussex, the referrals to police 
for follow up were between 50 – 75% per month and post Phase 2 go-live, the EDs have reduced the 
referrals to police, in line with the referral criteria for only critical concern/high-risk patients to be 
referred to between 40 – 50% (1 month only).  Prior to the policy change the ED had referred patients 
to the police considered medium to high risk, and this has now changed to only those of critical 
concern/high risk. This risk is assessed on a case-by-case basis prior to referral and after liaison with 
Sussex Partnership NHS Foundation Trust (SPFT) as first line, to review any existing mental health 
history, prior to calling police.  If there is any doubt in whether to refer or not to the police, they will 
refer, for police to decide whether they will follow up.  

The Divisional Directors of Nursing for both medicine divisions, together with the Managing Director for 
Urgent/unplanned care, have attended the system wide meetings led by the Sussex ICB, to represent 
the Trust with system partners, SPFT, Police, Local authority (AMHP service) and East Sussex Health 
Care NHS Trust (ESHT).  These commenced early 2024 and have continued throughout last year and 
into 2025, with working groups still ongoing for both missing persons and s136 phases.  

The Trust has fully reviewed and revised the Missing Persons policy, with more information around the 
required processes in relation to patients who are at risk of absconding, and actions to be taken when 
patients do leave.   This was done collaboratively across primarily the medical divisions and ED 
teams, but also with the other Divisions.  There is detailed information around the legal principles and 
powers available to staff to detain and prevent patients from leaving (Mental Health Act and Mental 
Capacity Act) alongside more detailed information about the police response to missing persons, and 
criteria of those patients of critical concern who they will respond to.   There are clear guidelines, flow 
charts and documentation to be used for the assessment of vulnerable patients, a process if concern 
are intending to leave and once have left.  This includes the communication needed to patient, next of 
kin (NOK), and other system partners who may or may not be involved in the patient’s care pathway or 
management plan, and police involvement if deemed at high risk.  The new policy also highlights that 
any patient self-presenting to ED will be escalated directly by the receptionist to the triage or nurse in 
charge to ensure early review regarding risk and follow up.   

The policy essential documentation and guidelines therein, were circulated to all wards and EDs 
before May 25th when phase 2 of RCRP was introduced across Sussex, and the main documents and 
flow charts to be used sent as separate, ready to hand information.    These were further recirculated 
in Q2 (following slight update/ minor amendments to the policy early September, which included the 
system escalation responses) to ensure there was a renewed focus for clinical teams. 

There was also trust wide communication to all staff as part of the Trust’s “Theme of the Week” in 
December 2024, where targeted information is shared at daily safety huddles across all the clinical 
areas for a week.  This included key points around managing patients who have absconded, who 
should be contacted, documentation and follow up via incident reporting. 

The Divisions of Medicine have continued to work collaboratively with SPFT colleagues over the year 
reviewing ED documentation (reviewing assessments of both triage and Mental Health Liaison Team 
(MHLT), enhanced observation processes, and the communications between the EDs and the 

 
 
 
 
 
 MHLTs).  There will be a further review and update to the documentation following a further meeting 
planned in early March 2025. 

There has been ongoing discussion with Sussex Police since October with regard to the handover 
process of patients when conveyed to ED by the police (outside of s136 process), to ensure this is 
robust and any such patient is handed over directly to an ED nurse when booking in at reception, so 
they can be immediately reviewed and prioritised for triage assessment.   The police have developed 
a handover form (draft copy can be sent if required). This has taken 3 months to finalise and take 
through police governance processes and is being taken for ratification by the police service on March 
5th.  Once this is able to be used this will greatly help with pre-hospital information about the vulnerable 
person and aid ongoing risk assessments and follow up, especially in a scenario should the patient 
leave before being seen by MHLT.  

The RCRP missing persons working group is also working on a pan Sussex poster for ED waiting 
rooms to encourage patients not to leave without seeking advice from reception or ED personnel and 
also information for external help and support services. This is currently being reviewed by Experts by 
Experience (EbEs) and, once more feedback has been received by them, the poster will be designed 
and used in all EDs. 

Further work being undertaken in the ICB wide missing persons group will be commencing with regard 
to how to proceed with a whole system policy ‘Missing from Emergency Department’.  Trust senior 
nursing staff will continue to work collaboratively in these groups to ensure these pieces of work are 
taken forward for UHSx.  

Since May 2024, UHSx have worked further with Sussex Police to review missing patients who have 
been referred to police for follow up post absconding.  Daily reports are sent to the hospital nurse 
directors, medicine divisional directors of nursing, and ED matrons/heads of nursing, in order to review 
the patients, to confirm if request for police follow up was appropriate in terms of risk of patient or not, 
and also to share any feedback and learning.  

The Trust has commenced on the Royal Sussex County Hospital and Princess Royal Hospital sites a 
fortnightly meeting to discuss cases with senior nurse leads/ED, police, SPFT and security teams 
present.  This is helping to inform learning and improve processes and communication between all 
system partners.  Similar meetings will be set up for Worthing Hospital and St Richard’s Hospital sites 
to facilitate the same shared learning and improvements in processes. It is hoped these can 
commence in March 2025.  

Post coroner’s inquest, the Divisional Director of Nursing for Medicine, Worthing, has further followed 
up with lead in SPFT for Worthing site, and having reviewed the guidelines produced for MHLT 
colleagues, has developed some similar bullet point guidelines for wards and EDs for quick easy 
reference, and is recirculating these across the Trust with the key flowcharts and missing person 
documentation from the policy.  This will provide further quick reference laminated guidance at point of 
care to help staff at the time when faced by an absconding patient, to ensure correct processes are 
followed to promote the patient’s safeguarding to reduce potential harm after leaving the department.  
This can be provided as evidence should HM Coroner request this.     

 
 
 
 
 
 
 The ED at Worthing has also commenced a ‘streaming’ model at the front door during the day, i.e a 
nurse situated within the reception area to help with capacity and redirection of some patients away 
from ED and into Urgent treatment centre or Same day emergency care services.  As well as providing 
immediate brief assessment by a nurse at point of booking in, this will reduce numbers waiting to be 
seen by the ED team, and both of these improvements should assist with prompt risk assessment of 
MH patients self-presenting, and also the time to first triage and MH risk assessment.  Both issues for 
ED in this sad case.  

I hope the above information provides HM Coroner with the assurance that UHSx has learnt from this 
extremely sad incident, and that there are processes in place and embedded across our EDs and 
wards with the aim to reduce the likelihood of such harm happening in the future.  We will continue to 
work collaboratively with ongoing improvements with colleagues in SPFT and the Police in order to 
improve the pathway of care for these patients.   

Yours sincerely  

Chief Executive