Suzanne Ellerby

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

39 Victoria Street  
London  
SW1H 0EU  

9 February 2026 

HM Coroner Anna Loxton 
HM Coroner’s Court Surrey 
Station Approach 
Woking GU22 7AP 

Dear Ms Loxton, 

Thank  you  for  the  Regulation  28  report of  14  November 2025  sent  to  the  Department  of 
Health  and  Social  Care  about  the  death  of  Suzanne  Julia  Ellerby.  I  am  replying  as  the 
Minister with responsibility for Patient Safety, Women’s Health and Mental Health.       

Firstly, I would like to say how saddened I was to read of the circumstances of Suzanne’s 
death and I offer my sincere condolences to their 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.  Please  accept  my  sincere  apologies  for  the  delay  in  responding  to  this 
matter. Thank you for the additional time provided to the department to provide a response 
to the concerns raised in the report. 

The report raises concerns over vulnerable patients often being transferred back to primary 
care by secondary mental health services for their onward care, which is affected by way of 
a discharge letter. Your concern was that NHS England has not provided any guidance in 
respect  of  expectations  for  follow  up  by  primary  care  services  when  this  transfer  of  care 
takes place. As such, the onus is on vulnerable patients to ensure they follow up their care 
with their GP, without any safety netting in place should they fail to do so. 

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

NHS England has assured the Department that they continue to support local systems to 
improve the quality, safety and continuity of care for people with mental health needs who 
require support from secondary mental health services. As part of this work, NHS England 
has developed draft guidance, the Personalised Care Framework, which sets out the core 
expectations for care and support for people accessing NHS-commissioned community 
mental health, crisis and inpatient services, as well as those receiving support through 
integrated primary care and the voluntary, community and social enterprise sector. This 
guidance has been shared in draft form with systems to support early adoption. 

 
   
 
 
 
 
 
 
 
 
 
 
  
  
  
 
 The Personalised Care Framework sets out core principles, including that people using 
specialist mental health services should have a care and support plan that is kept up to 
date and reflects their needs at that time; that there should be a clearly identified 
professional within the service with responsibility for the individual’s care and support plan 
and for developing a trusted therapeutic relationship; and that care and support plans 
should be reviewed when circumstances change. The framework also makes clear that 
individuals should be able to re-access support promptly where their mental health 
deteriorates, including following a period of stability. 

The guidance further emphasises the responsibility of services to support safe and 
effective transitions, including between secondary and primary care. Where a person is 
transferring away from a service, the transferring service is expected to be satisfied that 
appropriate arrangements are in place and that the receiving service is ready to continue 
delivery of the care and support plan. 

In relation to your second concern, where secondary mental health services consider that 
there may be a risk that a patient will not engage with primary care, services should take 
appropriate steps to follow the patient up and support their engagement. Patients with 
significant ongoing risk should not be discharged solely to primary care, and decisions 
about discharge should be informed by individual clinical judgement and personalised risk 
assessment, rather than the application of rigid criteria. 

As set out above, the Personalised Care Framework also makes clear that people who 
have received specialist mental health support should be able to re-access help quickly 
when needed, including where their mental health deteriorates or where they have been 
transferred between services. The guidance further highlights the importance of involving 
family members or carers, where appropriate, in the development of care and support 
plans. These plans should include clear information on what to do if a person’s mental 
health worsens, including how to access appropriate support and the signs that may 
indicate a potential relapse. 

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. 

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

Yours sincerely,

Ms Anna Loxton,  
HM Assistant Coroner 
Surrey Coroner’s Court  
Station Approach,  
Woking  
GU22 7AP 

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

26th January 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Suzanne Julie Ellerby 
who died on 4th January 2025.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 14th 
November 2025 concerning the death of Suzanne Julie Ellerby on 4th January 2025. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Suzanne’s family and loved ones. NHS England 
is keen to assure the family and yourself that the concerns raised about Suzanne’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  Suzanne’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 that vulnerable patients are often transferred back to primary care 
by secondary mental health services for their onward care, which is effected by way 
of  a  discharge  letter.  Your  concern  was  that  NHS  England  has  not  provided  any 
guidance in respect of expectations for follow up by primary care services when this 
transfer of care takes place. As such, the onus is on vulnerable patients to ensure they 
follow up their care with their GP, without any safety netting in place should they fail 
to do so. 

Transfer of care by mental health services 

NHS England continues to support  systems to improve care for people with mental 
health problems needing help from secondary mental health services. NHS England 
has drafted guidance called the Personalised Care Framework (PCF), that sets out 
the  core  aspects  of  care  for  people  who  require  help  from  secondary  or  integrated 
primary health services, the Voluntary Community and Social Enterprise (VCSE) and 
secondary care mental health services. It has been shared as a draft with systems to 
facilitate early adoption.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 The  PCF  sets  out  the  core  principles  that  all  people  using  NHS  commissioned 
community mental health, crisis and inpatient services should: 

•  have a care and support plan that is current and that is reflective of the needs 

of the person at that point; 

•  have a person within the service responsible for their care and support plan and 

for developing a trusted therapeutic relationship; 

•  be able to have their care and support plan reviewed when things change, as 
well as being able to quickly re-access help when they need to (such as when 
their mental health deteriorates following a period of stability). 

The  PCF  guidance  will  also  emphasise  the  responsibility  of  all  services  to  support 
effective transitions, including between secondary and primary care, and that where a 
person is transferring away from a service, the transferring service should be satisfied 
that the receiving service are ready to continue the care and support plan. 

Primary Care Follow Up Guidance 

If secondary mental health services feel that there is any risk that a patient may not 
engage with their GP, such as where the patient has relocated and is not known to a 
GP practice, then it would be important that they follow the patient up and support the 
patient to engage with the GP. However, patients with significant risk should not be 
discharged back to their GP - this is difficult to define with criteria and is best based 
on personal risk assessment.  

As set out above, the PCF stipulates that every patient seen by specialist mental health 
services should be able to quickly re-access help when they need to (such as when 
their mental health deteriorates following a period of stability), or when transferred to 
another service.  

The  PCF  also  makes  it  clear  that  family  members  should  be  involved  in  the 
development of the care and support plan – which should include details of what to do 
if  a  person’s  mental  health  is  deteriorating,  for  example  how  to  access  appropriate 
help and support, and should include signs of a potential relapse.  

The PCF states:  

Where a person is transferring away from a service, that service has a responsibility 
to support the transition, sharing important information including how best to engage 
the person, the care and support plan including relapse indicators, risk assessment 
and  safety  plan  and  formulation.  The  transferring  service  should  be  satisfied  the 
receiving service are ready to continue the care and support plan.  

Where  a  patient  is  being  discharged  from  the  community  mental  health  service  to 
primary  care,  a  care  planning  meeting  should  take  place  which  should  include  the 
patient (and/or a family member, carer or support network member where the person 

 
 
 
 
 
 
 
 
 
 
 lacks capacity) and their GP. At the point of transition, the patient and GP should be 
provided with written confirmation of: 

the reason for the change in care; 

• 
•  a  discharge  plan  that  details  how  they  can  re-access  support  from  the 

• 

community mental health service;  
information about other available community support which may be relevant for 
the patient;  

•  details  of  ways  to  contact  the  service  –  including  a  working  hours  telephone 

number and email address;  

•  a copy of the patient’s updated care and support plan and other relevant plans 

developed as part of their care and treatment;  

•  medicines reconciliation (a list of a patient’s current medications).  

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 
Suzanne, 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