Stephen Taylor

Ms Sarah Clarke, 
Kent and Medway Coroners’ Service 
Oakwood House 
Oakwood Park 
Maidstone 
Kent 
ME16 8AE 

Chief Executives Office 
 Priority House 
Hermitage Lane 
Maidstone 
Kent 
ME20 6PH 

6 March 2026 

Dear Ms Clarke 

Inquest into the death of Mr Stephen Taylor 

Kent and Medway Mental Health NHS Trust response to the Regulation 28 report to 

prevent future death. 

I  write  in  response  to  the  Regulation  28  Report  dated  14  January  2026,  sent  to  Kent  and 
Medway Mental Health NHS Trust (KMMH) following the conclusion of the inquest into the 
very sad death of Mr Stephen Taylor on 26 May 2025.  

In your report to the Trust, you raised the following matters of concern: 

1.  Mr Taylor was in contact with multiple services during a period of escalating 

mental distress. Each service operated within its own framework, but there was 
no evidence of coordinated, real-time escalation or ownership of risk across 
services.  

KMMH and NHS Talking Therapies Collaborative are currently in discussion 
facilitating a phased training and support package to mutually ensure patients are 
placed with the best service provider to meet needs of patients at point of referral.  

The aim is to improve communication of risk within referrals and action appropriately; 
to reduce number of patients passing between services before treatment is offered; 
and ensure patients are offered the right service, at the right time. 

It is my understanding that points 2-5 inclusive refer to findings relating to the Trust Urgent 
Mental Health Helpline and therefore I have outlined our actions to resolve the issues which 
you have highlighted; 

 
  
 
 
 
 
 
 
 2.  Clinical decision-making consistently relied on Mr Taylor’s denial of immediate 
intent and his stated ability to keep himself safe, despite significant indicators 
of  elevated  risk,  including  a  previous  serious  suicide  attempt,  escalating 
distress,  severe  anxiety,  sleep  disturbance,  reduced  self-care,  and  repeated 
concerns raised by a close family member. 

With  regard  to  improving  risk  recognition  within  the  Kent  &  Medway  Urgent  Mental 
Health  Helpline,  the  staff  from  this  service  are  undergoing  a  2-day  Clinical  Risk 
Assessment  &  Management  (CRAM)  training  event  to  support  improved  risk 
recognition  and  risk  curiosity,  and  to  promote  deeper  questioning  of  patients  who 
present with elevated risks and/or risk factors. This will include a focus on creation of 
a co-produced care and risk management plan. 

3.  Referrals to secondary mental health services were identified as necessary by 
more than one service but were treated as routine rather than urgent, and were 
not actioned immediately.  

As a result of this very sad death, the Urgent Mental Health Helpline, has generated 
visual prompts at each call station to support clear identification and pathways for call 
handlers/clinicians to direct, where risk is of concern, a referral for a rapid assessment 
within 4 hours by our Rapid Response service. It is expected that our staff will not rely 
on a risk prompt tool but will be equipped to identify risk accurately and utilise a curious 
approach  to  seeking  further  risk  information,  from  the  patient,  their  families  and 
referrers. 

4.  Family provided information indicating heightened and escalating risk which did 
not result in a same-day escalation or urgent face-to-face clinical assessment.  

The visual aid for urgent 4-hour assessment is now by each workstation to ensure it is 
an action the triage team must take.  

5.  Responsibility for escalation became diffuse across multiple services, creating 
a  foreseeable  risk  that  no  single  service  took  ownership  of  urgent  risk 
management 

The  Urgent  Mental  Health  Helpline  Standard  Operating  Procedure  has  undergone 
thorough review which has resulted in an update to:  

•  staff training expectations for CRAM.  
•  a clear list of high-risk categories for patients, for example veterans, and 
demographics with known associated risk factors, and those who have a 
history of impulsive or planned self-harm acts.  

•  expectation of staff to review available clinical records that are practicable to 
access during the clinical triage e.g. CRAM documentations ‘risk event log’.  
•  an update for urgent referrals to be triaged within a shorter timeframe (from 

72 hours to 24 hours). 

 
 
 
 
 
 
 
 
 
 •  update to the ‘immediate risk to life’ response under Right Care Right Person. 
Staff are being trained to understand the appropriate pathway and method to 
request this emergency Police response. 

I am sincerely sorry for the short fall in the care of Mr Taylor.   KMMH are committed to 
ensuring that the improvements that have been implemented are sustained.  

Thank you for bringing your concerns to my attention.  I hope that the detailed information 
provided, including the attached timetable for action, offers you a level of assurance about 
both the seriousness with which we have received and responded to your concerns, and the 
significant improvements we have made since the sad passing of Mr Taylor.  

Please do let me know if I can be of any further assistance. 

Yours sincerely 

Chief Executive

Sarah Clarke, Area Coroner  
Kent and Medway Coroner Service 
Oakwood House  
Oakwood Park  
Maidstone  
Kent  
ME16 8AE 

Dear Ms Clarke  

10/03/2026 

We write in response to the Regulation 28 report dated 14 January 2026 following the tragic death 
of Mr Taylor.  

Summary 

The following detailed reply outlines the care that was provided by Vita Health Group for Mr Taylor, 
which was delivered in line with the NHS Talking Therapies for Anxiety and Depression Manual and 
NICE guidance for the management of Self-Harm (NG225). It describes how the assessment of 
associated risk factors was considered, resulting in a judgement that the case should be treated as 
‘non-urgent’; a process later repeated by Kent and Medway Mental Health NHS Trust leading to the 
same outcome. Learning from Mr Taylor’s death is described with actions taken to reduce the risk of 
a similar outcome occurring in the future, including changes to operating procedures describing how 
onward referrals to secondary care should be managed. 

The Service 

Vita Health Group (VHG) is the lead provider of NHS Talking Therapies within the Kent and Medway 
region. The remit of NHS Talking Therapies is to provide a range of talking therapy interventions for 
people who experience common mental health problems such as anxiety and low mood, that fall 
within the mild to moderately severe range. Severity of symptoms is self-reported by people who 
access the service and validated by a range of routine outcome measures. These include the PHQ-9 
and GAD-7 which measure the severity of symptoms for depression and anxiety respectively.  
Within the Kent and Medway NHS Talking Therapies Service, a separate internal ‘Duty Team’, also 
managed by VHG, are on hand to support clinicians if ad-hoc supervision is required, and are often 
used to support with clinical risk and/or safeguarding related queries, and to support with the 
administration of such queries where necessary.  However, the Duty Team is not an out of hours 
service or crisis line; it is a team to support clinicians, rather than a patient facing team. If a patient 
or family member calls the administration team or reception with concerns, the Duty Team may 
become involved in dealing with those concerns as the service would look to assist.  

Head Office:  

Vita Health Group  
3 Dorset Rise, London 
EC4Y 8EN 

www.vitahealthgroup.co.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Although risk assessment and management are an essential component of the care provided by NHS 
Talking Therapies Services, and services are expected to work with people who present with risks (in 
relation to self-harm and suicide), it is not the remit of NHS Talking Therapies to provide mental 
health crisis support, or to manage the care of people for whom risk is imminent and who cannot 
keep themselves safe from self-harm. In this context, immediate or imminent risk is often referred 
to as ‘dynamic’ risk.  

In the event of a patient presenting with mental health needs beyond the remit of NHS Talking 
Therapies (typically if the presenting problems are out of scope, e.g. evidence of symptoms of 
serious mental illness, or if dynamic risk factors make treatment unsafe within primary care), the 
care pathway is for the person to be referred into the Adult, or Older Adult Mental Health Team. In 
Kent and Medway, these services are provided by Kent and Medway Mental Health NHS Trust. 
Urgent referrals are responded to within 72 hours whilst routine non-urgent referrals take longer. 
Emergency support is provided by 999 and the Crisis Support Team can be contacted and aim to 
provide support within 4 hours.  

Assessment of Mr Taylor’s risk 

When Mr Taylor was initially assessed by VHG in 2024, part of the assessment included an extensive 
and holistic risk assessment, which in line with NICE guidance NG225 (Self-harm: assessment, 
management and preventing recurrence) identified risk factors as well as protective factors as part 
of a risk formulation. The main risk factors identified were a suicide attempt over 10 years ago, 
current unemployment and a sense of losing hope that support was available to help him with his 
current situation. Whilst this was of concern, it was in the context of Mr Taylor reporting that he 
wasn’t currently experiencing suicidal thoughts and did not feel that he was a risk to himself. 
Positive factors were also identified in that he was motivated to engage with help; he felt lucky to be 
alive following his stroke, he reported that his wife was a strong protective factor, and he reported 
that should things change, he would be able to access support and ask for help. To support this, a 
risk management plan was devised with Mr Taylor outlining who he would contact and how he 
would access support if his situation (regarding feeling a risk to himself) changed.  

Mr Taylor appeared to engage well with his subsequent treatment and on the final session he 
attended (29/4/25), his outcome measures indicated that he had recovered from his initial 
symptoms of depression. Mr Taylor cancelled his final scheduled session twice and sadly died before 
this took place. Clinical records show that the risk assessment was reviewed at every subsequent 
session, and no concerns were raised about escalating or new risk factors.  

Mr Taylor’s daughter subsequently contacted the Kent & Medway NHS Talking Therapies service, 
and on 22/5/25 spoke with the Duty Team. She disclosed that Mr Taylor had become acutely 
anxious, and she was concerned given his history. Additional risk factors were shared and 
considered, including current lack of sleep and worry about finances. It was also shared that she was 
not aware of any current planning or intent towards a suicide attempt. 

Head Office:  

Vita Health Group  
3 Dorset Rise, London 
EC4Y 8EN 

www.vitahealthgroup.co.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In this scenario, where additional information is provided, the team will either note the information 
to be included in the assessment the next time the patient is seen or, if the information raises a 
concern, an assessment is made about what level of escalation is required.  For instance, does it 
need Crisis Team within 4 hours, an urgent referral within 72 hours or longer via a non-urgent 
referral.  

Although Mr Taylor had not been reviewed directly by the clinical team, the Duty Team noted the 
concerns shared by his daughter, and agreed a plan with her, that a non-urgent referral was most 
appropriate and would be made to the Older Adult Mental Health Team. The rationale for this was 
that whilst Mr Taylor’s presentation had deteriorated and new risk factors had been reported, the 
absence of dynamic or immediate risk factors such as risky behaviour, or evidence of planning or 
intent towards a suicide attempt, meant that an urgent referral was not indicated and therefore 
unlikely to be accepted. However, due to an escalating presentation, additional support from the 
Older Adults Mental Health Team was still indicated.   

VHG considered Mr Taylor’s daughters concerns and reasonably assessed the risk that referral to the 
Older Adults Mental Health Team on a non-urgent basis was appropriate. The Duty Team 
understood at this time that Mr Taylor’s daughter agreed with this plan. The duty worker wished to 
review the referral with the treating clinician so more information could be added to the referral 
before sending it which regrettably resulted in a delay, with the referral not being actioned prior to 
Mr Taylors tragic death, 4 days later.  

In the meantime, we understand Mr Taylor’s daughter called the Older Adults Mental Health Team 
directly on 23/5/25 who also agreed a non-urgent face-to-face assessment was required.  

Learning 

NHS Talking Therapy Services across the country are not medically led and do not provide an 
objective view of a person’s presentation. Instead, assessment of the patient’s presentation is based 
on what the patient reports and validated by self-reported outcome questionnaires (as set out in the 
NHS England Talking Therapies Manual). However, where necessary and indicated, clinicians within 
the service will consider factors that are inconsistent with that self-reporting, to inform the 
assessment process and subsequent decision making.  

When assessing for risk of suicide, a person’s self-reported view and reassurance are always 
important, but other risk factors are considered as part of the decision-making process. This 
weighing up of risk factors is ultimately a judgement call, and the judgement in this case was 
informed by Mr Taylor’s denial of immediate intent, his stated ability to keep himself safe, alongside 
several other factors such as lack of risky behaviour. This was in line with NICE guidance NG225 
which sets out that risk should not be stratified and should instead risk factors should be considered 
as part of a risk formulation. With hindsight, we know that tragically the judgement that Mr Taylor 
could keep himself safe was wrong.  

Head Office:  

Vita Health Group  
3 Dorset Rise, London 
EC4Y 8EN 

www.vitahealthgroup.co.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 VHG did escalate the risk but recognise that the decision of the Duty Team to review the case with 
the treating clinician led to a delay in the referral being made. The subsequent assessment of Mr 
Taylor by Kent and Medway Mental Health NHS Trust following referral by his daughter also 
concluded that a non-urgent referral was indicated. However, VHG recognise that there should have 
been more prompt action to raise the referral in a case such as this where there were significant 
concerns being raised by a family member. VHG is committed to learning. As such, the following 
actions have been taken as a result of Mr Taylor’s tragic death: 

•  The Duty Standard Operating Procedure was reviewed and updated in November 2025 and 
now includes (1) an explicit reference to the management of routine referrals, and states 
these should be actioned on the day that the referral decision is made and consent received, 
and (2) reference to the importance of the careful consideration of family members’ 
information within the clinical decision-making process. 

•  A reflective session with the Duty Team took place on 03/12/25 sharing the learning from 
this case and the changes that have made to the Duty Standard Operating Procedure as a 
result. 

In closing, Vita Health Group wish to reiterate our shared commitment to ensure we are delivering 
high quality services for patients, carers and their families.  

Yours sincerely,  

Director of Clinical Services  
On behalf of Vita Health Group Ltd.  

Head Office:  

Vita Health Group  
3 Dorset Rise, London 
EC4Y 8EN 

www.vitahealthgroup.co.uk