Sapphire Bernard

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

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

28 March 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Sapphire Kathleen 
Bernard who died on 30 October 2023  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  5 
February  2025  concerning  the  death  of  Sapphire  Kathleen  Bernard  on  30  October 
2023. In advance of responding to the specific concerns raised in your Report, I would 
like  to  express  my  deep  condolences  to  Sapphire’s  family  and  loved  ones.  NHS 
England are keen to assure the family and the Coroner that the concerns raised about 
Sapphire’s care have been listened to and reflected upon.   

Your Report raises concerns over the lack of available mental health inpatient beds 
and the unsuitability of Accident & Emergency (A&E) departments as a holding place 
for those people waiting for mental health admissions, particularly for patients who are 
also neurodiverse.  

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,  however,  this  should  be  considered  as  part  of  a 
transformational  approach.  This  is  supported  by  the  NHS  Long  Term  Plan  (LTP), 
which saw an additional £2.3 billion 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 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, 
supported by delivering the 10 high impact actions for mental health discharges. 

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 2023-2025. 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.  

Crisis services, including Crisis Resolution Home Treatments Teams, are available at 
short notice to help individuals resolve a mental health crisis or to support them while 
it is happening. Additionally, from this year, all mental health providers in England offer 
access to 24/7 age-appropriate crisis support via the NHS 111 ‘select mental health 
option’ – making it easier to seek help.  

NHS England’s ambition is not just to improve the access point and connection to the 
specialist mental health points of access, but to bring significant improvements and 
expansion in the mental health services that ‘sit behind’ the point of access, so that 
people can be facilitated to access support that meets their needs and preferences in 
a more timely way. To this effect, we are moving at pace and are beginning to measure 
response times to those presenting to urgent and emergency mental health services, 
either  in  the  community  and/or  emergency  departments,  with  the  aim  of  supporting 
these people to access appropriate care more quickly.    

NHS  England  recognises  the  unsuitability  of  emergency  departments  for  people 
experiencing  mental  health  crisis  once  their  immediate  physical  health  needs  have 
been  attended  to.  We  are  aware  of  the  increasing  numbers  of  patients  waiting  in 
emergency departments for mental health beds and, since the time of this incident, we 
have  introduced  national  level  monitoring  of  all  patients  in  emergency  departments 
waiting over 72 hours for mental health placements. Due to this oversight, individual 
patient cases are being escalated at a national level and executive input is then sought 
to expedite care. 

From Winter  2024/25 we  have  also  introduced action  cards for  trusts  and  systems, 
articulating key actions to be taken by trusts and systems to reduce the time patients 
spend  in  emergency  departments.  These  include  specific  actions  for  people  with 
complex learning disabilities and autism.  

NHS  England’s  South  East  region’s  Mental  Health,  Learning  Disability  and  Autism 
(MHLDA)  Team  are  in  the  process  of  developing  a  Standard  Operating  Procedure 
(SOP)  for  managing  mental  health  presentations  with  A&E  departments.  This  has 
followed  Quality  &  Safety  visits  to  A&E  departments,  which  have  concluded  that 
patients are safer being admitted. The SOP should be approved and finalised by April 
2025  and  findings  are  due  to  be  shared  with  South  East  ICBs,  as  well  as  multi-
disciplinary teams and the Urgent & Elective Care (UEC) Recovery Board.  

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 
Sapphire, 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

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

Tel: 0800 433 4545 

E-mail: 

Website: www.sussex.ics.nhs.uk  

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

2 April 2025 

Dear Ms Schofield 

Sapphire Bernard 

I write in response to your Regulation 28 report, dated 5 February 2025, setting out your 
concerns after hearing evidence at the Inquest in relation to the death of Sapphire Bernard.   

I wish to begin by extending my sincere condolences to Sapphire’s family and friends. The 
inquest proceedings must have been an extremely difficult time for them. 

I address your concerns as follows, following consultation with senior commissioners in the 
mental health team: 

The  lack  of  inpatient  beds  leading  to  the  unacceptable  wait  time  in  A&E  for  those 
suffering with their mental health who are awaiting a psychiatric bed.    
The  role  of  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  people  of  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  302  commissioned  acute adult  care  beds  and  40  Independent  sector beds.  In 
addition  to  the  40   acute  adult  beds  in  the  independent  sector  NHS  Sussex  and  Sussex 
Partnership commissioned an additional 14 beds between January- March 2025 to support 
winter pressures. These have now been extended for Quarter one 2025/26 taking the total 
number  of  acute  adult  beds  in  the  independent  sector  to  54.  Further  to  this,  SPFT  have 
redesigned their acute dementia ward in Brighton & Hove to support population need which 
will reopen in May 2025 as an adult ward and increase the SPFT bed base by 15 adult beds.  

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.    

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 NHS Sussex recognises that some people wait longer than we would like to access mental 
health  inpatient  care due  to patient  flow  and  acuity  of  patients,  NHS  Sussex are  working 
closely with partners to improve timely discharge to support prompt admission.         

In Sapphire’s case a bed was not found for her within a 19-day period.   
SPFT  Mental  Health  Liaison  Teams,  assess  patients  in  Emergency  Departments  and  on 
acute hospital medical wards and seek community alternatives for patients as a matter of 
routine.  These  alternatives  may  include  referrals  to  Crisis  Resolution  Home  Treatment 
Teams, Havens, Staying Well services (crisis cafes), Recovery Houses and Assessment & 
Treatment Services. Sapphire’s supported accommodation placement issued  notice on the 
9th October 2023 and therefore they could not return to their accommodation with community 
support. Sapphire was repeatedly clinically reviewed during their admission to East Sussex 
Hospitals  NHS  Trust  and  the  clinical  opinion  remained  that  they  required  inpatient 
psychiatric admission. Sapphire was issued with Section 17 leave to the hospital grounds 
whilst waiting for admission. 

At the end of October 2023 there were 71 patients waiting for acute inpatient care across 
Sussex-  the  Trust  manages  its  inpatient  provision  on  a  Sussex  wide  basis.  Additionally, 
there  were  115  patients  classified  as  Clinically  Ready  for  Discharge  which  is  25%  of  the 
Trust's acute in-patient bed provision 

To support an improved oversight of patients who have increased waits within A&Es and 
inpatient  wards  in  Sussex,  both  ESHT  and  SPFT  host  weekly  provider  calls  to  discuss 
patient flow with further escalation to NHS Sussex as required. Since 2023, NHS Sussex 
have  oversight  of  high-level  data  (numbers  not  patient  details)  provided  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. 

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.   
East  Sussex  Healthcare  NHS  Trust  (ESHT)  have  confirmed  that  Sapphire  arrived  in  the 
Emergency  department  at  19.54  on  2nd  October  2004.  Sapphire  was  moved  from 
Emergency department to Acute Admission Unit from 3rd – 20th October and then moved to 
De Cham ward on 20th October where they stayed until their discharge to SPFT inpatient 
services. ESHT’s policy supports the admission of patients awaiting mental health beds to 
acute inpatient beds to support patient experience. 

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

ESHT have developed a Mental Health Support Team in 2024, which includes a Head of 
Nursing  (HoN),  a  registered  Mental  Health  Nurse  (RMN)  and  11  Mental  Health  Support 

 
 
 
 
 
 
 
 
 
 Workers  (MHSWs).  The  HoN  commenced  employment  in  January  2025  with  ongoing 
recruitment to the MHSW posts. The MHSWs will work directly under the RMN to support 
and enhance close observational care of MH patients.  

The  primary  function  of  the  HoN  for  Mental  Health  is  to  act  as  a  subject  matter  expert, 
advisor and educator to the team at large. ESHT is working closer with SPFT to discuss 
ways in which to improve inter-organisational working: this includes accessibility of service, 
time to referral, time to be seen, time to Mental Health unit or to Section as necessary.  

ESHT is working to review and where appropriate to improve Mental Health patient safety, 
for example in the Mental Health rooms in A&E. NHS Sussex has no role in the set up or 
environment of an NHS Provider, however, updates are required for any new construction 
projects  as  part  of  the  Commissioning  process.  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.  

This is the second inquest that I have heard where a death occurred following a 
lengthy wait in A&E for a psychiatric bed.  In both cases the patients were 
transgender and had a diagnosis of autistic spectrum disorder. 

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

As background, SPFT offer mixed sex accommodation within bed base as  commissioners,  
NHS  Sussex  does  not  specify  the  numbers  of  mixed  sex  accommodation  as  this  is 
dependent on demand and capacity. In 2011, the  Department of Health wrote to all NHS 
Chief  Executives  to  request  that  they  eliminate  mixed  sex  accommodation,  with  further 
National Guidance in 2019 regarding the delivery of same-sex accommodation. This aimed 
to prioritise the safety, privacy and dignity of all patients with a move to ensure people are 
treated  where  possible  in  single  sex  ward.  CQC  report  Sexual  Safety  on  Mental  Health 
Wards 2018 national guidance on eliminating mixed sex accommodation on mental health 
wards.   

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.  

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

 
  
 
 
 
 
 
 
 
 
 Please contact me if I can be of any further assistance. 

Yours sincerely, 

Chief Nursing Officer  

On behalf of NHS Sussex