Mark Vidler

Mr. Ian Potter  

Kent and Medway Coroners' Service  

Oakwood House  

Oakwood Park  

Maidstone  

Kent 

ME16 8AE 

Chief Executives Office 

Priority House 

Hermitage Lane 

Maidstone 

Kent 

ME16 9PH 

6 March 2026 

Dear Mr Potter 

Inquest into the death of Mr Mark Stuart VIDLER  

Kent and Medway Mental Health Trust Response to the Regulation 28 Report to 

Prevent Future Death 

I  write  in  response  to  the  Regulation  28  Report  dated  11  January  2026,  sent  to  Kent  and 

Medway Mental Health NHS Trust (the Trust) following the conclusion of the inquest into the 

very sad death of Mr Mark Stuart VIDLER on 8 May 2025.  

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

1.  Some staff at the Trust were so focussed on 'process' that they lost sight of the 

need for patient centred care. This was accepted within the Trusts PSII report. I 

was insufficiently reassured that action has been taken to address this matter.  

2.  The  process  in  place  for  triaging  and  considering  referrals  to  the  Rapid 

Response Team is reliant, for the most part, on call handlers working through a 

script and there is a total lack of clarity regarding clinical decision making in this 

regard. The Trust acknowledged in its PSII report that there was "no evidence of 

senior clinical oversight of the decision making or clarity as to where the final 

clinical  decision  sits  regarding  accepting  or  declining  referrals".  A  senior 

 
 
 
 
 
 
 manager from the Trust told me, in evidence, that there is still work to be done 

to address this concern.  

The Trust wide Rapid Response Standard Operating Procedure is being revised and 

amended to ensure referrals received are accepted by call handlers. No referral will be 

declined until a senior clinician has had oversight, and alternative care agreed. As such 

each referral will be reviewed by a Rapid Response clinician in collaboration with the 

referring clinician, thereby ensuring decision making is person centred.  

The revision of the Trust wide Home Treatment Team and Rapid Response Standard 

Operating Procedure review which is currently underway,  is due for completion by 1 
April  2026.  In  addition;  to  the  revision  of  the  SOP’s  both  the  Home  Treatment  and 

Rapid Response Teams are booked to undertake CRAM training for both qualified and 

unqualified  staff.  This  will  be  completed  by  April  2026.  This  training  will  specifically 

address the need for clinicians to be curious and ask specific risk questions around 

safety  and protective factors  as  well  as  co-written  plans  of  care  in  conjunction  with 

carers and family where to do so. This will ensure person centred care is at the centre 

of all assessments.  

3.  Evidence I considered showed that some risk factors, such as the masking of 

symptoms, were well documented. However, the HTT clinician still appeared not 

to acknowledge the extent of such risks. This raises the risk of a repeat of this 

concern in the future. 

The Home Treatment and Rapid Response Teams have planned and dedicated 

Clinical Risk Assessment & Management (CRAM) training sessions where masking 

of symptoms will be covered as a learning outcome. CRAM is the clinical tool that 

teams use to assess and care plan for risks that are identified.  

The Trust has implemented quality audits to determine the quality of the Risk 

Assessment & Management plans across the Trust, and as such there is an ongoing 

Trust wide quality improvement drive to establish improvements particularly around 

risk recognition and safety planning. As part of this work, there is weekly tracking of 

our improvement trajectory targets for completion of the CRAM documents. 

This activity is currently part of the Trusts Quality Action Plan. 

 
 
 
 
 
 4.  I heard evidence that the decision to discharge Mark from the HTT was made at 

a multidisciplinary team (MDT) meeting prior to the HTT nurse visiting Mark on 

6  May  2025.  This  raises  the  concern  that  the  decision  was  pre-determined.  I 

heard no evidence that this situation has changed. 

The HTT have initiated a twice weekly MDT discussions with Community services 

which focuses discussion on aspects of individual patients care including those 

patients for whom discharge is planned from HTT. This allows for the wider support 

system to debate and consider the decision to discharge.  

In addition, as part of the Trusts ongoing development, of understanding and 

managing risk with our patients, a risk assessment is completed at discharge. If the 

clinician completing the risk assessment identifies a deterioration in mental state this 

can and should delay that decision- the team have a mechanism for discussion and 

decision making regarding clinical care, on a daily basis, and access to a Consultant 

Psychiatrist for advice and guidance in complex cases. 

5.  Both the nurse from MHT+ and the consultant psychiatrist gave evidence that 

the  MHT+  were  not  included, as  the  receiving  team,  in  the  MDT  decision  on  6 

May 2025. They considered that this would have been useful and is something 

that can and has happened in the past. I was told that this left  Mark 'in limbo' 

following his discharge from HTT and I was told that this is something that has 

not changed since.  

Following this Inquest outcome, the Home Treatment Team service have implemented 

a  twice  weekly  clinical  MDT  interface  meeting  with  local  MHT  and  MHT+  teams  to 

enable  and  ensure  timely  discussion  of  specific  cases.  Feedback  from  the  clinical 

teams  has been  positive as  these  forums are the opportunity  to discuss  patients  of 

concern where risk continues to be identified. 

The Rapid Response Team will have senior clinical input into these interface forums 

where  decisions  impacting  on  patient  care  can  be  discussed  and  decisions  made 

clinically  to  ensure  the  person  has  an  agreed  discharge  plan  that  promotes  clinical 

safety and is based on senior clinical consideration. The revised Standard Operating 

Procedure will detail that MHT+ colleagues including medics must be invited to these 

forums to assist with community treatment planning and will be audited 3 monthly to 

ensure  quality,  patient  safety  and  positive  patient  outcomes  agreed  across  the 

interface of services.  

 
  
 
 
 This practice improvement will be included in the revised Trust wide Home Treatment 

Team and Rapid Response Standard Operating Procedures review which are 

currently underway review, and due for completion by 1 April 2026.  

6.  I heard evidence that the Trust does not have care co-ordinators and the 

clinician felt that this could lead to similar situations arising in the future.  

The  Trust  has  and  is  undergoing  transformation  in  line  with  the  Community  Mental 

Health Framework (CMHF) which includes a national directive to move away from care 

co-ordination. As part of our continuous improvement  agenda and refinement of the 

community model of care the Trust has identified a number of service improvement 

which we will be making and which will include the introduction of a named worker.  

There have been a number of workshops held across the organisation, by Directorate 

and  work  is  underway  to  finalise  the  refinement  model,  and  implementation 

timeframes. 

7.  The  Collaborative  Assessment  and  Management  of  Suicidality  (CAMS)  work 

undertaken  by  the  Trust  lacks  "dedicated  resource  in  place  to  manage  or 

support implementation" (quote taken from Trust PSII report). I also heard that 

the  CAMS  programme  cannot  currently  be  integrated  with  the  Trust's 

computerised records system, due to copyright issues. This matter was due to 

be resolved by June 2025; however, it remains unresolved with a current target 

date of June 2026. I was told that there is no system in place to safety net the 

use of both paper and computerised records in the meantime.  

By  the  end  of  February  2026,  the  CAMS  clinical  documentation  forms  will  be 

accessible as stand-alone documents on Rio clinical record system. These can only 

be completed by those undertaking specialist CAMS training or those who have fully 

trained in use of the National CAMS model.  

The  Trust  are  currently  considering  options  in  relation  to  a  dedicated  workforce  of 

CAMS trained workers across our services. In addition, the continued roll out of this 

specialist  service  is  under  review  by  the  organisation.  This  will  inform  the  finalised 

CAMS Standard Operating Procedure. In the meantime, a 6-month secondment role 

has  been  agreed  to  support  the  CAMS  service  (band  7  clinician).  This  role  is  split 

equally between CAMS practice and training staff in CRAM. 

 
 
 
 
 8.  I  heard  evidence  that  as  a  result  of  the  referral  to  the  Rapid  Response  Team 

being declined, Mark's mental health care technically rested with the MHT+ team, 

which  only  works  until  17:00.  As  a  result,  the  Approved  Mental  Health 

Practitioner service (responsible for arranging MHA assessments) would have 

been unable to speak to the referrer. While this was not an issue in the specific 

circumstances of this case, I consider that it raises risks for others in the future. 

With clarity being established through the Home Treatment Team & Rapid Response 

Standard  Operating  Procedure,  we  expect  that  this  will  not  occur  in  the  future.    In 

addition to the robust adjustment to the Rapid Response referrals received process 

outlined above, the Trust continues to promote the use of the  Urgent Mental Health 

Helpline, by patients known or unknown, and their families 24/7. 

Thank you for bringing your concerns to my attention and I am sincerely sorry for the shortfalls 

in the care of Mr Vidler. 

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  the Trust has received and 

responded to your concerns, and the significant improvements that have been made since the 

sad passing of Mr Vidler.  

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

Yours sincerely 

Chief Executive