James Sheppard

From 

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

39 Victoria Street   
London  SW1H 0EU   

27 June 2025  

Our ref: 

HM Area Coroner Roland Wooderson  
Gloucestershire Coroner's Court  
Corinium Avenue  
Barnwood  
Gloucester  
GL4 3DJ  
By email: 

Dear Mr Wooderson,  

Thank you for the Regulation 28 report of 8 May 2025 sent to the Department of Health and 
Social Care about the death of James Oliver Sheppard. 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 James’ death, 
and I offer my sincere condolences to his family and loved ones. The circumstances your 
report describes are very concerning and I am grateful to you for bringing these matters to 
my attention.     

The  report  raises  concerns  over  insufficient  bed  availability  in  psychiatric  units  to  meet 
patient demand.   

I am sure you will appreciate that the number of mental health inpatient beds required to 
support a local population is dependent on both local mental health need.   

I  expect  individual  trusts  and  local  health  systems  to  effectively  assess  and  manage  bed 
capacity through the ‘flow’ of patients being discharged or moving to another setting.   

The 2025-26 priorities and operational planning guidance 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 
placements, and to reduce waits longer than 12 hours in A&E.   

As part of our mission to build an NHS fit for the future, we will 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.  This will 
hopefully  reduce  delays,  through  increasing bed  availability, for those  who  need  inpatient 
care the most.  

 
    
  
  
  
  
  
       
 
 
 
 
 
 
 In  order  to  better  support  an  individual  and  prevent  them  reaching  a  crisis  point,  NHS 
England is piloting a 24/7 Neighbourhood Mental Health Centre model in England, building 
on learning from international exemplars. Six early implementor sites 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 self-refer as can their loved ones and system partners.  

In addition, 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.   

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.  

On another note, the Government is also committed to tackling suicide as one the biggest 
killers in this country. The Suicide Prevention Strategy for England sets out priority areas for 
action to prevent suicides.  This includes the need to provide tailored, targeted support to 
priority groups such people in contact with mental health services and providing effective 
crisis support within and outside of the NHS.    

Through the Suicide Prevention Strategy, the British Transport Police Harm Reduction Team 
(HaRT)  is  working  in  partnership  with  Network  Rail,  mental  health  trusts  and  other  key 
partners to provide support to individuals that present on railways multiple times. The pilot 
project  has  found  that,  following  this  support,  people  were  significantly  less  likely  to  be 
present in the railway environment.   

To support local areas to tackle suicides in high frequency locations and public spaces, Office 
for Health Improvement and Disparities (OHID) developed resources such as ‘Preventing 
suicides in public places: a practice resource’ which provides local areas with a step-by-step 
guide to identifying locations and taking action.   

Samaritans has delivered suicide intervention training to over 27,000 members of the rail 
industry  workforce.  This  is  in  addition  to  the  Small  Talk  Saves  Lives  campaign  which,  in 
partnership  with  Network  Rail  and  Samaritans,  supports  rail  passengers  to  identify  when 
someone is at risk of suicide and how to approach them  

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely,   

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR  
PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH

Chief Executive’s office 
Edward Jenner Court 
1010 Pioneer Avenue 
Gloucester Business Park 
Brockworth 
Gloucester 
GL3 4AW 

Tel. 0300 421 8348 

PRIVATE AND CONFIDENTIAL 

Roland Wooderson 
Area Coroner for Gloucestershire  
Coroner’s Office  
Corinium Avenue, 
Barnwood 
Gloucester GL4 3DJ 

Sent by email and Recorded Delivery 

18 June 2025 

Dear Mr Wooderson, 

Re: Inquest touching the death of James Oliver Sheppard 

I write in relation to the above inquest which concluded on 8 May 2025. 

On 8 May 2025 you made a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 
and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Your report was sent to 
the Department of Health and Social Care and to me, as the Chief Executive Gloucestershire Health and 
Care  NHS  Foundation  Trust  ("the  Trust").  I  am  writing  to  provide  you  with  the  Trust  response to  your 
concerns which relate to insufficient beds available in psychiatric units to meet patient demand. 

We are grateful for the acknowledgement during your concluding remarks at the inquest that the Trust is 
responsible  for  delivery  of  psychiatric  beds  locally  and  issues  of  commissioning  and  total  levels  of 
available resource are responsibilities held in the wider health system locally and nationally. As such, our 
response  is  focused  on  what  we  can  influence.    As  examined  during  the  hearing,  particularly  in 
consideration of the witness testimony provided by 
, significant work has been undertaken 
over the past few years to manage mental health bed capacity and patient flow within the Trust. Although 
bed availability and resourcing continue to present challenges across mental health wards nationally, the 
measures  implemented  by  the  Trust  have  improved  the  structure  and  efficiency  of  bed  management 
systems and significantly reduced the use of Out of Area Placements over the past three years, clearly 
demonstrating the Trust commitment towards an ongoing improvement of processes to ensure that every 
possible effort is made to ensure that those patients who require in-patient mental health care have access 
to a bed as quickly as possible. Our further work is focused on reducing, wherever possible, the average 
length of stay of inpatients to ensure that the current number of beds are being used as efficiently and 
effectively as possible.  The Trust will be monitored nationally on this measure as part of NHS England’s 
Performance Assessment Framework. 

Main office: Edward Jenner Court, Pioneer Avenue, Gloucester Business Park, Brockworth, Gloucester, GL3 4AW 
Chair: 

Chief Executive: 

 
 
 
 
 
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In its ongoing efforts to improve the position locally, the Trust has also engaged in discussions with the 
local Integrated Care Board (NHS Gloucestershire ICB) and the development of an inpatient strategy is 
one of the agreed priorities for the Integrated Care System this year. We will ensure that the importance 
of adequate access to inpatient care is formally acknowledged through our Contract Management Board 
meeting with the ICB. 

As  a  Trust,  the  safety  and  wellbeing  of  those  we  provide  service  to  is  paramount  and  despite  the 
unfortunate circumstances in which this query has arisen, we welcome the opportunity you have provided 
for us to further address the issue of beds availability in psychiatric units. We will also note the response 
you receive from the Department of Health and Social Care on this issue which we are aware presents a 
challenge to mental health providers across the country.  We have taken this opportunity, as we do with 
all inquests, to learn from this and continue to implement steps to ensure that we provide the best possible 
quality care. 

Yours sincerely, 

Chief Executive