Jessica Smithson

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

39 Victoria Street   
London SW1H 0EU   

Joanne Kearsley  
The Coroner’s Office  
2nd and 3rd Floor, Newgate House  
Newgate  
Rochdale   
OL16 1AT  

31 October 2025  

Dear Ms Kearsley,   

Thank you for your Regulation 28 report of 12 August 2025, sent to the Secretary of State 
for  Health  and  Social  Care,  about  the  death  of  Jessica  Smithson.  I  am  replying  as  the 
Minister with responsibility for mental health.        

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Smithson’s 
death, and I offer my sincere condolences to her 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. Thank you also for the additional time provided to the Department to provide 
a response to the concerns raised in the report.  

Your  report  raises  concerns  about  the  delayed  roll  out  of  crisis  text  support  services 
nationally, the lack of consistency in the approach taken by charities currently offering these 
services, and the impact of having no locally commissioned crisis text support service within 
the Greater Manchester area.   

I understand your concerns.   

In preparing this response, my officials have made enquiries with NHS England to ensure 
we adequately address your concerns.  

As set out in the Suicide Prevention Strategy for England, mental health crisis text services 
are an important part of delivering accessible and effective mental health support across the 
country. NHS England has confirmed that all integrated care boards (ICB) have been asked 
to put in place integrated crisis text services and ICBs have now submitted their plans, with 
delivery  expected  across  all  areas  by  Spring  2026  and  we  have  been  requesting  regular 
progress reports on this.   

More broadly, the Government is committed to delivering effective care for those in crisis.  
This includes the introduction of the ‘mental health option’ for NHS 111, the roll out of 24/7 
psychiatric  teams  in  every A&E  and  investing  up  to  £120  million  to  bring  the  number  of 

A7  
    
  
  
 
  
  
  
  
  
   
   
  
  
  
  
 mental  health  emergency  departments  up  to  around  85,  providing  reactive,  short  term 
intensive support for people in acute mental health crisis as an alternative to A&E.    

Our 10-Year Health Plan sets out our vision for a neighbourhood health service, which will 
bring  care  into  local  communities,  convene  professionals  into  patient-centred  teams,  end 
fragmentation  and  abolish  the  NHS  default  of  ‘one  size  fits  all’  care. As  part  of  this,  NHS 
England is currently piloting six 24/7 neighbourhood mental health centres, which expand on 
the ‘no wrong door’ approach of the Community Mental Health Framework, providing open 
access to mental health care for patients and reducing long waits.   

I  hope  you  will  understand  that  charitable  organisations  providing  crisis  text  services  are 
independent of both Government and the NHS.   

I would expect your concerns regarding the current lack of a locally commissioned crisis text 
support service to be addressed by NHS Greater Manchester ICB in its response to your 
report, and I understand from NHS England’s response to you that it will be reviewing the 
ICB’s response to consider whether any further actions are required.  

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

Yours sincerely,   

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR  

                             WOMEN’S HEALTH AND MENTAL HEALTH  

A8

Date: 17 September 2025 

Private & Confidential 
Ms. Joanne Kearsley 
Senior Coroner for the area of Manchester North 
HM Coroner's Court 
Floors 2 and 3 
Newgate House 
Newgate 
Rochdale  
OL16 1AT 

Dear Ms. Kearsley 

Re: Regulation 28 Report to Prevent Future Deaths – Jessica Lynda Smithson 

Thank you for your Regulation 28 Report dated 8 August 2025 regarding the sad death of Jessica Lynda 
Smithson. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by 
offering our sincere condolences to Jessica’s family for their loss. 

Thank you for highlighting your concerns during the inquest which concluded on the 7 August 2024. On 
behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. 
We recognise it is very important to ensure we make the necessary improvements to the quality and 
safety of future services.   

During the inquest you identified the following cause for concern for NHS Greater Manchester to 
consider and respond to: 

Within the Greater Manchester Area there is no commissioned crisis text mental health 
support service. Whilst GM residents can message national services, often the location of 
an individual texter will not be known. 

The court heard from Greater Manchester Police that they receive a significant number of 
referrals which have been sent by the crisis service to the Metropolitan Police, almost one 
a day where there has been a real and immediate risk to a person’s life identified. All of 
these referrals require and immediate police response (they are outside of Right Care 
Right Person). If there was a GM commissioned service, it is likely that any search for the 
location of the individual would be done by GMP and would shorten the timeframe in 
which they could respond to the risk. 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In addition, a GM commissioned service would have a greater understanding of local 
pathways in order to refer people who may have a deteriorating mental health before they 
reached their pint of crisis. 

NHS GM alongside the mental health trusts have considered options for the provision of crisis text 
services and are currently considering our preferred model through our Greater Manchester Mental 
Health Clinical Effectiveness Group (CEG) as our established clinical governance route. Our preferred 
model is for a text service to be incorporated into the Greater Manchester 111 Mental Health crisis line 
service so that texts are handled by Greater Manchester Mental Health First Responders based within 
the team.  

Currently, there is a transformation programme underway to:  

•  Consolidate existing crisis line services into the single 111 service 
•  Develop a new Mental Health urgent triage service to support 999 calls  
• 
•  Bolster community provision across Crisis resolution home treatment teams and Voluntary sector 

Implement crisis resolution 4-hour 24/7 response  

crisis spaces.  

These services are planned to be mobilised in Quarter 3 of 2025/26 and we will commence a review of 
capacity and demand which will enable implementation of the crisis text service. We are exploring 
options available to us to implement this in a phased approach with consideration given to approaches 
elsewhere in the country such as in Northampton.  

NHS GM has decided on this integrated model for implementation of a text service after we have 
considered all options for crisis text available to us and have a shared preference for a service that will 
be integrated with our existing 111 team, therefore providing consistency of offer for people whether they 
call or text in need of help. This was following system-wide agreement. Our transformation work relating 
to crisis services is significant and we are planning for this in a phased way, backed by the appropriate 
capacity/demand work during Quarter 3 of 2025/26.  Once Trusts have recruited to new posts in the 
crisis team, and merged existing services, Greater Manchester commissioned crisis text services will be 
implemented before we have the fully established service up and running, which will minimise the risk of 
destabilising crisis services.  

For additional information, NHS GM has commissioned SHOUT (Shout is a free, confidential, 24/7 text 
messaging service for anyone who is struggling to cope) previously and took the decision to discontinue 
after one year in 2020/21 based on an evaluation by Health Innovation Manchester and negative service 
user feedback online. This was also done in the context that the universal offer commissioned by NHSE 
was in place so at this time NHS Greater Manchester does not currently commission a text crisis service. 
In this instance, Jessica accessed SHOUT, commissioned by NHSE. The interface between SHOUT and 
Greater Manchester Police should be considered within any commissioning arrangements between 
NHSE and the provider.  

Once a crisis text service is implemented in Greater Manchester as part of the crisis transformation, it 
will be delivered by local providers who already have established relationships and interface processes 
with Greater Manchester Police, so this issue is unlikely to be as significant. However, it will still be 
reviewed during the scoping and mobilisation phases of the service. This process is being monitored by 
the NHS GM Mental Health Clinical Effectiveness Group (MH CEG) for clinical scrutiny and oversight 
and then will be proposed and recommended to the GM CEG for endorsement as per the NHS clinical 
governance process. Once the new system is in place, I will update you further.  

4th Floor, Piccadilly Place, Manchester  M1 3BN   
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

 
  
 
 
 
 
 
 
 
 I hope that this response addresses your concerns but if you do have any further questions, please 
contact me. 

Best wishes 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
Tel: 0161 6257791  www.gmintegratedcare.org.uk

Joanna Kearsley 
HM Senior Coroner 
Greater Manchester North  
The Coroner’s Office 
2nd and 3rd Floor 
Newgate House 
Newgate 
Rochdale  
OL16 1AT 

Dear Coroner, 

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

13th October 2025  

Re: Regulation 28 Report to Prevent Future Deaths – Jessica Lynda Smithson 
who died on 28th August 2024.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  8 
August 2025 concerning the death of Jessica Lynda Smithson on 28 August 2024. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to  Jessica's family and loved ones. NHS England  is 
keen  to  assure  the  family  and  yourself  that  the  concerns  raised  in  respect  of  the 
circumstances surrounding Jessica’s death have been listened to and reflected upon.   

Your Report raised the concern that there currently is not a 24/7 crisis text service in 
every  Integrated  Care  Board  (ICB)  across  England,  despite  the  critical  role  such 
services play being highlighted in the National Suicide Prevention Strategy 2023 for 
England. You also raised that there has been a delayed roll out, and the current gap 
in  provision  means  that  a  health-related  service  is  being  provided  by  charity 
organisations who have differing policies and processes regarding the immediate risk 
to life, and who have a limited ability to understand local mental health NHS pathways. 

Anyone in England can access age-appropriate crisis support by calling NHS111 and 
selecting  the  ‘mental  health  option’,  with  services  commissioned  and  designed  to 
deliver  consistent  triage,  risk  assessment  and,  where  necessary,  rapid  face-to-face 
assessments. To further enhance accessibility, NHS England has requested that all 
ICBs put in place integrated crisis text services and ICBs have now submitted their 
plans, with delivery expected across all areas by Spring 2026.  

We  would  suggest  the  Coroner’s  Office  approaches  the  charity  directly  for  further 
information about the support provided, if required. As this is a non-NHS provider, we 
are unable to comment on their service delivery arrangements or clinical governance 
processes. 

Your Report also directed some concerns to NHS Greater Manchester ICB (GM ICB), 
regarding the current lack of a locally commissioned service and the implications of 

                                                                                                                       
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 
  
 this. As your Report has also been sent to GM ICB, they will respond to those concerns 
separately and NHS England will review this and consider any further actions required.  

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 
Jessica, 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 England