Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0123, written 21 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Feb 2025 |
|---|---|
| Reference | 2025-0123 |
| Deceased | Luke Worrell |
| Coroner | Andrew Harris |
| Coroner area | South London |
| Category | Mental Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. MHRA 2. NHS England 3. Department of Health 4. Royal College of Psychiatrists 5. Care Quality Commission, Chief Executive 1 CORONER I am Andrew Harris, Assistant Coroner, London South jurisdiction 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INQUEST On 21st January 2022, as Senior Coroner, London Inner South, after a Safeguarding Adults Investigation, I opened an inquest into the death of Mr Luke Alexander Worrell, who had died in hospital aged 39 on 2nd January 2021. The inquest was concluded on 7th September 2023, having called an expert pharmaceutical physician. On 21st September 2023 I took urgent sick leave. I resigned from my position on 31st October 2023, after which I had no jurisdiction. On 21st September 2024, I received a request, in my new role as Assistant Coroner in South London, to determine whether a preventing future death report was needed. I agreed and the case was transferred on 27th November and I was given access to the case file on 27th January 2025. Submissions as to the need for a PFD report were filed, but in view of the passage of time, I do not consider it fair to issue a report to those involved with his care now in 2025, on the basis of evidence 16 months ago about a death 4 years ago. However the issues are potentially generic and so I address my report to national organizations. The medical cause of death was: 1a Ruptured Oesophagus 1b Vomiting from ileus 1c Gastro-intestinal upset from Clozapine administration II Treatment resistant schizophrenia, urinary tract infection The narrative conclusion was: He died from unintended consequences of necessary medical treatment. There were two significant failures in care, which contributed to his death. The first was a failure to recognize the side effect of Clozapine on his gastro-intestinal tract. The second was the failure to recognize the level of risk Mr Worrell presented to himself after discharge, and in particular the failure to recognise the need for face to face assessment by a psychiatrist in response to his presentation on 7th and 14th December 2020, which amounted to neglect. 4 CIRCUMSTANCES OF THE DEATH Mr Worrell suffered from paranoid schizophrenia, dissocial personality disorder and some learning difficulty. He spent most of his life in hospital detention or custodial settings. He had a history of illicit substance misuse, non- compliance with medication and non- engagement with health services. During the Covid pandemic, he was discharged from hospital on 28th October 2020 on oral Clozapine. His mother, the GP and his 24 hour support service had not contributed to discharge planning. He was assessed on the day before discharge as having “less capacity to make informed decisions about his follow up” and he refused the Home Treatment Team's input post discharge. His mother considered he was not ready for discharge; the residential support service wanted him to remain under mental health (MH) section on section 17 leave, as it enabled much easier recall to hospital. This was not considered by the psychiatrist who was his responsible physician as its use had 'fallen out of practice' and he was instead the subject of a community treatment order. On 7th December he declined medication, opened his door naked with a delusion that there was a t-shirt on his mattress touching which would cause death and socks would kill Stevie. It was suspected that he had bought Spice instead of food, and alcohol was found in his room, but neither the care coordinator nor psychiatrist considered that he needed a MH assessment, despite having demonstrated almost all relapse indicators in his contingency and relapse plan, which required one. By 14th December he had persistent vomiting, stopped eating, self- isolated with a barricade and refused medication. 111 was called as support staff and CC felt he should be taken to hospital. The GP identified the self neglect but Mr Worrell declined to speak to him on the phone and referred to mental health. Ambulance services were severely stretched by Covid, and the paramedic in the early hours inappropriately accepted that Mr Worrell did not need waking and applied a triage assessment without consultation and made a referral back to mental health services. He took his Clozapine on 16th and was eating, but refused to attend the clinic. By 17th he had failed to attend two review meetings with his psychiatrist, attendances at the clinic and GP consultations, which persisted. On 22nd a GP telephoned and was reassured that he was about to attend the Clozapine clinic and lack of red flags and advised being taken to A&E if he worsened. His mother persuaded him to attend the clinic with her, but he collapsed there and was taken to A&E on a best interests basis. He was grossly dehydrated, partially conscious and confused, with a severe metabolic alkalosis due to persistent loss of gastric acid from vomiting, requiring intensive care. His GI tract was dilated with a significant amount of fluid, due to an ileus from Clozapine administration, which was not recognised and was continued, but probably absorbing little. His care was complicated by postural pneumonitis, confusion preventing reinsertion of NG tube and an arterial line being blocked. He had a coffee ground vomit on 31st December and this caused a rupture of a weakened oesophagus and a deterioration the next day leading to a cardiac arrest, from which resuscitation was inevitably unsuccessful. He died at 11.00 hours on 2nd January in hospital. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. – 1. The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine 2. Inappropriate use of community treatment order, when there was sufficient evidence to keep on a MHA section. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths. I believe that the following organizations would wish to learn of the evidence given in the inquest about the circumstances of this death and are in a position to mitigate or prevent future deaths. I attach my judgment to assist them: 1. MHRA 2. NHS England 3. Department of Health 4. Royal College of Psychiatrists 5. Care Quality Commission, Chief Executive 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 17th April 2025. I, the coroner, may extend the period. If you require any further information or assistance about the case, please contact the Inner South case officer, : 8 COPIES and PUBLICATION I have sent a copy of my report to the following Interested Persons: , mother of the deceased Oxleas NHS Foundation Trust, Medical Director Queen Elizabeth Hospital, Woolwich, A&E Director London Borough of Greenwich, Safeguarding Lead Supported Living Services, Chief Executive I am also sending this report to the Independent Panel on Deaths in Custody, as arguably the deceased should have been in detention. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 [DATE] [SIGNED BY CORONER] 21st February 2025 Andrew Harris, Assistant Coroner, South London
4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161 www.cqc.org.uk Car Mr Andrew Harris Assistant Coroner HM Coroner for London Inner South Coroners Court 1 Tennis Street London SE1 1YD 08 May 2025 Dear Mr Harris, Care Quality Commission: Response to Regulation 28 Report to Prevent Future Deaths following the inquest into the death of Mr Luke Alexander Worrell. Thank you for your Regulation 28 Report to Prevent Future Deaths dated 21 February 2025 about Mr Worrell's death. I am replying on behalf of the Care Quality Commission (CQC). Firstly, I would like to say how saddened I was to read of the circumstances of Mr Worrell’s death, and I offer my sincere condolences to his family and loved ones. Your report’s circumstances are concerning, and I am grateful to you for raising these matters. In the Regulation 28 Report to Prevent Future Deaths, the following concerns were raised to the CQC: 1. The lack of awareness by a series of clinical staff of the potential fatal side effects of Clozapine 2. Inappropriate use of community treatment order, when there was sufficient evidence to keep on a MHA section. In response to the individual points raised: 1. The Care Quality Commission (CQC) recognises the serious concerns arising from the lack of awareness among some clinical staff regarding the potentially fatal side effects of Clozapine. As the regulator of health and social care in England, we are committed to supporting safe, high-quality care for people receiving treatment with Clozapine, both in inpatient settings and in the community. Clozapine remains an essential treatment for individuals with mental health conditions such as treatment-resistant schizophrenia; however, its use carries significant risks, including agranulocytosis, myocarditis, and gastrointestinal hypomotility, which require stringent monitoring and management. To ensure high standards of care, the assessment of Clozapine use, including through community Clozapine clinics and the monitoring of Clozapine related concerns, is conducted by our mental health inspectors within the CQC integrated assessment and inspection teams. These teams are further supported by our team of specialist medicines inspectors and our mental health senior specialists. In addition, our medicines inspection team delivers targeted Clozapine training and awareness sessions for our mental health inspectors across our integrated assessment and inspection teams. These are delivered through dedicated face- to-face training sessions and development days to strengthen the knowledge and vigilance of our integrated assessment and inspection teams. Our dedicated mental health senior specialists support our integrated assessment and inspection teams in monitoring intelligence and assessing providers. This includes evaluating the safe and lawful use of Clozapine. Furthermore, the CQC medicines inspection team maintains regular engagement with the Health Services Safety Investigation Body (HSSIB), particularly in relation to investigations into Clozapine-related deaths in inpatient settings. Learning from these investigations is incorporated into our regulatory approach, enhancing our understanding of the safe use of Clozapine in inpatient and community settings. 2. The CQC is concerned by instances of the inappropriate use of Community Treatment Orders (CTOs), particularly where there is sufficient clinical and legal justification to maintain a person on a detention under the Mental Health Act (1983). The inappropriate application of CTOs can compromise both the safety of the individual and the effectiveness of their care and treatment. As the independent regulator of health and social care in England, we expect providers to ensure that all decisions relating to the use of the Mental Health Act, including transitions to CTOs, are based on clear clinical evidence, follow legal frameworks, and prioritise the individual’s rights and wellbeing. To support this, the CQC has a team of dedicated Mental Health Act Reviewers who work alongside our integrated assessment and inspection teams. These specialists provide expert advice and oversight in assessing the use and application of the Mental Health Act across both inpatient and community mental health services, including the use of CTOs. During the CQC assessment processes, our reviewers assess whether decisions regarding CTOs are legally compliant, clinically justified, and in the best interests of the person receiving care. They also monitor how well providers involve individuals, carers, and advocates in the decision-making process, and whether services uphold people’s rights under the Act. Where we identify inappropriate use of CTOs or concerns about compliance with the Mental Health Act, we can undertake additional monitoring, engagement and regulatory action as necessary to drive improvement and hold providers to account. We aim to ensure that all people receiving care under the Mental Health Act are treated lawfully, safely, and with dignity and respect. All system partners in the health and social care sector must recognise the potentially fatal side effects of Clozapine. Failure to monitor and manage these risks can lead to avoidable harm or death. Equally, the appropriate use of Community Treatment Orders is critical to ensuring individuals receive necessary treatment while maintaining oversight and safeguarding their rights. Collaborative awareness and accountability across services help provide safe, person-centred care and uphold the standards we are committed to as a sector. The safety of people using mental health services remains a top priority for the CQC, and we will continue to take action where standards fall short to ensure that providers deliver safe, effective, and person-centred care. Internally, the CQC incorporates information from incidents, notifications, and Regulation 28 Prevention of Future Deaths reports into its ongoing monitoring and assessment planning. Our internal Specific Incidents Guidance process evaluates whether incidents indicate avoidable harm or breaches of fundamental standards. Where necessary, further enquiries are made, and the CQC may undertake targeted or unannounced inspections. If risks are confirmed, regulatory actions such as requirement notices or enforcement measures may be taken to ensure compliance and drive improvements in care. The Care Quality Commission’s local integrated assessment and inspection teams actively monitor Oxleas NHS Foundation Trust and Lewisham and Greenwich NHS Trust through continuous engagement and risk-based assessments. This includes gathering intelligence from various sources such as patient feedback, incident reports, and partner organisations. Regular meetings with the trusts and attendance at key committees, like Oxleas’ mortality surveillance committee, allow the CQC to review performance, address concerns, and seek assurance on improved care quality and safety. In addition to this local monitoring, the CQC has committed to a national review of adult community mental health services across England, following the 2024 Section 48 special review of Nottinghamshire Healthcare NHS Foundation Trust. This work includes inspections of services such as community-based mental health services for adults of working age and mental health crisis services and health-based places of safety to identify gaps in care quality, patient and public safety, and staff experience. The review will assess both individual trust services and provide a broader national overview of community mental health service provision. We are grateful for the information you have shared. It is invaluable in helping us monitor the quality of care provided across services and ensure that providers meet the standards expected under the Health and Social Care Act (2008) and the associated Regulated Activities Regulations (2014). We appreciate the coroner raising these concerns with us. We will continue to monitor the trusts and any information we receive in line with our internal processes and methodology. If you have any further queries, please do not hesitate to contact us. Yours sincerely, Deputy Director Operations Care Quality Commission – London & East of England Network
Parliamentary Under-Secretary of State for Patient Safety, Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU 25 April 2025 Our ref: Mr Andrew Harris Assistant Coroner London Inner South Coroners Court 1 Tennis Street London SE1 1YD By Email: Dear Mr Harris, Thank you for your Regulation 28 report of 21 February 2025 sent to the Secretary of State about the death of Luke Alexander Worrell. I am replying as the Minister with responsibility for patient safety and mental health. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Worrell’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these matters to my attention. Your report raises concerns over levels of awareness of clinical staff around the potentially fatal side effects of clozapine and the use of a Community Treatment Order (CTO) to support Mr Worrell when there may have been sufficient evidence to detain Mr Worrell under the Mental Health Act. I note that you have also addressed these matters of concern to NHS England, the Medicines and Healthcare Products Regulatory Agency (MHRA), the Royal College of Psychiatrists, and the Care Quality Commission. I look forward to working together with these bodies where appropriate to avoid a repetition of the tragic events of this case. I understand your concern that clinical staff administering clozapine need to have a firm understanding of the drug’s potential side effects. I am aware that the Chief Executive of Medicines and Health Care products Regulatory Agency has provided a response to your report, which sets out the protocols it has in place to ensure clinicians are aware of the side effects of clozapine. This includes ensuring that the special warnings and precautions for use section of the Summary of Product Characteristics (SmPC) for clozapine includes information on the medicine’s anticholinergic effects and ensuring that labelling and Patient Information Leaflets accurately reflect the risk of gastrointestinal disorders. In its response, the MHRA has considered the evidence provided in your report and acknowledges the concerns relating to the level of awareness of clinical staff around the potentially fatal side effects of clozapine. Whilst the MHRA is unable to comment on the specific clinical decisions made in Mr Worrell’s case, the MHRA is currently reviewing the product information for clozapine which will carefully consider the information provided to healthcare professionals, patients and their families and carers and whether this can be improved to provide greater clarity on the side effects of clozapine. The MHRA will engage with stakeholders to ensure the regulatory documents for clozapine meet the needs of both patients and prescribers. I understand this review is expected to be completed this year and that the MHRA will inform you of the outcome. I am aware that the National Medical Director of NHS England has written to you setting out the additional measures that have been taken to ensure responsible clinicians are aware of the potentially fatal side effects of clozapine. These include ongoing work to raise awareness in the health community around the potential risks of clozapine. I understand your concerns around whether the use of a CTO was the appropriate course of action for Mr Worrell’s treatment, as opposed to detaining him under the Mental Health Act. Whilst I am unable to comment on the specific decision made by the psychiatrist to place Mr Worrell under a CTO, the CTO should not have been a barrier to providing better support Mr Worrell. CTOs are a form of supervised community treatment where an individual can be quickly recalled to hospital to be detained and treated. CTOs are intended to maintain ongoing contact with mental health services to provide support and help prevent relapse. In certain circumstances, patients subject to a CTO may be recalled to hospital under the Mental Health Act. Under section 17E of the Act, a patient can be recalled to hospital if they require medical treatment in hospital for their mental disorder and there would be a risk of harm to the health or safety of the patient or to other persons if the patient were not recalled to hospital for that purpose. I am aware that the National Medical Director has advised that, in cases like Mr Worrell’s, inpatient mental health teams still have the option to use section 17 to recall individuals to hospital. He has also advised that clear guidance is available within the Mental Health Act Code of Practice1 for responsible clinicians to make decisions on guardianship, section 17 leave, and CTOs. This guidance outlines circumstances for clinicians to consider when making decisions on whether a CTO or section 17 leave would be the most suitable course of action for a patient. This guidance states that section 17 leave is only suitable for short-term absences from inpatient services for a fixed period or purpose. Section 17 may also be suitable in the longer- term (for more than seven consecutive days) where the clinical team wish to see how the individual manages outside of hospital before making a decision to discharge. For patients who are able to live in the community, a CTO should be considered a better option than longer-term leave for the management of their care. Where longer-term leave is considered under section 17 (for more than seven consecutive days), the responsible clinician must first 1 Code of practice: Mental Health Act 1983 - GOV.UK consider whether the patient should be discharged on a CTO instead. Any decision to authorise section 17 leave for more than seven days on a second occasion should be fully documented, including why a CTO discharge is not appropriate. Through the Mental Health Bill, which is currently making its way through Parliament, we are introducing further professional oversight in decisions regarding the use and operation of CTOs. The community clinician (the approved clinician who is responsible for overseeing the patient’s care as a community patient) will be involved in decision making in addition to the hospital-based responsible clinician. This includes the decision to make a person subject to a CTO, to vary or suspend conditions made under a CTO, to recall to hospital a patient subject to a CTO, to revoke a CTO after a patient has been recalled, and to discharge the patient from the CTO. This will help ensure better join up between inpatient and community clinical teams and make sure that patients subject to a CTO are benefitting from the framework they provide. I agree with the point your report raises around the importance of involving the patient, family and carers, and clinicians in communities when planning and supporting an individual to be discharged from hospital. Statutory guidance on discharge from mental health inpatient settings 2 should be referred to by responsible clinicians to ensure that decisions on discharge are firmly centred around patients and their chosen carers and that they are actively involved throughout the process with appropriate input from relevant professionals involved in their ongoing care. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, 2 Discharge from mental health inpatient settings - GOV.UK
10 South Colonnade Canary Wharf London E14 4PU United Kingdom gov.uk/mhra Mr Andrew Harris Assistant Coroner London South Jurisdiction By Email: Reference: 10 March 2025 Dear Mr Harris, Regulation 28 Report relating to the death of Luke Alexander Worrell Thank you for your Regulation 28 report relating to the death of Mr Luke Alexander Worrell which was received on 20th February 2025. I would like to offer my sincere condolences to Mr Worrell’s family on their tragic loss. I understand from your report that Mr Worrell’s death resulted from ruptured oesophagus, vomiting from ileus and gastro-intestinal upset associated with clozapine treatment. Your report identified the following matters of concern relating to clozapine: 1. There was lack of awareness by a series of clinical staff of the potential fatal side effects of clozapine. 2. There was an inappropriate use of community treatment order, when there was sufficient evidence to keep the patient on a Mental Health Act section. The Medicines and Healthcare products Regulatory Agency (MHRA) is an executive agency of the Department of Health and Social Care with responsibility for the regulation of medicinal products in the UK. We ensure that medicines are efficacious and acceptably safe, and that information to aid the safe use of a medicine, including possible side effects are appropriately described in the authorised product information. This comprises the Summary of Product Characteristics (SmPC, intended for healthcare professionals), labelling, and Patient Information Leaflet (PIL, provided to patients in each medicine pack). The product information can support discussions between healthcare professionals and patients. The PIL is not intended to replace the discussion with prescribers about the benefits and risks of treatments. The current special warnings and precautions for use section of the SmPC for clozapine states within the sub-section relating to anticholinergic effects that, “Clozaril has been associated with varying degrees of impairment of intestinal peristalsis, ranging from constipation to intestinal obstruction, faecal impaction, paralytic ileus, megacolon and intestinal infarction ischaemia (see section 4.8). On rare occasions these cases have been fatal. Particular care is necessary in patients who are receiving concomitant medications known to cause constipation (especially those with anticholinergic properties such as some antipsychotics, antidepressants and antiparkinsonian treatments), have a history of colonic disease or a history of lower abdominal surgery as these may exacerbate the situation. It is vital that constipation is recognised and actively treated.” Gastrointestinal disorders are also described in the undesirable effects section of the SmPC of clozapine, which lists constipation, intestinal obstruction and paralytic ileus as possible adverse reactions to the treatment with clozapine. In addition, the contraindication section states that clozapine is contraindicated in patients with paralytic ileus. Similar messages can be found in the current PIL for clozapine. In October 2017, we published an article in our bulletin Drug Safety Update which was distributed to healthcare professionals reminding of the potential fatal risks of intestinal obstruction, faecal impaction, and paralytic ileus. This information is also highlighted in the British National Formulary. We have considered the evidence provided and the circumstances leading to Mr Worrell’s death and acknowledge that your concerns relate to lack of awareness of clinical staff of the potentially fatal side effects of clozapine, and clinical decisions. Unfortunately, we cannot directly address these points, as it is not within our remit to comment on the clinical decisions in specific cases. We continuously review the safety of medicines on the UK market and take appropriate regulatory action as required. Currently, we are reviewing the product information for clozapine. As part of this review, we will be giving careful consideration to the information which is provided to healthcare professionals, patients and their families and carers, and whether this can be improved to provide greater clarity. We intend to engage with relevant stakeholders during this process to ensure the regulatory documents meet the needs of patients and prescribers. It is anticipated that this review of clozapine will be completed this year, and we will inform you of the outcome. Should you have any further questions, please do not hesitate to contact my office at Executive.Office@mhra.gov.uk. Yours sincerely Chief Executive Medicines and Healthcare products Regulatory Agency E:
Mr Andrew Harris
HM Assistant Coroner
London Inner South
Southwark Coroner’s Court
1 Tennis Street
London SE1 1YD
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
14 April 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Luke Alexander Worrell
who died on 2 January 2021
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20
February 2025 concerning the death of Luke Alexander Worrell on 2 January 2021. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Luke’s family and loved ones. NHS England are
keen to assure the family and the Coroner that the concerns raised about Luke’s care
have been listened to and reflected upon.
Your Report raises concerns that there is a lack of awareness amongst clinical staff of
the potential side effects of Clozapine, and that Luke was subject to the inappropriate
use of a community treatment order.
Side effects of Clozapine
NHS England has undertaken considerable work to highlight to clinicians and
colleagues the importance of keeping people safe from the side effects of Clozapine,
which are well-recognised.
The risks and side-effects of Clozapine are listed in the British National Formulary
(BNF), last updated on 26 February 2025, and the Summary of Product Characteristics
on the Electronic Medicines Compendium (EMC), last updated on 13 February 2024.
The BNF and EMC are both information resources for medications that healthcare
professionals would be expected to make reference to.
In October 2022, updates were made to the Specialist Pharmacy Service website page
on Clozapine (see https://www.sps.nhs.uk/articles/managing-constipation-in-people-
taking-clozapine/) to specifically highlight the risks of constipation and fatal cases of
intestinal obstruction, faecal impaction, and paralytic ileus.
In February 2022, NHS England’s National Specialty Advisor for Mental Health
Pharmacy wrote to all Mental Health Chief Pharmacists, asking them to raise
awareness about the potential risks of Clozapine across their health community.
Prior to this, in October 2017, the Medicines and Healthcare products Regulatory
Agency (MHRA) issued a medicines safety bulletin highlighting the risks of fatalities
related to bowel problems associated with Clozapine: https://www.gov.uk/drug-safety-
update/clozapine-reminder-of-potentially-fatal-risk-of-intestinal-obstruction-faecal-
impaction-and-paralytic-ileus.
NHS England are also aware that the Royal College of Psychiatrists are undertaking
some work around raising awareness of Clozapine risks.
Inappropriate use of a community treatment order, where there was sufficient
evidence for a Mental Health Act section
NHS England are unable to comment on whether there was sufficient evidence for the
responsible clinician to keep Luke under mental health section on Section 17 (S17)
leave, rather than discharging him onto a community treatment order (CTO), based on
the information provided in your Report, but this is an available option to inpatient
mental health teams.
The Mental Health Act 1983 Code of Practice provides clear guidance on deciding
between guardianship, S17 leave and a CTO. S17 leave is “primarily intended to allow
a patient detained under the Act to be temporarily absent from hospital where further
in-patient treatment as a detained patient is still thought to be necessary. It is clearly
suitable for short-term absences for a fixed period or specific purpose e.g., to allow
visits to family and to trial living more independently” (see Chapter 31.4 of the Code of
Practice). The Code of Practice states that a “Leave of absence may be useful in the
longer term (more than seven consecutive days) where the clinical team wish to see
how the patient manages outside hospital before making the decision to discharge.
Leave for a longer period should also be for a specific purpose or a fixed period, and
not normally more than one month. For most patients who are able to live in the
community, a CTO should be considered a better option than longer-term leave for the
ongoing management of their care. Reflecting this, whenever considering longer-term
leave for a patient (that is, for more than seven consecutive days), the responsible
clinician must first consider whether the patient should be discharged onto a CTO
instead. Any decision to authorise section 17 leave for more than seven days on a
second occasion should be fully documented, including why a CTO or discharge is not
appropriate” (see 31.5).
CTOs are a form of supervised community treatment where someone can be quickly
recalled to hospital to be detained and treated. They are intended to maintain ongoing
contact with mental health services to provide support and help prevent relapse. In
certain circumstances, patients subject to a CTO may be recalled to hospital under the
Mental Health Act. Under section 17E, the patient can be recalled to hospital if they
require medical treatment in hospital for their mental disorder and there would be a
risk of harm to the health or safety of the patient or to other persons if the patient were
not recalled to hospital for that purpose.
Your Report also highlights the importance of involving the patient, family, carers and
clinicians in the community when planning and supporting an individual to be
discharged from hospital. Statutory guidance (
settings - GOV.UK) reaffirms this point, stating that services must “ensure that people
and their chosen carers (including those with parental responsibility for children and
young people) are the centre of discharge planning and are actively involved
throughout the process, with appropriate input from relevant professionals and
services involved in their ongoing care”. NHS England guidance (NHS England »
Acute inpatient mental health care for adults and older adults) provides further
guidance on joint and effective discharge planning.
A reformed Mental Health Act is currently being scrutinised by parliament. The Bill
strengthens the protocol around discharging individuals from detention under Part 2
of the Act so that, where currently a patient’s responsible clinician can unilaterally
decide to discharge a Part 2 or unrestricted Part 3 patient from hospital, under the Bill
they will be required to consult with another clinical professional. A similar protocol will
apply to people under guardianship and community treatment orders, where the
detaining authority will need to consult with another. The Bill further strengthens
professional oversight in decisions regarding the use and operation of CTOs, where
the community clinician (the approved clinician who is responsible for overseeing the
patient’s care as a community patient) will be involved in decision making in addition
to the hospital-based responsible clinician.
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 Luke,
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
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