Sophie Towle

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

39 Victoria Street 
London 
SW1H 0EU 

11 February 2026 

Alexandra Pountney 
HM Assistant Coroner, Nottingham 
and Nottinghamshire  
24 The Ropewalk 
Nottingham NG1 5EF 

Dear Ms Pountney, 

Thank you for your Regulation 28 report to prevent future deaths dated 25th September 
2025,  about  the  death  of  Sophie  Louise  Towle.  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 Sophie’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.  

Your report raises two concerns addressed to the Department regarding lack of joint 
agency  policy/cross-sector  working  between  physical  and  mental  health  trusts  in 
relation  to  the  insertion  of  foreign  bodies  and  an  issue  of  staffing  on  mental  health 
wards. 

I have been advised by NHS England that ICBs are currently delivering their 3-year 
strategic  plan  for  commissioning  mental  health  inpatient  services.  The  plans  will 
realise the aims set out in the NHS Mental Health Inpatient Commissioning Framework 
(NHS  England  2024).  This  Framework  is  a  national  guide  for  how  Integrated  Care 
Boards (ICBs) plan inpatient mental health services. It sets out what “good” looks like: 
care  that  is  safe,  therapeutic  and  person‑centred;  delivered  as  close  to  home  as 
possible; and integrated with physical healthcare and community support.   

The Medium-Term Planning Framework reiterated the expectation that ICBs should 
only  commission  models  of  hospital  care  in  step  with  this  framework  from  2027 
onwards. The framework makes it clear that during hospital stays, interventions and 
treatment  for physical and  mental health  conditions are  commenced  or maintained, 
and a physical health check is completed.   

In practice, this means mental health inpatient hospitals must actively involve physical 
healthcare professionals in care arrangements where the need exists or arises during 
the stay; though, the day-to-day functioning of this would be up to local determination 
and the patients’ individual circumstances. 

1 

 
 
 Regarding your second concern of staffing on mental health wards, I have been 
advised by NHS England that the National Quality Board guidance outlines the 
expectations and framework within which decisions on safe and sustainable staffing 
should be made to improve health outcomes 
(https://www.england.nhs.uk/wp-
content/uploads/2022/03/Safer_staffing_mental_health.pdf).  

Trusts should provide assurance on staffing levels to the board as per Developing 
Workforce safeguards (https://www.england.nhs.uk/wp-
content/uploads/2021/04/Developing-workforce-safeguards.pdf)”

This improvement resource makes specific reference to adopting the expectations in 
mental health services, recognising the nuances that exist in this provision. It is 
devised for use by NHS staff at all levels, grades, and disciplines, from novice to 
expert and lists all the essential recommendations for safe staffing.  Trusts should 
provide assurance on staffing levels to the board as per Developing Workforce 
Safeguards (https://www.england.nhs.uk/wp-content/uploads/2021/04/Developing-
workforce-safeguards.pdf) 

The Government is not able to comment on staffing levels locally, as responsibility 
for the staffing and operations of mental health services lies with the relevant 
trust.  However, we do recognise the wider need to improve care in NHS mental 
health services. 

Establishment reviews were undertaken across all inpatient areas of the 
Nottinghamshire Healthcare NHS Foundation Trust between September and 
October 2025, reporting into the quality committee in October 2025 and public board 
in November 2025. Overall, the staffing position within the trust’s inpatient areas has 
improved across several key domains. Most inpatient areas are now deploying 
staffing in line with agreed staffing plans.

The use of temporary staffing has reduced significantly across the trust, with 
particularly notable reductions within the Mental Health Care Group. This 
improvement follows targeted work to minimise the use of enhanced therapeutic 
observations and the introduction of strengthened senior oversight of roster 
management and staffing deployment. 

Governance arrangements have also been enhanced. Staffing is now overseen 
through a weekly Executive led Workforce Performance Group, alongside increased 
senior leadership involvement in key staffing decisions. Focused work on recruitment 
has strengthened the overall vacancy position within the inpatient areas, allowing a 
greater level of consistency for service users. This has reduced across the mental 
health inpatient areas from 13.6% in July 2024 to 6.94% in December 2025. 

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

Yours sincerely,

Nottinghamshire Healthcare NHS Foundation Trust  

Highbury Hospital 

Highbury Road  

Nottingham 

NG6 9DR 

2 January 2026 

Private and Confidential  
HM Assistant Coroner Alexandra Pountney 

Dear Ms Pountney  

Regulation 28 Response: Ms. Sophie Towle  

I write in response to the inquest which was concluded on 24 October 2025 into the death 
of Ms Sophie Towle. We accept your findings in relation to the received Regulation 28 and 
offer our sincere apologies to the family of Sophie.  

Please find below the Trust response in relation to the relevant matters of concern and 
actions taken. 

Lack of joint agency policy/cross-sector working between physical and mental 
health Trusts in relation to the insertion of foreign bodies  

Staff  at Nottinghamshire Healthcare  Foundation  Trust  (NHFT) and Sherwood  Forest 
Hospital  Trust  (SFHT) have  collaborated  on  creating  a 
joint  management  policy 
that provides guidance to staff on the management of patients who have inserted a foreign 
body.  This includes the recommendation of joint meetings to support joined up collaborative 
care  for  patients  requiring  support  from  both  services.  This  is  being  trialled  for 
three months, and the impact of its use will be reviewed.  

Sherwood Forest Hospitals shared the draft of the policy for the management of insertion of 
foreign  bodies for input  from  mental  health  services.  We  have  reviewed  from  a  Liaison 
Psychiatry and inpatient perspective and agreed interface and actions alongside the need 

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
 
 
 
 
 
 
 
 
  
 for  multi-agency  joint  reviews  where  indicated.  The  roles  and  responsibilities  of  each 
agency are outlined in this policy. 

VTE risk assessment and associated policy and training at Nottinghamshire 
Healthcare Foundation Trust  

a.  The staff do not have a proper working knowledge of the current local VTE 

policy.   

We have worked with our E-learning department to create an electronic link to the policy 
and  competency  questions  to  ensure  that  people  have  both  read  and  understand  the 
implications of the policy to their practice. It will be reportable so that there is oversight and 
assurance that all who need to be aware of the policy have read it. This has been trialled as 
a pilot to ensure it is effective and functional prior to being fully rolled out and will report into 
the Urgent Care Improvement Group for ongoing oversight.  

b.  The knock-on concern from this is that the training around the VTE policy is 
not robust in its content or is otherwise not being properly engaged with by 
staff.   

E-learning training for medical  staff  members  has  recently  gone  live  and  uptake  will  now 
be monitored for compliance. The e-learning was created as a bespoke module recognising 
that the modules available on Learning for Healthcare were only relevant to physical acute 
hospitals and primary care. The locally developed Trust module also places significant focus 
on the risks of VTE associated with Psychiatry. The development of this module is aligned 
to  the  NICE  guidance  (Venous  thromboembolism  in  over  16s)  and  the  evidence  base 
available through Thrombosis UK online source.  

A  reflective  learning  session  was facilitated on  the  22  July  2024  with  the  medical  team 
involved in Sophie’s care by a Trust GP and the Associate Director for Physical Health. This 
learning  was also  shared  via  presentation  to  the  Resident  Doctors  Forum  on the  16  July 
2024 and shared through the physical health forum for wider consideration across services.  

The Electronic Patient Record system RiO was updated in June 2024 to ensure clarity that 
all inpatients require VTE assessment with a mandatory field of actions to be taken if there 
are risk factors identified. This also includes a risk alert activation on the patient’s electronic 
record. Amendments  were  made  to  the  VTE  risk  assessment  template  form  within  the 
Electronic  Patient  Record  system  RiO  in  June  2024  to  ensure  clarity  that  all  inpatients 
require a VTE risk assessment on admission with the addition of a mandatory field of actions 
to been taken if there are risk factors identified. This also includes a risk alert activation on 
the patient’s electronic record.  

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
  
  
   
  
  
  
  
 
 Additional training was delivered to Fir Ward staff to support identification of a deteriorating 
patient,  this  included  simulations  and  tabletop  National  Early  Warning  Scores  (NEWS2) 
reviews.  

To increase staff awareness a VTE poster has been developed and is displayed in ward 
offices and clinic rooms.  The Trust VTE policy was reviewed and updated in April 2025 to 
amend the frequency of re-assessment of VTE risk, provide clarity on which patients require 
re-assessment  of  VTE  risk  and  the  training  expectations  of  those  performing  VTE  risk 
assessments.  

An E-Learning module for VTE risk prevention and management for medical staff within the 
trust has been developed, which has been peer reviewed with consultants from other mental 
health trusts and is now live with the expectation of this being annual essential training.  

The  ‘Fundamentals  of  Care’  training  package  developed  for  Nursing  and  Allied  Health 
Professional  Staff  was  updated  in  May  2025  to  include  VTE  risk  assessment  alongside 
recognition, assessment and actions required in relation to other essential physical health 
conditions. There have been 1084 staff trained to date and further regular sessions as part 
of the trust training offer.  

VTE assessment has been added as a metric in the Trust’s Integrated Performance Report 
to ensure adequate visibility, governance and assurance.  

VTE Assessment is included in the Safe Now Dashboard which ensures weekly Associate 
Director of Nursing (ADON) oversight and is reported up to the Trust Executive Leadership 
Team.  

c.  The current policy has been weakened in its terms, in particular at paragraph 
1.6 where the requirement for an updated assessment of risk on at least a 
weekly basis has been removed. I understand from the evidence 
that, notwithstanding the wording changes to the policy, prompts are given 
on VTE risk assessment at the weekly MDTs. I am concerned that the policy is 
not reflective of the encouraged practice on the Wards. I am also concerned 
that, whilst this happens on Fir Ward, it is important that guidance is 
consistent across all wards within the Trust. The common document across 
the wards is the local policy and therefore I am concerned about the clarity 
and robustness of its terms.   

The revised policy was reviewed in line with NICE guidance (Venous thromboembolism in 
over  16s;  reducing  the  risk  of  hospital  acquired  deep  vein  thrombosis  or  pulmonary 
embolism,  2019).,  As  part  of the  review  of  the  policy,  policies  from  4  other  mental 
health organisations  were reviewed  for comparison on  standards  relating  to  VTE  risk  re-

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
  
  
  
  
  
  
  
  
 assessment. The review of our policy and subsequent changes are in line with other mental 
health organisations.  

The policy expects that VTE reassessment is carried out at the time of a change in clinical 
condition  or  risk. This  has  been  reflected  within  adult  mental  health  services  inpatient 
areas within the daily board  review  process  which  now  includes  prompts  relating  to  VTE 
risks  and reassessment. This  is  a  daily  process  to  adhere  to  the  requirement  to  early 
identification of change rather than a previous focus on re-assessment at least weekly which 
could  have  resulted  in  further  missed  opportunities.  This  process  ensures  timely 
identification and response to a change in risk factors.  

Within the ward based weekly Multi-disciplinary Team (MDT) meetings, a review of VTE risk 
changes remains within 
team  are  considering  any 
identified new changes that  have  occurred  since  the previous MDT which  have  led  to  the 
need for reassessment.   

to  ensure 

template 

the 

the 

Ward Managers or the nurse in charge of the ward attends daily ‘Safe Care Meetings’. This 
is a meeting where staffing, clinical needs, acuity and other factors impacting on the wards 
are  raised  to  the Matrons  and  Head of  Nursing.  This reports into  a  daily  Sit-Rep  meeting 
which  reviews  any  issues  of  concern  or  unmet  needs  and  either  provides,  authorises  or 
further escalates unmet needs for action to senior levels in the Trust.   

The  VTE  policy reflects the  expected  standard  across  our Trust inpatient  services.  It  is 
recognised  that  the  local  systems, processes and  practice  need  to  be  included and 
reflected within the Trust policy. Within the next 3 months, an appendix will be added to the 
policy 
in 
approach 
the 
delivering practice against this policy standard.   

our inpatient services 

outlining 

across 

local 

The disbanding of the Personality Disorder Hub at NHCT  

In line with wider community mental health service improvements, the Personality Disorder 
pathway has been reviewed and an associated improvement plan developed. The pathways 
consist of two parts: a hub, which is senior clinical leads, and the spoke part, which relates 
to the clinical staffing linked to each local mental health team. As part of the Improvement 
Plan, the Personality Disorder Hub has not been disbanded. Key clinical leads from within 
the  Hub  will  remain  in  place  to  ensure  ongoing  oversight  of  the  clinical  interventions, 
development  of  the  clinical  pathway  and  oversee  and  evaluate  clinical  effectiveness. 
Changes to the spoke part of the pathway has been made which is in relation to the line 
management of the staff within the spoke part of the personality disorder pathway. Further 
details in relation to this are outlined below.   

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
  
  
  
  
 
 
  
 
 
 Background  

The Personality Disorder pathway was implemented in 2021/ 2022 in line with NHS England 
recommendations (https://www.longtermplan.nhs.uk/publication/nhs-mental-health-
implementation-plan-2019-20-2023-24/   with  an  ambition to  create  a  clear  Personality 
Disorder  treatment  pathway,  improve  access  to  evidence-based  psychological  therapies, 
reduce  waiting times and  increase  available  staff  training  on  Personality  Disorders.  The 
changes aimed to include ensuring equity in the offering of specialist psychological therapies 
for  Personality  Disorder,  employing  specialised  Personality  Disorder  Practitioners  placed 
within Local Mental Health Teams (LMHT) in liaison roles and offering training and guidance 
to Trust-wide services.   

As part of the improvement programme of works for mental health community services, the 
Personality  Disorder  Pathway  was  highlighted  as  an  area  of  concern.  This  follows  an 
independent  evaluation  carried  out  by  the  University  of  Nottingham  and  the  Institute  of 
Mental Health (IMH) and a more recent report in 2024 from Jonathan Warren that consisted 
of an evaluation of the service and an externally commissioned review of the functioning of 
community mental health services.   

To further assess the current service provision the pathway was reviewed and benchmarked 
against  NHSE  Maturity  Index  for  Complex  Emotional  Needs in  March  2025.  This  is a 
national tool to  support  organisations  and  whole  systems  of  community  transformation  in 
assessing their level of service development to deliver transformed services for people with 
personality  difficulties  across  the  breadth  of  the  community  and  in  a  way  that  supports 
people to access services at the right time and place to meet their needs appropriately.  

The maturity index applies to those involved in the leadership, management and delivery of 
services, in primary care, secondary care, the voluntary sector, local authorities and most 
importantly those people with lived experience of the system and services.   
It consists of a series of questions and prompts that are drawn from the ‘Annexes: Guidance 
to help development of 2021/22 proposals for adult and older adult community mental health 
transformation  funding’,  the  3  year  community  mental  health  roadmap  with  supporting 
annexes, Mental Health Implementation Plan 2019-2024, and the case for change document 
National Confidential Inquiry into Suicide and Safety in Mental Health Report (NCISH).  

The Maturity Index is a benchmarking document based upon The Community Mental Health 
Roadmap which was developed as part of the national transformation programme to guide 
systems in considering the key elements required to deliver community transformation at a 
system wide level.    

The roadmap is broken down into both the specifics for complex emotional needs services 
as well as the critical core elements of service. (see figure 1 below).  

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
 
 
 
 
 
 
 Figure 1 

Findings of the Review and Next Steps  

Governance & Leadership  
Of  the  ten  specific  core  domains  three  areas  were  deemed  not to be  in  place  and 
action was required which were a strategic planning and working group in place to meet the 
core needs of people with a Personality Disorder inclusive of key stake holders from VCSE, 
third sector and Primary Care, inclusive of joint working with the Trust’s Chief Psychological 
Professions Officer. A further unmet need was in relation to the wider concept of ‘No Wrong 
Door’ approach and wider collective responsibility for a patient’s treatment. Two domains 
were found not to be in place but actions in place to address which was having in place a 
specific planning meeting, it was recognised there is currently a fortnightly oversight meeting 
however this was commissioned by the Care Group Nurse, AHP & Quality Director as part 
of the wider Improvement plan, with aims to agree the longer term planning group and a gap 
in relation to longer term strategic planning with clear ambitions, outcomes and deliverables 
with milestones. 

Four  domains  were  rated  as  being  in  place  but  need  improvement;  these  were  a  lead 
professional  being  in  post,  although  there  is  a  named  individual, issues  were  found  in 
relation  to  the  resilience  of  this  role,  wider  strategic  and  system  support  needed. Lead 
professional feeding into pathway steering group, although this was in place initially this was 
stood  down  and  needs  to  be  recommissioned  following  the  improvement  group  work. 
Experts by experience are part of the core model however it was identified that this needs 

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
 
 
 
 
 to be stronger and more visible and lastly there was very limited provision to measure patient 
experience. There are no agreed and rolled out patient rated outcome Measures (PROMS) 
in line with national recommendations although Core 10 (a patient rated outcome measure) 
is  in  place.  One  domain  was  found  to  be  working  well  and  that  was  having  a  dedicated 
Psychologist with significant clinical expertise within this field of practice.   

Establishment & Core Function  
On review of these 24 domains 13 were rated to be not in place and include access to CAT 
therapy,  a  clear  clinical  model identifies modes  of  treatment,  adopted  principles  across 
inpatient  and  crisis  services,  training  to  crisis  and  inpatient  teams  alongside  governance 
over longer stay inpatient admissions and interlinked pathway. Eight areas were identified 
as  being  in  place  but  required  improvement  which  include  the  range  of  evidence  based 
interventions, MBT is available but not part of the Adult Mental Health  or clinical pathway, 
no clear strategy to access Health Education England (HEE) funded training places, wider 
training with a focus on partner in primary care and subsequent developed relationships, 
three domains were assessed as working well and this was Dialectical Behaviour Therapy 
(DBT) being part of the pathway however no current data on demand and no current waiting 
list, adherence to evidencing criteria for level 2 inpatient rehabilitation but not for acute and 
wider support for carers growing with the carer support worker roles.  

Intervention and Support Across the Core Mental Health Teams  
This section incorporates ten domains, six domains rated as not being in place and requires 
action;  these  include  sections  such  as  wider  link  and  scoping  with  Primary  Care,  Local 
Authority, inclusive of GP leads being in place and supporting with work, engagement with 
Voluntary,  Community,  Social  Enterprise  (VCSE)  and  wider  working  as a holistic  MDT, 
evidence of culturally sensitive interventions and wider awareness of regulating emotions 
across  pathways.  Three  domains  have  been  rated  as  being  in  place  but  require 
improvement and these are Understanding and having VCSE infrastructure as part of the 
wider  patient  pathway,  a  consideration  of  cultural  differences  and  how  these  differences 
could present, integrated core services considering the whole person, which is partly met 
associated to wider roles within the LMHT. One domain was rated as working well which 
was having a core assessment which is based upon a biopsychosocial model.   

Dedicated Function, Support and Consultation to the Local Authority, VCSE & 
Primary Care  
Two domains were rated as not being in place and require action which include having an 
operational model for training, consultation and support for Local Authority, VCSE, Primary 
Care  to  upskill  clinicians,  and  a  lack  of  function  for  services  to  reflect,  consult  and  wider 
reflective thinking. Two areas rated as being in place but require improvement and these 
are scoping and provision of training and associated training needs, whilst some training is 
available there is a wider requirement needed to meet these wider core domains.   

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
  
  
  
  
 Provision to Meet the Needs of Young People, With Alignment to Children & Young 
People’s Services  
Many domains within this section were rated as being in place but require improvement. The 
service  does  have  a  transitional  protocol  with  a  Young  Persons  transitions  lead 
however additional improvements  are required to  evaluate  and demonstrate changes  to 
services  based  on  Young  People’s  experiences  of  services  alongside  wider  workforce 
development being evidencable to meet the need of this patient group.  

Provision for Older Adults  
All four domains were rated as not in place and require action.   

Embed Experts by Experience in Service Development and Delivery  
One domain rated as not in place and requires action which was having lived experience as 
part of pathway governance meetings and operational groups, two domains were rated as 
not being in place but actions in hand to address which is having some dedicated resource 
to support coproduction and principles of coproduced commissioning in place. One domain 
has been rated as in place but requires improvement and this is in relation to Peer Support 
Worker roles & lived experience roles. Three domains rated as being in place & working well 
and this is in relation to recruitment of lived experience roles and associated support.  

Creating a Service Offer that Supports a Preventative Approach  
One domain rated as not being in place and requires action which was having a service in 
place that focuses on prevention and escalation into secondary care services, one domain 
was  in  place  but  needs  improvement  and  this  was  around  support  for  people  waiting  for 
intervention, one domain not in place but action in hand relating to personalised care.   

Organisational Change Requirement & Consultation  
On completion of the maturity index, it was clear there were wider improvements required to 
the PD pathway for patients. An organisational change was proposed and approved by the 
Executive  Leadership  Team,  the  Mental  Health  Care  Group  Senior  Leadership Team 
(SLT) and the Care Unit SLT.   

The organisational change case for change stated, whilst it is clear the current Personality 
Disorder Service has dedicated staff that are passionate about delivering services to 
people with Personality Disorder, the current service configuration led to a fractured 
pathway where:  

•  Core interventions such as MBT are not properly integrated  
• 

Inequitable waits for interventions for people that are not open to the Personality 
Disorder Pathway  

•  An inconsistent approach delivered across teams for people with a personality 

disorder.   

•  One of the key directives for the Personality Disorder Pathway was to increase 

access to services including to Psychological Interventions creating a needs-led, 

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
  
  
  
  
 
 community-based offer could be developed for patients with the most complex 
needs. This would have a direct impact on admission rates to acute care which 
currently has not been supported by clinical data. Service change is required to 
ensure patient need is met, with measurable clinical outcomes and joined up 
pathways across the wider system.  

The change that  was  completed  integrated  key  workers  from  within  the  PD  pathway  into 
core  local  mental  health  teams  (LMHTs).  This  change constituted a  change  in  line 
management,  as  it  was  clear  from  the  review  that  the  pathways  were  fractured,  with  an 
inequitable service offer based upon the geographical area.   

The  PD  Hub,  which 
needs remains in place.   

is 

the  overarching  strategic 

lead 

for  Complex  Emotional 

The  Lived  Experience  Development  Lead  moved  under  the  line  management  of  the 
Associate Director of Nursing, with a broader responsibility to embed lived experience and 
peer support across all Local Mental Health Services.  Supporting our ambition to increase 
the number of lived experience roles across the community.   

The  review identified that  based  on  Nottinghamshire  prevalence  rates  for  Complex 
Emotional  Needs,  having  a small,  segregated resource  was  creating  not  only  a  health 
inequality but people with complex emotional needs were not experiencing the same level 
of intervention as other people with another mental health condition or diagnosis. There was 
also significant variation in caseload numbers some being as low as 6 for 1.0wte worker and 
low  levels  of  clinical  activity  whilst  internal  community  mental  health  waiting  lists  for 
interventions  for  people  with  Complex  Emotional  Needs,  who  were  not  open  to  the  PD 
pathway was growing with the longest wait over 48 weeks. To support wider integration and 
reduce the clear health inequality, the Mental Health Practitioner (MHP) roles, community 
support  workers  and  Peer  Support  Workers  were  merged  into  the  LMHTs,  continuing  to 
work  with  their  patient  caseload,  however  with  the  same  remit  as  their  colleagues  within 
teams.   

In  line  with  NHS  organisational  change  processes  consultation  with  staff  from  the 
Personality  Disorder  Pathway  occurred  from  the 13 August  2025  to  24 September  2025 
(extension of 2 weeks). Counter proposals were received from some staff however all had 
cost  implications  or  further  risks  such  as  wider  segregation  and  not  in  line  with  the  NHS 
Mental Health Community Framework.   

As the intention was for no reduction or closure in services, (as described within this paper, 
all patients open to the Personality Disorder pathway were also open to core LMHT teams) 
and given  the  two  previous  independent  reviews  and  the  assessment  against  the  NHSE 
maturity  index, no  wider  consultation  was  thought  to  be  required, given  the  emphasis  on 
improving access and reducing health inequalities.  

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
 
 
 
 
 
 
 Impact on Clinical Activity   
As  part  of  the  review,  attempts  had  been  made  to  quantify  clinical  activity.  The  data 
suggested that across the core service patients accessing the Personality Disorder pathway 
on average received one contact per week. Clinical staffing activity was also reviewed and 
data  recorded  suggested  on  average  that  per  WTE,  8  clinical  contacts  are  delivered  per 
week. Whilst it is recognised that some staff are currently attending additional training for 2 
days per week, we would expect to see a higher level of clinical activity given that this staff 
group are not conducting a wider series of tasks as seen within Local Mental Health Teams.   

92% of CEN (Personality Disordered) patients, were seen by the staff within the LMHTs, 
with only 8% being supported by the PD Spoke Service.   

Due to the configuration of the separate Personality Disorder Pathway, the people that were 
accessing the Personality Disorder pathway were not part of core LMHT MDT oversight and 
planning, did not have wider access to roles such Health Improvement Workers and were 
not part of the daily risk oversight meetings that core LMHT services operate.   

This change formed part of a wider programme of work focusing on:  

1.  Clear communications to all LMHT workforce regarding the expectation for all to 

work with and treat people with a Personality Disorder / Complex Emotional Needs.  

2.  Rebranding of the pathway moving away from stigmatising labels of diagnosis.  
3.  Development of a workforce training plan for all clinical staff within LMHTs to meet 
the needs of people with Complex Emotional Needs inclusive of SCM training.  
4.  Review of roles aligned to the Hub alongside development and clarification of key 

areas of accountability and responsibility.  

5.  Ensuring that the pathway is psychologically informed and therefore the lead is 

recommended to be a psychologist by professional registration.   

6.  Consideration of the wider roles and need for a Nurse Consultant, working part 

clinically.   

7.  Identifying key areas of training and wider pathway resilience across core 

community services.  

8.  Redesign of the Hub consultation meeting in terms of ToR and attendees.   
9.  MBT service to be relocated to AMH Community Services. Wider work as part of 

this is to explore the form and function of this service to ensure fidelity.  
10. Patient PROMS to be aligned to national guidance in line with wider LMHT 

improvement work.  

11. Monthly pathway steering group to be initiated that also considers specific Equality, 

Diversity & Inclusion data and enablement strategies.   

12. Clear clinical pathways to be developed across Acute and Crisis services.   

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
 
 
 
 
 
 
 13. Pathway development to be agreed in line with stepped care model considering 

brief, moderate and intensive treatment with clarity around complexity to aid clinical 
pathway navigation.   

Pathway improvement work to develop in the form of a project plan in line with the Maturity 
Index.  

Overview of PD Pathway Vs Proposed Complex Emotional Needs Pathway  

PD Pathway  Proposed Complex 

Comments  

Emotional Needs 
Pathway within Core 
LMHT  

Wrap-around MDT    No   

Yes   

Embedded within 
daily Risk meeting  

No   

Yes  

Access to the 
service   

No change   

Referral pathway  

No change  

Location of service   

No change  

Access to MBT  

No   

Yes  

Access to DBT  

In part  

Yes  

Embedding the newly proposed 
pathway within core LMHT teams 
will support wider integration.   
Embedding the newly proposed 
pathway within core LMHT teams 
will align to risk and oversight 
meetings.  
Usual routes for access will 
remain via internal and system 
partners.   
The same referral pathway via the 
LMHT remains in place.   

The service offer will continue to 
be available across all localities.   

This service is 
currently operated within the 
forensic care group, the proposal 
recommends that this is reviewed 
and considered to be part of the 
wider clinical pathway.  
There is currently variation in 
access to this intervention. The 
proposal includes having access 
to DBT for all geographical 
localities.   

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 Access to Structured 
clinical management  

Yes  

Yes although 
improved.  

Access to 
supervision  
PD HUB  

Yes  

Yes  

Yes  

Yes  

Patient rated outcome 
measures  

No  

Yes  

Lived Experience   

Yes  

Yes  

Waiting Time   

Yes  

As part of the wider proposal 
change and due to prevalence 
rates for complex emotional 
needs, the wider core LMHT will 
work with all patient needs 
therefore growing access to 
interventions for people with 
complex emotional needs.  
No change has been made to this 
offer.  
The PD Hub as it is currently 
known is made up of 3 senior 
roles that support the oversight of 
the clinical pathway, training and 
supervision. There are no plans to 
change this approach.   
In line with current improvement 
work patients within the Complex 
Emotional Needs pathway will be 
part of the wider PROMS roll out 
within core LMHT services.  
There will remain lived experience 
embedded into the core pathway 
and no changes proposed to 
change this.  
We will see a positive impact on 
waiting times for people with 
complex emotional needs with 
moving away from a smaller 
segregated workforce working 
with a smaller number of patients 
outside of core community teams. 
The growth in the pathway 
expectations will ensure there is 
the right staff with the 
right expertise and training to 
better meet demand.  

Next Steps for the Complex Emotional Needs Pathway   
The Terms of reference, agenda and membership for the Complex Emotional Needs have 
been developed, the first meeting took place in November 2025. The ICB is a core member 
of  this  group,  alongside  a  range  of  clinicians  and  service  representatives,  who  will  work 
together to shape the future of treatment provision. The meeting will be chaired by the ADOP 

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
  
  
 for Mental Health Community Services, however, the lead for this meeting will be the CEN 
Senior Psychologist.   

Expected Impact  

Following the changes being implemented that have been discussed within this paper we 
envisage the following impact.  

•  All staff working within mental health community services to work with people with 

Complex Emotional Needs.  

•  Community mental health teams training analysis across the workforce to include 

intervention for people with Complex Emotional Needs.  

•  The clinical pathway to be clearly developed with a stepped care level of input for 

people with Complex Emotional Needs.  

•  Due to the reconfiguration of the Personality Disorder Pathway people with 

Complex Emotional Needs to not exceed wait times of 18 weeks for treatment.  

•  People with Complex Emotional Needs that the PD pathway had struggled to 

engage were discharged to the LMHT service. This caused poor patient outcomes 
and fractured engagement. Due to the change in configuration people will not be 
discharged from one worker to another based on engagement. The emphasis will 
be on therapeutic engagement and personalised care.  

•  Services that sit outside of core Mental Health community services but see patients 
with Complex Emotional Needs will be reviewed to consider the patient experience 
and removal of internal bureaucracy.  

•  Patients with Complex Emotional needs have the same level of risk oversight, 

risk management and risk escalation as all patients within community mental health 
teams.  

•  Patients being seen with Complex Emotional Need will be offered and encouraged 
to complete patient rated outcome measures, the same as wider patients within 
core mental health community teams so that their care and input can be measured 
and evaluated.  

•  The level of intervention for people with Complex Emotional needs will available 
across all geographical localities of Nottinghamshire and removal of a health 
inequalities such as increased access to CBT which was only available in the North 
of Nottinghamshire.  
In line with wider community improvement work in relation to working with VCSE, 
third sector and other organisations, people with Complex Emotional Needs will be 
part of this and included within this work.  

• 

•  The Complex Emotional Needs steering group has a bespoke Improvement Plan 

which incorporates all areas of improvement required in line with the Maturity Index 
for Complex Emotional Needs.   

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
 
  
 
  
  
 Summary  
An internal review of the Personality Disorder pathway was carried out due to quality and 
patient experience  concerns across  wider  community mental health  services.  The  review 
was  based upon  NHS  England  Maturity  Index  for  people  with  Complex  Emotional  needs 
and benchmarked against the Personality Disorder pathway and wider community mental 
health services. Central to the review was patient experience, feedback and health equality. 
The  outcome  of  the  review  will  ensure  services  are  designed  and  developed  in  line  with 
patient  need  opposed 
to evidence based 
interventions for people with complex emotional needs regardless of where they live. The 
review  and  changes  proposed demonstrates a  continual  commitment 
to  service 
improvement based on quality, safety and meeting the needs of the local communities in 
which we serve.   

to  service  need  with equitable access 

Staffing on mental health wards  

As  discussed  at  the  Inquest,  the  safe  staffing  tool identifies what  staffing  numbers  are 
needed is set by NHS England via the Mental Health Optimal Staffing Tool, (MHOST). In 
October  2025,  the  Trust  reviewed  the  staffing  establishment  tool  (MHOST)  which  were 
agreed  by  the  Ward  Managers, Matrons and  Nurse  Directors  to  be  sufficient  to  meet  the 
clinical demands. This then reports to the board for oversight at the most senior level within 
the Trust.   

Any staffing concerns are raised in the morning ‘safe now’ meeting where staffing for that 
day and the following few days are reviewed to ensure that there are enough staff on each 
shift and to authorise additional staff via the trust ‘bank’ of staff if there isn’t adequate staffing.  
The final state is the authorisation to book agency staff if regular or bank staff are unable to 
fill the shifts. If observation levels change for patients on the ward which indicates more staff 
are needed, this will also be reported through this meeting. If the requirement for additional 
staff  occurs  outside  of  this  meeting  time,  direct  approval  to  book  additional  staff  can  be 
sought 24/7 via the out of hours silver on-call manager.  

Staffing  levels  are  reviewed  in  the  daily  ‘sit-rep’  meetings,  which  is  the  point  that  any 
concerns are actioned if needed. Within this meeting, the balance between substantive staff 
and  temporary  staff  is  reviewed,  this  is  to  ensure  there  are  substantive  staff  who  know 
the patients and ward environment. There are a number of bank staff that do work regularly 
on certain sites and also develop this knowledge of the patients and environments. Staffing 
levels are also discussed with the Chief Nurse and the Nurse Directors of the care group in 
a senior meeting weekly for Trust oversight.   

Within the inpatient environments, the Trust has a high percentage of newly qualified nurses 
in their preceptorship period. Due to recognising their experience is minimal at this point in 
their career, the preceptee is not left as the only registered nurse on a ward and will have a 
more experienced nurse working at the same time, leading the shift.   

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
 
  
  
  
  
 The attendance at the Safe Care and Sit-Rep meetings has been streamlined so that the 4 
inpatient Matrons take it in turns to attend with the expectation that the other Matrons are 
attending the board reviews and, on the wards, to review firsthand the staffing levels on the 
wards and to oversee clinical quality on the ward. Any concerns will also be escalated to the 
Head of Nursing and Associate Director of Nursing.   

To support preceptee nurses there are Practice Development Nurses in post who work on 
the wards to role model, mentor and coach staff and also deliver direct training. These are 
directly overseen by the Head of Nursing who also spends time on the wards and with Ward 
Managers to understand the current ward contexts and senior clinical nursing support.   

A review of ward inductions is planned with learning taken from areas of good practice within 
the Trust. The Head of Nursing will work with Practice Development Nurses to review the 
inductions,  which  include  assessments  of  competence  for responsibilities  such  as 
observations. and  support  teams  to  embed them. The  observation  competencies  are 
completed by all staff prior to them being able to access the electronic observations system. 
The additional quality work will be completed by March 2026. 

The staffing for Fir ward for the past two months is indicated in the table below:  

100% equates to the basic MHOST safe staffing rate which for Fir ward is 6 staff on an early 
shift, 6 staff on a late shift and 5 staff on a night shift for up to 17 patients.  2 of these staff 
are planned on the rosters to be Registered Nurses.  

As seen above the ward is consistently above the 100%. The temporary staffing figures are 
the percentage of staff that are not working as a substantive member of staff on the shift on 

Highbury Hospital, Highbury Road, Nottingham NG6 9DR 

 
 
 
 
  
  
  
  
  
  
 
  
 the ward. This can include substantive staff picking up additional shifts, regular bank staff 
that work on the ward and also other bank or agency staff. The temporary staffing figures 
are mostly in line with the increase from baseline of the fill rate.   

The Trust has taken the concerns highlighted seriously. I hope that this response provides 
you, Sophie’s family and the other parties involved with reassurance in terms of changes 
already made and ongoing plans to improve these important areas of patient care moving 
forward. 

Yours sincerely 

Deputy Chief Executive Officer 

Highbury Hospital, Highbury Road, Nottingham NG6 9DR

Inquest touching the death of Sophie Towle

Response of Sherwood Forest Hospitals NHS Foundation Trust to Regulation 
28 report to prevent future deaths

This is the organisational response from Sherwood Forest Hospitals NHS Foundation 
Trust  (SFH)  to  the  Regulation  28:  Report  To  Prevent  Future  Deaths  issued  by  HM 
Coroner,  following  the  conclusion  of  the  inquest  touching  the  death  of  Miss  Sophie 
Towle. 

We offer our condolences to Miss Towle’s family, and we hope this response, the new 
guideline  for  the  management  of  deliberately  inserted  foreign  bodies  and  the 
introduction  of  a Mental  Health  Inpatient  Transfer  to  an  Acute  Hospital  –  Hospital 
Passport provides reassurance that the Trust recognises and acknowledges its failings 
and is committed to ensuring that we learn from this to prevent future deaths.

The two matters of concern raised within the report which relate to SFH (points 1 and 
4) and responses for each point are as follows:

1) Lack of joint agency policy/cross-sector working between physical and 
mental health trusts in relation to the insertion of foreign bodies

During  the  Inquest  it was  acknowledged  that  there  is  no  embedded  mechanism  for 
arranging  a  multi-disciplinary  team  (MDT)  meeting  between  the  psychiatric  team 
(Nottinghamshire  Healthcare  NHS  Foundation  Trust)  and  the  physical  health  team 
(Sherwood  Forest  Hospital).  In  addition,  the  inquest  highlighted  that  there  was  no 
clinical  documentation  or  guidance  for  staff  which  prompts  physical  health  staff  to 
consider an MDT approach. 

In  response  to  these  findings,  a  series  of  cross-organisational  meetings  were 
convened  between  Sherwood  Forest  Hospital  and  Nottinghamshire  Healthcare, 
facilitated  by  the  Governance  Support  Unit. The  purpose  of  these  meetings  was  to 
explore methods by which both organisations could work collaboratively, specifically 
in relation to patients who have deliberately inserted foreign bodies, as well as other 
patient cohorts who may require input from both the psychiatric and physical health 
teams. 

During these discussions, the implementation of the "Mental Health Inpatient Transfer 
to an Acute Hospital – Hospital Passport", which was already in development by the 
Sherwood Forest Hospital’s Mental Health Specialist Nurse, was considered. It was 
agreed that this passport would be utilised for all inpatient mental health transfers from 
Nottinghamshire  Healthcare  to  Sherwood  Forest  Hospital.  The  aim  is  to  improve 
communication  with  Emergency  Department  colleagues  and  the  discharging  team, 
where appropriate.

The Mental Health Inpatient Transfer to an Acute Hospital – Hospital Passport includes 
contact details for key locations, which staff have identified as beneficial for facilitating 

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 effective  communication.  Both  organisations  have  reaffirmed  their  commitment  to 
enhancing  communication  between  the  Trusts.  The  Governance  Support  Unit  at 
Sherwood Forest Hospital have agreed to organise a meeting at the end of February 
2026 with Nottinghamshire Healthcare to review implementation of the Mental Health 
Inpatient Transfer to an Acute Hospital – Hospital Passport. A 3-month review date has 
been agreed due to the low numbers of mental health patients requiring transfer to 
acute services. The aim of the review meeting is to collaboratively discuss usability of 
the passport and provide an opportunity to discuss any challenges which have been 
identified and identify any further actions or amendments required. 

In addition to the introduction of the passport, the new guideline for management of 
patients with deliberately inserted foreign bodies, as detailed in part 2 of the response, 
has  been  developed.  These  procedures  provide  clear  guidance  regarding  the 
circumstances in which an MDT is required, specify the team responsible for arranging 
the meeting, and reflect a shared commitment from both organisations to ensure that 
MDT discussions are undertaken in order to safeguard our patients. 

4) The policy and procedures around the management of insertion of foreign 
objects for SFH

During  the  Inquest  proceedings  HM  Coroner  reported  that  the  standard  operating 
procedure (SOP) for the management of deliberately inserted foreign bodies content 
was lacking in specificity, had vague language which was open to interpretation and 
did not provide clear advice to medical professionals accessing it for guidance. HM 
Coroner also acknowledged that there was no reference to consultation with mental 
health services. 

Upon conclusion of the Inquest, a comprehensive review of the SOP for deliberately 
inserted  foreign  bodies,  as  initially presented  to  HM  Coroner,  was  undertaken. This 
review was conducted with the support and oversight of the Governance Support Unit 
to ensure rigorous examination and improvement of the procedure.

As a direct outcome of the review process, the previous SOP for the management of 
deliberately inserted foreign bodies has been archived. In its place, a new, approved 
guideline has been developed to address the concerns raised by HM Coroner. This 
guideline  provides  clear,  concise,  and  practical  guidance  to  clinical  staff  and 
incorporates recommendations to ensure specificity and clarity. 

Furthermore, the guideline incorporates a flowchart designed to assist clinical staff by 
offering  clear  advice  regarding  the  minimum  circumstances  for  contacting  mental 
health services. Additionally, Appendix A contains the referenced document entitled 
"Mental Health Inpatient Transfer to an Acute Hospital – Hospital Passport.” Which will 
promote communication between physical and psychological health teams.  

The development of the new guideline was informed by a robust consultation process, 
which  included  input  from  key  stakeholders  across  Trauma  and  Orthopaedics,  the 

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 Emergency  Department,  Safeguarding,  and  Nottinghamshire  Healthcare.  This 
collaborative approach ensured that expert advice and perspectives from all relevant 
disciplines  were  considered.  In  addition,  Nottinghamshire  Healthcare’s  Trust  wide 
Procedure  for  the  Management  of  Foreign  Bodies  (2023)  was  reviewed  to  ensure 
there was no discrepancy in advice being provided.  

On 28th November 2025, the document entitled “Management of Deliberately Inserted 
Foreign  Bodies  Guideline”  was  formally  ratified  at  the  Surgery,  Anaesthetics  and 
Critical  Care  Divisional  Governance  meeting.  The  final  approved  guideline  is  now 
available on the Trust intranet for clinicians to access and has been disseminated to 
all staff directly involved in the management of patients presenting with deliberately 
inserted foreign bodies. 

The Trust is committed to ongoing improvement of clinical guidance and ensuring the 
highest standards of patient care. We are confident that the new guideline addresses 
the issues identified by HM Coroner and provides comprehensive support to clinical 
teams managing these complex cases.

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