Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0510, written 13 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Oct 2025 |
|---|---|
| Reference | 2025-0510 |
| Deceased | Jack Peatling |
| Coroner | Sean Horstead |
| Coroner area | Essex |
| Category | Suicide (from 2015) · Mental Health related deaths · Community health care and emergency services related deaths |
| Organisation named | Essex Partnership University NHS Foundation Trust · Mid and South Essex NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The National Medical Director, NHS England: and Secretary of State at the Department for Health and Social Care: CORONER I am Sean Horstead, area coroner, for the coroner area of Essex CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 23rd June 2023 I commenced an investigation into the death of Jack Mathew Peatling, aged 20 years. The investigation concluded at the end of the article 2 (non-jury) inquest on the 10th October 2025. The Conclusion of the inquest was a Short Form Conclusion of Suicide in conjunction with an expanded Narrative Conclusion expressed (in summary) in the following terms: Jack Peatling’s death was directly contributed to by the non- availability of an in-patient bed in an EPUT Mental Health Assessment Unit. His very high level of risk of suicide had been determined by a formal Mental Health Act assessment to require an immediate period of assessment and treatment as in-patient with a recognition, in terms, that his risk of suicide was such that he could not be kept safe in the community. Jack spent six days at home awaiting a bed before taking his own life by the fatal deployment of a ligature. 1 2 3 4 CIRCUMSTANCES OF THE DEATH 1 On a background of diagnoses of anxiety and depression and historical attempts at suicide and repeated self-harm, Jack made two further serious attempts to take his own life, on the 29th May 2023. When his mother intervened and frustrated these suicide attempts, he inflicted a grave wound to his left arm Following a formal Mental Health Act (MHA) assessment at Basildon Hospital the following day, Jack’s (informal) admission to a Mental Health Assessment Unit (MHAU) was confirmed as urgent and necessary for appropriate assessment, management and treatment of his anxiety and depression and his impulsive suicide attempts. With the agreement of Jack and his mother, the assessment determined that in the context of his on-going very high level of risk of suicide, with high levels of impulsivity, Jack could not be safely managed in the community. Over the next 6 days the Essex Partnership University NHS Foundation Trust (EPUT) were unable to identify the required in-patient bed anywhere in Essex. Evidence confirmed that demand for such beds outstripped supply and that this had been and remained a chronic issue, locally and nationally. Attempts were made to manage Jack’s risk of suicide in the community with a single visit from a Home Treatment Team (HTT) Psychiatrist on the 31st May and then subsequent short daily visits to Jack at his family home by an HTT Community Psychiatric Nurse. It was acknowledged by the professionals involved in the MHA assessment itself, by the HTT clinicians and psychiatric nurses subsequently involved, as well as by Jack himself and his mother, that his risk of suicide could not be safely managed in the community. Accordingly, Jack’s death by suicide on June 5th 2023 was directly contributed to by the non-availability, over several days, of a bed in an EPUT MHAU in Essex. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (a) A highly vulnerable 20-year-old man, with a history of anxiety, depression and impulsive previous suicide attempts made two further serious attempts to take his own life and inflicted an extensive wound to his arm after those suicide attempts were frustrated by his 2 mother. The subsequent formal MHA assessment determined Jack to be such a high risk of suicide that an immediate period of assessment and treatment as a (voluntary) in-patient on an MHAU was required as his high risk of suicide could not be safely managed in the community. (b) No such bed was available over the six days between the MHA assessment and Jack’s suicide with still no indication, at the time of his death, as to if or when a bed would be available. By default, and notwithstanding point (a) above, the HTT, absent an in-patient bed, became responsible for his care in the community. (c) In his evidence, it was further expressly recognised by the HTT psychiatrist who saw Jack on the 31st May that his “very, very high risk” of suicide at that time could not be managed safely in the community by the HTT and, further, that Jack was “untreatable” in the community. (d) Nonetheless, and notwithstanding the unanimous clinical view, the non- availability of an EPUT MHAU in-patient bed meant that the HTT were required to attempt to mitigate this unmanageable level of risk in the community, something that the HTT was, as had been anticipated, unable to do. (e) The evidence confirmed that a lack of available in-patient beds for high- risk mental health patients who, as was acknowledged at the time, cannot be managed safely in the community, is a chronic and on-going situation in Essex and, the inquest was told, nationally. (f) Jack took his own life by deploying a ligature on the sixth day awaiting the necessary, required in-patient bed. Had an in-patient bed been made available, he would probably not have died. Jack’s death was avoidable. (g) Absent the provision of available mental health in-patient beds for very high-risk patients that formal Mental Health Act assessments have clinically determined cannot be managed safely in the community, then further avoidable deaths by suicide amongst this cohort of vulnerable patients appears inevitable. 6 7 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this 3 report, namely by 5th December 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The Family of the deceased. Essex Partnership University NHS Foundation Trust. Essex County Council. Mid and South Essex NHS Foundation Trust. 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. She 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 13.10.2025 HM Area Coroner for Essex Sean Horstead 4
2 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.
Parliamentary Under Secretary of State for Women’s Health and Mental Health 39 Victoria Street London SW1H 0EU 12 January 2026 Sean Horstead HM Area Coroner HM Coroner's Office County Hall Seax House Victoria Road South Chelmsford CM1 1QH Dear Mr Horstead Thank you for your Regulation 28 report to prevent future deaths dated 13th October 2025 about the death of Jack Mathew Peatling. I am replying as the Minister with responsibility for mental health and patient safety and I am grateful for the additional time you have allowed for me to do so. Firstly, I would like to say how saddened I was to read of the circumstances of Jack’s 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. I also understand that this tragic case is being considered as part of Lampard Inquiry – the independent statutory inquiry investigating the deaths of mental health inpatients in Essex between 2000 and 2023. Your report raises concerns addressed to the Department regarding a lack of available in-patient beds for high-risk mental health patients who, as was acknowledged at the time, cannot be managed safely in the community. I note that NHS England have also provided a response and are aware of the issues in some systems around high bed occupancy and limited local bed availability which can be found here: 2025-0510 - Response from NHS England I understand your concerns. We are determined to bring mental health waiting times down and intervene earlier, so people get the right mental health support at the right time in the right place. I expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting. The NHS Operational Planning Guidance for 2025-26 contains fewer targets across the board to focus on the fundamentals of good care. It sets a requirement for 1 Integrated Care Boards to take action to reduce the average length of stay in adult acute mental health beds, in order to improve local bed availability and reduce the need for inappropriate out of area placement. This involves making use of alternatives described below: • Reducing avoidable ambulance dispatches and conveyances, and reduce handover delays by working towards delivering hospital handovers within 15 minutes, with joint working arrangements that ensure that no handover takes longer than 45 minutes and improving access to urgent care services at home or in the community including urgent community response and virtual ward (also known as hospital at home) services Improve and standardise urgent care at the front door of the hospital by increasing the proportion of patients seen, treated and discharged in 1 day or less using the principles of same day emergency care and optimising the urgent care offer to meet the needs of their local population, including the use of urgent treatment centres . • • Reduce length of stay in hospital and ensure that patients are cared for in the most appropriate setting by increasing the percentage of patients discharged by or on day 7 of their admission in line with existing guidance. Additionally, by working across the NHS and local authority partners to reduce average length of discharge delay in line with the Better Care Fund (BCF) policy framework. ICBs should review BCF commitments to ensure they represent the best use of resources, and plan sufficient intermediate care capacity to meet demand, including through surge periods across the year. Over the period 2026/27 to 2028/29, integrated care boards have been asked to drive real productivity gains including reducing the average length of stay in adult acute mental health beds, through the recently published Medium Term Planning Framework. We have committed £26 million in capital investment to open new mental health crisis centres, reducing pressure on busy emergency mental health and A&E services and ensuring people have the support they need when they need it. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
Mr Sean Horstead
HM Area Coroner for Essex
Essex and Thurrock Coroner’s Service,
Essex County Council,
Seax House,
Victoria Road South,
Chelmsford,
CM1 1QH
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
16th December 2025
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Jack Mathew Peatling
who died on 5th June 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13th
October 2025 concerning the death of Jack Mathew Peatling on 5th June 2023. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Jack’s family and loved ones. NHS England is keen
to assure the family and yourself that the concerns raised about Jack’s care have been
listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for
any anguish this delay may have caused to Jack’s family or friends. I realise that
responses to Coroners’ Reports can form part of the important process of family and
friends coming to terms with what has happened to their loved ones, and I appreciate
this will have been an incredibly difficult time for them.
Your Report raised concerns that there were no inpatient mental health beds available
for Jack despite him being determined as a high risk of suicide and unable to be
managed safely in the community. You were concerned that this lack of bed availability
is a chronic and ongoing issue nationally.
Mental Health Beds
NHS England is aware of the issues in some systems around high bed occupancy and
limited local bed availability. This is related to long lengths of stay and high numbers
of patients clinically ready for discharge but unable to be discharged, leading to flow
pressures across systems. To improve this, in 2025/26, NHS England made £75
million of additional capital available for local systems to invest in improving local bed
capacity and reduce the use of Out of Area Placements.
However, given increasing lengths of stay and the increased number of patients
clinically ready for discharge, providing more beds will be considered as part of a whole
system transformation approach. This was supported by the NHS Long Term Plan
(LTP), which saw an additional £2.3 billion funding invested in mental health services
from 2019/20 – 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 2025/26 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. NHS England is taking steps to address current
operational pressures driving these issues.
If local beds are not available, Out of Area Placements are currently used to ensure
patient care is delivered in an inpatient setting if needed. NHS England plans to reduce
and eliminate the use of Out of Area Placements as they can result in poorer outcomes
for patients and provide additional risk to patient safety.
Essex Partnership University NHS Foundation Trust
Essex Partnership University NHS Foundation Trust (EPUT) has advised that when
there is insufficient capacity to meet all hospital admission demands, the Chair of the
twice-daily situation report meetings is mandated to seek assurance that sufficient
community mitigation and safeguards are in place to continue with community
intervention as an alternative to admission. Furthermore, Home Treatment Teams
(HTTs) are instructed to raise as a priority for admission those individuals for whom
the HTT is unable to provide adequate mitigation and/or where there is an escalating
risk presentation.
If a patient's clinical need is escalated and indicates an urgent inpatient admission is
required, and if there is insufficient mitigation to support a community alternative, a
bed will be sourced. This commitment extends to actively scoping and securing out-
of-area provision when local capacity is exhausted, ensuring that every effort is made
to provide the necessary level of care.
EPUT recognises that the lack of available inpatient beds for high-risk mental health
patients, who cannot be managed safely in the community, is an ongoing challenge.
They are committed to addressing this system-wide issue and preventing further
avoidable deaths.
Since the time of this incident, EPUT has implemented a series of significant changes
aimed at improving patient flow, bed management and overall patient safety:
Clinical Patient Flow Lead: They have introduced a clinical patient flow lead whose
role is to review admission requests against bed demand and support clinical
formulation and decision-making when prioritising beds.
Clinical Director in Flow and Capacity Team: A clinical director has been recruited to
the flow and capacity team. This director is a Consultant Psychiatrist who reviews
complex and high-risk cases, supports the prioritisation of beds against demand and
provides oversight of patients in out-of-area beds.
Surge Management Tool: A Surge Management Tool (SMART) has been
implemented to support patient admission demand and repatriation. This platform
provides a local and system-wide overview of operational pressures, enabling them to
track patient flow between care settings, view current demand and capacity, and map
all patient admission referrals and repatriations from a range of providers and services.
Therapeutic Acute Inpatient Operating Model: A new, innovative operating model for
inpatient care, the therapeutic acute inpatient operating model for adults and older
adults, will be introduced. This model aims to provide consistent quality of care 24/7,
integrated with place-based community models and the wider system. It is designed
to enhance patient experience by working in partnership with patients and carers,
reduce health inequalities and increase Trust capacity to provide high-quality
therapeutic care. The model is informed by national and best practice guidance,
developed by multi-professional clinicians, colleagues with lived experience, and wider
system stakeholders.
These changes detail EPUT’s commitment to learning from past incidents and to the
continuous improvement of their systems and processes to ensure the safest possible
care for patients. Should HM Coroner require any further detail, we would recommend
contacting EPUT directly.
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 Jack,
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
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