Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0551, written 28 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 | 28 Oct 2025 |
|---|---|
| Reference | 2025-0551 |
| Deceased | Patricia Genders |
| Coroner | Nick Armstrong |
| Coroner area | West Sussex, Brighton and Hove |
| Category | Community health care and emergency services related deaths |
| Organisation named | Sussex Partnership 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Secretary of State for Health and Social Care 2 NHS England & NHS Improvement ( reg 28 reports) 1 CORONER I am Nick ARMSTRONG, Assistant Coroner for the coroner area of West Sussex, Brighton and Hove 2 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. 3 INVESTIGATION and INQUEST Patricia’s mental health declined leading to extended periods of time in hospital from August 2020 after demonstrating suicidal ideation and a preoccupation with cliffs. Following a short period of home leave over Christmas 2023, Patricia was discharged in January 2024. Whilst the discharge on 2nd January was the least restrictive option, it was not an appropriate or safe decision given that she was actively non-compliant with medication and the timing of her discharge with regard to the anniversary of her husband’s death and the fact that there was a known delay before the package of care was to be provided. Additionally, Christmas was not an appropriate period to judge the success of home leave, given it is not an accurate reflection of everyday life and likely to involve substantially more social interaction and support than usual. This decision to discharge Patricia possibly contributed to her death. The allocated 5-hour package of care was intended to run alongside the Home First help. This 5-hour package did not materialise, which led to greater social isolation. The absence of the package of care possibly contributed to Patricia’s death. It is worth noting that Home First did not provide cover for the two Occupational Therapists who took annual leave from 12th February. Despite agreed protocols that Police should call the Blue Light Line before conveying patients under Section 136, Patricia was taken straight to the A&E department at the Royal Sussex County Hospital, which was not the most appropriate location. This possibly contributed to Patricia’s death. Having contacted Blue Light Line, the Police were told a place was available for Patricia at Eastbourne Haven and that she should be taken there. The Police should not have refused to transport her. The Haven would have provided a more therapeutic environment, and she would have been under the protection of the Police/Secure Care, both of which can restrain patients under Section 136. This contrasts with the Enhanced Observation Unit which is an unsuitable environment for patients detained under the Mental Health Act. It is also noted that the Eastbourne Haven is not close to any cliffs. The decision not to transport Patricia to Eastbourne Haven probably contributed to her death. Following a failed attempt to abscond during the early hours of 22nd February, Patricia absconded from the EOU later that morning. She was able to walk through the door that was supposed to be secure with ease. Whilst a call was made immediately to Security, communication between ward staff and Security was insufficient to locate Patricia with the necessary urgency. The nurse allocated to Patricia that morning made appropriate attempts to deter her from Regulation 28 – After Inquest Template Updated 15/07/2025 TG leaving the hospital site at which point he did not follow her. Had Patricia been followed, it is possible the Police could have prevented her from reaching the cliffs and therefore preventing her death. This would have made up for the fact that hospital staff were unable to provide police with adequate information to help locate Patricia, partially caused by the fact that staff hadn’t had the opportunity to read Patricia’s notes following handover. It appears that there was, at the time, a general and widespread lack of understanding of the RSCH policy pertaining to absconding patients and staff leaving the site boundary. These factors relating to the response to Patricia absconding possibly contributed to her death. 4 CIRCUMSTANCES OF THE DEATH Patricia Genders died on 22 February 2024 This followed lengthy periods in hospital for mental ill-health, starting from August 2020. Her final discharge was on 2nd January 2024 and the intention was for this to be supported by an agreed package of home care which was absent. A period of worsening mental ill-health followed this discharge. On 21st February 2024, Patricia was detained under section 136 of the Mental Health Act 1983 to facilitate conveyance to a place of safety for mental health assessment. She was admitted to the A&E Department at the Royal Sussex County Hospital and detained under Section 3 of the Mental Health Act and then admitted to the Enhanced Observation Unit and placed under one-to-one arms- length observation. She absconded at about 8:00am on the morning of 22nd February and was subsequently found by a member of the public on the coastal side of the safety fence . Following the arrival of Police, Paramedics and the Fire & Rescue Service, there was an attempt by the Fire & Rescue Service to rescue Patricia. She was taken to A&E and shortly after arrival was pronounced dead at 10:12am. Her mental ill-health means that her capacity and, therefore, her intention when stepping off the ledge cannot be ascertained. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Please also refer to the jury’s findings of fact, which accompany this report and contain the circumstances of Tricia Genders’ death, and Section 4 of the Record of Inquest (the narrative conclusion). My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long. This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around. Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact Regulation 28 – After Inquest Template Updated 15/07/2025 TG on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and firemen at the cliffs. All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation. I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern. The evidence I heard is that three things are required of those responsible for commissioning these services: Strengthening the 111 and Blue Light Line services so that calls are answered and 1. people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment. 2. hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions. 3. available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds. For a while, there will need to be an increase in the number of mental health beds An improved 24/7 crisis response, to deal with those who present at A&E out of Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by December 23, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Care Quality Commission West Sussex County Council Adult Safeguarding Brighton and Hove City Council Sussex Partnership NHS Foundation Trust (SPFT) University Hospitals Sussex NHS Foundation Trust Sussex Police Regulation 28 – After Inquest Template Updated 15/07/2025 TG who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. They may send a copy of this report to any person who they believe 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 Dated: 28/10/2025 Nick ARMSTRONG KC Assistant Coroner for West Sussex, Brighton and Hove Regulation 28 – After Inquest Template Updated 15/07/2025 TG
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.
Department of Health & Social Care Nick Armstrong Assistant Coroner Griffin Building, Gray’s Inn London W C 1 R 5 L N Dear Mr Armstrong, Parliamentary Under-Secretary of State for Women’s Health and Mental Health 39 Victoria Street London SW1H OEU 19 December 2025 Thank you for your Regulation 28 report to prevent future deaths dated 25 th October 2025, about the death of Patricia Genders. I am replying as the Minister with responsibility for mental health 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 Patricia’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. We recognise there are fundamental problems in NHS mental health services and, although the government has already taken significant steps to stabilise and improve this, we know there is still much more to do. Your report raises concerns addressed to the Department regarding the following points: a need to strengthen the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available; an improved 24/7 crisis response to deal with those who present at A&E out of hours; and a need to increase in the short term the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds. In relation to strengthening the 111 and Blue Light Line services, I understand you were informed that only about half of the calls are answered. We are working hard to ensure those experiencing mental health crisis receive swift care in the most appropriate setting and we have made substantial progress, including introducing the mental health option via NHS 111 and expanding 24/7 liaison mental health teams to all general acute hospitals. The introduction of a ‘mental health’ option when calling NHS 111 provides a crisis mental health triage service for individuals who require urgent mental health support. To supplement the NHS 11 1 mental health crisis triage service, we are also deploying mental health professionals in 999 call emergency operation centres and clinical assessment services to ensure people experiencing a mental health crisis are directed towards appropriate services. We continue to increase mental health expertise for ambulance services including ensuring that mental health professionals are embedded in all emergency operation centres and improve training for ambulance staff to enable effective response to those in mental health crisis. Your second recommendation highlighted the need for improved 24/7 crisis response, to deal with those who present at A&E out of hours. Our 10 Year Health Plan sets out ambitious plans to create up to 85 mental health emergency departments as alternatives to A&E for people in crisis and transform neighbourhood mental health services to shift the focus from hospital to community. There has also been investment into a range of wider local mental health urgent and emergency care infrastructure schemes, including: o o o o new and improved crisis cafes, crisis houses, health-based places of safety, improvements to emergency departments and crisis lines. Funding has also been provided for specialised mental health ambulances which are being rolled out across the country. The mental health vehicles will be staffed by both physical and mental healthcare professionals trained to deliver support on-scene or to transfer people to the most appropriate place for care. More broadly, our Urgent and Emergency Care Plan for 2025/26 focuses on those improvements that will see the biggest impact on UEC performance. This includes reducing A&E waiting times to have at least 78% of A&E patients being admitted, transferred or discharged within 4 hours by March 2026. The plan is backed by almost £450 million of capital investment to expand Same Day Emergency Care and Urgent Treatment Centres to avoid unnecessary admissions to hospital and support the diagnosis, treatment and discharge on the same day for patients. Regarding your concern on a need for an increase in the number of mental health beds available in the independent sector. Individual trusts and local health systems are responsible for effectively assessing and managing 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 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 placement, and to reduce waits longer than 12 hours in A&E. 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. I hope this response is helpful and reassures you that we are working to address your concerns. NHSE will be providing a separate response, which will address specific issues in relation to this case Thank you again for bringing these concerns to my attention. All good wishes,
Nick Armstrong
Assistant Coroner
West Sussex, Brighton & Hove
The Coroner’s Office,
Woodvale,
Lewes Road,
Brighton
BN2 3QB
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
19th January 2026
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Patricia Genders who
died on 22nd February 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 28th
October 2025 concerning the death of Patricia Genders on 22nd February 2024. In
advance of responding to the specific concerns raised in your Report, I would like to
express my deep condolences to Patricia’s family and loved ones. NHS England is
keen to assure the family and yourself that the concerns raised about Patricia’s care
have been listened to and reflected upon.
Firstly, it is noted that your Report was addressed to “NHS England & NHS
Improvement”, but NHS Improvement no longer exists and the organisation has been
known as NHS England since 1 July 2022, once the Health and Care Act 2022 came
into force.
Your Report raised concerns with the overuse of Emergency Departments as a space
for people in mental health crisis whilst awaiting a dedicated mental health placement.
You highlighted that 111 and Blue Light Line (999) services need to be strengthened
and that there needs to be an improved 24/7 crisis response to deal with those who
present at Emergency Departments out of hours, through the establishment of teams
who can formally gatekeep inpatient admissions. You also raised that there needs to
be an increase in the number of mental health beds available in the independent sector
whilst longer term systemic change embeds.
National improvements
NHS England is rolling out dedicated 24/7 neighbourhood mental health centres to
better support the community, opening more specialist Mental Health Emergency
Departments alongside general Emergency Departments and having a 24/7
psychiatric liaison team available. A pilot programme for these centres started in
October 2025 which will run until July 2026. This will be followed by an Implementation
Support Programme which will roll out to sites from March 2026.
Alongside this, local system plans will be reviewed by NHS England’s regional leads
to determine whether there is suitable investment in 111 services, where capacity
constraints exist. This review will run from December 2025 – March 2026. Regional
leads will provide feedback to organisations on the plans and discuss areas of
improvement required within the plans.
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.
Since August 2024, the NHS 111 mental health call option has been established
around the country to support reductions in Emergency Department attendance and
Mental Health Response Vehicles have also been established to see and treat patients
away from an A&E setting. New integrated operational pressures escalation levels
(OPEL) scoring systems have also been established for mental health, enabling
greater transparency and escalation of risks across mental health pathways.
NHS England is also taking steps to address the current operational pressures driving
these issues. The 2025/26 priorities and operational planning guidance tasks local
health systems to improve patient flow through mental health crisis pathways and to
reduce waits of more than 12 hours in Emergency Departments.
Regional improvements
Colleagues in NHS England’s South East Region have confirmed that, to improve their
ability to respond to patients in mental health crisis and ensure the needs of mental
health patients are met in an appropriate environment, the NHS has committed to
establish Mental Health Emergency Departments (MHEDs), also described as Crisis
Assessment Centres (CACs), which will be co-located with Type 1 Emergency
Departments. They aim to offer calm, therapeutic settings and ensure timely onward
connection into mental health inpatient provision or into broader community services.
The intention is to provide a dedicated, therapeutic space away from the ‘main’
Emergency Department on a hospital site, acknowledging that the environment of
Emergency Departments is often not suitable to effectively support an individual in
crisis, and that there is harm caused by delays in transfer to more appropriate
environments. The NHS medium term plan 2026-29 asks Integrated Care Boards
(ICBs) to develop a plan for delivering their local approach to establishing MHEDs co-
located with or close to at least half of Type 1 Emergency Departments by 2029.
Sussex Partnership NHS Foundation Trust (SPFT) and Sussex ICB have set out a
series of actions to deliver improvements in the care provided to people in mental
health crisis. NHS England is monitoring the delivery of these plans through joint ICB
and provider oversight meetings. These plans do include reference to increased
capacity in 'blue light' and 111 services, alongside the delivery of 24/7 crisis response
services. Should the Coroner require further information regarding this, SPFT and
Sussex ICB would be best placed to provide this.
Sussex ICB has initially identified 3 mental health ED sites that would offer the greatest
population benefit - Royal Sussex County Hospital (Brighton), Eastbourne District
General Hospital, and either Worthing Hospital or Princess Royal Hospital (Haywards
Heath)
The modelling that has taken place to determine the locations has included population
Health (Public Health) data and needs analysis, Emergency Department attendance,
S136 conveyance data, waiting times for admission, benchmarking data (for example
Mental Health attendances as a percentage of overall attendances), and Sussex
specific analysis.
Sussex is currently implementing Neighbourhood Mental Health Teams (NMHTs)
these are aligned to their Integrated Care Team footprints as they strengthen their
community based neighbourhood offers. This is a combination of the existing Haven
and Staying Well service in the chosen geography. They are working through estate
options and investment opportunities together with alignment with the wider urgent
and emergency care plans. This is ensuring a fully integrated approach across mental,
physical and care needs and aligns with wider community-based assets including the
voluntary sector.
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
Patricia, 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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