Charles Stonley

Health Services Safety  
Investigations Body 

Lytchett House 
 13 Freeland Park 
 Wareham Road 
 Poole 
Dorset BH16 6FA  

Sent via email to: 

27 August 2025 

Mrs. Anita Bhardwaj 
Area Coroner for Liverpool and Wirral 

Dear Mrs. Bhardwaj 

Regulation 28 report response from HSSIB: Mr. Charles Andrew 
Stonley 

Thank you for providing us with the opportunity to respond to your 
regulation 28 report regarding the death of Mr. Stonley. We were very sorry 
to learn about the circumstances surrounding his death. 

We note that no specific matters of concern were highlighted for HSSIB to 
respond to in your report. Instead, we have attempted to take account of all 
the various concerns raised in the report in providing our response. 

Your report highlighted concerns about Mr. Stonley’s death in relation to:  

•  The legal powers and resources available for mental health patients 
in the Emergency Department of Hospitals suffering from a mental 
health crisis. 

•  Vulnerable patients being left in the Emergency Department for days 

increasing the risk of self-harm and death. 

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 HSSIB came into operation on 1 October 2023. We are a fully independent 
arm’s length body of the Department of Health and Social Care. We 
investigate patient safety concerns across the NHS in England and in 
independent healthcare settings where safety learning could also help to 
improve NHS care. We do not replace any existing investigation processes 
available within healthcare. 

Our job is to understand why patients may have been harmed or be at risk 
of harm and our investigations take a system perspective and aim to reduce 
the likelihood of patient safety incidents from happening. We share learning 
and support patient safety improvements across the whole healthcare 
system in England. 

During our series of investigations into Mental health inpatient settings we 
heard concerns about the care of people in mental health crisis which may 
benefit from a HSSIB investigation. We carried out a range of work to help 
further understand these concerns, including conversations with 
stakeholders, reviewing available data sets, and analysing existing 
literature. We agreed that we would progress work toward a HSSIB 
investigation.  

During this period, we also received a further PFD report in relation to Ms. 
Tracy Ostler, which has helped us to understand areas of concern we have 
identified about the crisis pathway. 

On 26 August, we approved two new HSSIB investigations into mental 
health crisis care. These investigations will help to address key areas of 
concern highlighted in your report. These investigations are: 

Mental Health Crisis: Care of patients in emergency departments 

This investigation is intending to: 

•  Explore the knowledge, skills, and resources available to emergency 
departments  to  care  for  patients  in  mental  health  crisis,  including 
access to information held by other services. 

•  Explore  how  the  physical  environment  in  emergency  departments 
impacts on the care provided to patients in mental health crisis.  

 
 
 
 
 
 
 
 
 
 
 
 •  Explore  staff  decision  making  about  when  to  admit  or  discharge 

patients who have presented in mental health crisis.  

This will include consideration of the impact of protected characteristics and 
health inequalities in this area of care. 

The investigation will launch in October 2025 with a final report anticipated 
to be available in Summer 2026. 

Mental Health Crisis: Ambulance service response via NHS 111 and 999 

This investigation is intending to: 

•  Explore how ambulance services triage and prioritise calls about 

patients in mental health crisis. 

•  Explore ambulance crew education, training, and assessment of a 

patient’s capacity when in mental health crisis.  

•  Explore ambulance crew decision making on when to convey a 

patient in mental health crisis to hospital, including access to relevant 
clinical advice and access to information held by other services. 

This will include consideration of the impact of protected characteristics and 
health inequalities in this area of care. 

This investigation will launch in Spring 2026, following completion of 
substantive work on the first report, and is anticipated to be available in 
Spring 2027. 

I would like to take this opportunity to thank you for sharing your report with 
us. The investigations we have now launched will help to address the issues 
you have identified at a national level. 

Yours sincerely,  

Chief Executive Officer

Anita Bhardwaj 
HM Area Coroner 
Liverpool and the Wirral Coroner’s Service 
Gerard Majella Courthouse,  
Boundary Street,  
Liverpool  
L5 2QD 

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

13th October 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Charles Andrew Stonley 
who died on 13 March 2025.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  20 
August 2025 concerning the death of Charles Andrew Stonley on 13 March 2025. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express  my  deep  condolences  to  Charles’  family  and  loved  ones.  NHS  England  is 
keen to assure the family and yourself that the concerns raised about Charles’ care 
have been listened to and reflected upon.   

Your Report raised concerns around the limited legal powers and resources available 
for  mental  health  patients  attending  the  Emergency  Department  (ED),  and  the 
detrimental impact this has on those attending  whilst suffering from a mental health 
crisis, as well as the shortage of beds in mental health facilities.   

NHS England recognises the concern that there is a lack of clarity about what legal 
powers are  available  to  health  professionals  to  forcefully  detain  someone  in  an  ED 
who is awaiting assessment or admission. In recent debates of the Mental Health Bill, 
the Department of Health and Social Care committed to engage with stakeholders to 
understand  how  the  current  legal  framework  is  applied  in  this  setting  and  identify 
solutions to the problems raised. They will also provide further guidance on the existing 
legal framework, including the handover process from police to healthcare, in the next 
revision of the Mental Health Act Code of Practice. 

NHS England is also taking steps to address the current operational pressures driving 
these issues. The NHS operational planning guidance for this year tasks local health 
systems to improve patient flow through mental health crisis pathways and to reduce 
waits of more than 12 hours in EDs. In 2025/26, the NHS is also investing £75 million 
in  capital  funding  to  reduce  mental  health  out-of-area  placements,  which  pose  an 
increased  suicide  risk  and  lead  to  longer  stays  away  from  the  patients’  support 
networks. 
At a local level, NHS Cheshire and Merseyside Integrated Care Board (ICB) is working 
with system partners to improve system flow for mental health inpatient beds. This is 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
   
 
  
 focusing on reducing the length of stay and the number of patients who are clinically 
ready for discharge (CRFD). By reducing CRFD patients, capacity will be created to 
enable people to access a mental health inpatient bed in a timelier manner. 

The ICB is also working with system partners on improved crisis response services, 
to mitigate the need for people to attend an ED for a mental health intervention. This 
includes providing access to crisis lines and crisis cafes. 

The ICB's providers are also working with them to improve the management of people 
who  do  present  to  an  ED  with  an  apparent  mental  health  need,  with  a  focus  on 
enhanced training and triage and reducing or eliminating 12 hour waits. To enhance 
this  work,  the  next  Director  of  Nursing  meeting  in  October  2025  will  focus  on 
agreement  of  key  actions  that  maintain  the  safety  of  patients  attending  EDs  with 
mental  health  needs.  It  is intended  that  this will  allow the  development  of  essential 
actions for safety, effectively a ‘red lines’ tool kit for Mental Health Safety in EDs, and 
reporting of any breaches to these required actions. A red lines tool kit is a guidance 
document co-created by the system Directors of Nursing/Chief Nurses to agree the 
range of acceptable adjustments that can be made during escalating pressures and 
what are the hard stop ‘red lines’ that should not be crossed for risk of compromising 
patient safety.  If any of these lines are crossed during period of exceptional service 
pressure an incident is raised to support a patient safety response to understand the 
causes and consider areas of improvement to prevent reoccurrence. 

Harm reviews are routinely conducted by the ICB’s mental health providers for 12 hour 
waits in EDs and for CRFD patients and the learning applied to service delivery. The 
ICB is also developing additional physical capacity in or near to EDs for people who 
are in mental health crisis, creating a safe and more appropriate location for them to 
receive their initial assessment and intervention by a mental health professional. 

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 
Charles, 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