Martin Bryant

05 March 2026 

Private and Confidential 
Ms Rebecca Mundy    
HM Assistant Coroner 
Coroner’s Court  
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Madam, 

Mr Martin Douglas Bryant (RIP)   

Chief Executive Office 
The Lodge 
Lodge Approach 
Wickford  
Essex 
SS11 7XX 

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 
5,  of  the  Coroners  and  Justice  Act  2009  and  regulations  28  and  29  of  the  Coroners 
(Investigations)  Regulations  2013,  dated  19th  January  2026,  received  by  the  Trust  on  21st 
January 2026 in respect of the above, issued to Essex Partnership University NHS Foundation 
Trust (EPUT) and NHS England following the inquest into the sad death of Mr Bryant. 

I would like to begin by extending my deepest condolences to Mr Bryant’s family. The Trust 
sympathises with their sad loss.  

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed 
and noted.  I will now respond in full to the concerns as they relate to EPUT in the hope that 
this provides both yourself and Mr Bryant’s family with comprehensive assurance of changes 
that have been made at the Trust to address the concerns you have raised.  

Concern 1) The reliance by EPUT that those suffering a mental health crisis will wait in the 
MHUCD’s open reception area, from which they are free to come and go as desired, whilst 
medical authority and/or beds are secured for them.  

Response:   
In line with the evidence presented to Court, Mr Bryant was identified as requiring admission 
and agreed to informal admission.  He waited with his partner in the reception area. 

In order to address the risks associated with waiting in an open reception area, management 
process has changed to ensure a risk assessment has been undertaken whilst patients await 
medical review and / or beds are secured for them.  There are clear escalation processes in 
place when patients are waiting for beds. 

This risk assessment is used to identify if someone is safe to wait in reception area and if not 
they will remain in an assessment room (this information was included in the action plan 
shared with Coroner and process had changed at point of inquest). 

The assessment rooms are situated in a corridor with ACT (Access through a swipe system 
so exit can be monitored by staff) which affords an additional level of safety in respect of 
vulnerable patients.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 Staff have been advised on the need to ensure there is not an over reliance on partner 
support; this learning is being shared via the care unit quality and safety governance 
structure and the wider learning functions through the ‘Learning Oversight Scrutiny 
Committee (LOSC)’. 

As the Court will be aware, the Trust may not detain a patient without legal authority to do so.  
Where appropriate, and if this is deemed in the patient’s best interests, common law is 
applied to restrict leave if a patient is deemed at risk.   These safeguards remain available to 
the Trust in order to keep patients safe in a proportionate and lawful manner. 

Concern 2) EPUT’s ability to accommodate improvement to where people wait within the 
MHUCD, particularly in light of the evidence given by nursing staff and the indication that 
rooms will always need to be kept vacant for patients requiring triage or assessment. 

Response:  
It is noted that witnesses in this Inquest were temporary bank staff and may not have been 
aware of changes that had been undertaken in respect of this concern (please also see our 
reply to under concern 1 above). 

In addition, the Court was provided with evidence in respect of the steps that have been 
taken by the Trust to continually review service demand and the need to close the MHUCD 
once capacity has been reached.   

The evidence provided at Court also highlighted the steps taken by the Trust to ensure 
security within the department.   

The MHUCD is no different in terms of waiting area as that of an A&E waiting area.  
However, the MHUCD has a clear criteria and escalation process in place for the temporary 
closure of the department, based on patient acuity and complexity exceeding safe staffing 
and resource levels, Triage times at risk of breaching the 30 minute standard, three of the 
five Assessment Rooms occupied by patients who cannot be safely managed in the waiting 
area and the department is at full capacity, including walk in patients. If capacity is reached 
and people can no longer be assessed or accommodated safely within the MHUCD, the 
department can temporarily be closed and patients will be diverted to local EDs during this 
time. 

Capacity of the unit is reviewed and there is the opportunity for escalation at the morning and 
afternoon MSE Locality Sit rep calls seven days a week. Capacity issues can also be 
escalated at lunchtime Senior Bed Escalation Huddles, which are held Monday-Friday.  

Concern 3) The lack of beds, locally and nationally, for mental health admissions and the 
suggestion given in evidence that patients can be waiting in the open reception area for days 
or sometimes weeks for a bed. 

Response:   
We respectfully advise that this concern is for NHS England to respond to. However, in an 
effort to provide assurance on this point, the Trust provided assurance re: the availability of 
beds as part of our evidence at this Inquest, namely that this continues to be a challenge for 
the Trust / the NHS as a whole. Every effort is made to assess and manage patients in a 
safe and timely manner, again flow and capacity challenges remain, leading to patients 
having to wait to been seen in the UCD. 

 
 
 
 
 
 
 
 
 
 
 
 
 However, as stated above, there are clear processes for the management of flow and 
capacity.   Escalation and review is conducted daily (up to three times a day); patients are 
prioritised (dependant on risk factors) whilst they wait in UCD. 

As per the evidence provided to the Court, the Trust has implemented the Therapeutic acute 
Inpatient Operating Model for adults and older adults. The objective of this model is to reduce 
length of stay when a patient requires hospital admission. This model aligns with national 
guidance around purposeful admissions including capacity and flow, therapeutic benefit, 
proactive, safe and effective discharge/transfer planning and trauma informed care. 

Datixes are completed for patients who have had to wait in the department for over 24 hours 
in order that these patients are again urgently considered and escalated where required. 
Harm review, forms part of the incident reporting process which is aligned with national 
definition of harm physically and psychologically. 

We are also working closely with our integrated care boards (ICBs), NHSE and wider system 
partners re bed pressures for admission and discharge to and from EPUT beds. This has 
included a recent workshop with Essex county council to review delayed discharges from 
EPUT beds into the community where accommodation needs are delaying discharges. 

I hope that I have provided reassurances around the steps that we have taken to address the 
issues of concern contained within your report.  We know there is an acute need to embed and 
effect change, hence we will monitor the above provisions to ensure these are contributing to 
our overall aim of keeping patents safe and delivering therapeutic care. 

Please do let me know if you require any further information at this stage. We understand that 
the Court will share a copy of this reply with Mr Bryant’s family.   

Yours sincerely, 

, Deputy Chief Executive 

On behalf of Paul Scott 
Chief Executive

Rebecca Mundy 
Assistant Coroner  
Essex and Thurrock Coroner’s Service 
Essex County Council 
Seax House 
Victoria Road South  
Chelmsford  
CM1 1QH 

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

2nd March 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Martin Douglas Bryant 
who died on 19 January 2025.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  19 
January 2026 concerning the death of Martin Douglas Bryant on 19 January 2025. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Martin’s family and loved ones. NHS England is keen 
to assure the family and yourself that the concerns raised about Martin’s care have 
been listened to and reflected upon.   

Your Report raised concerns around the following:  

1.  The reliance by Essex Partnership University NHS Foundation Trust (EPUT) 
that those suffering a mental health crisis will wait in the open reception area of 
the Mental Health Urgent Care Department (MHUCD), from which they are free 
to come and go as desired, whilst medical authority and/or beds are secured 
for them.  

2.  EPUT’s ability to accommodate improvement to where people wait within the 
MHUCD,  particularly  in  light  of  the  evidence  given  by  nursing  staff  and  the 
indication that rooms will always need to be kept vacant for patients requiring 
triage or assessment.  

3.  The lack of beds, locally and nationally, for mental health admissions and the 
suggestion given in evidence that patients can be waiting in the open reception 
area for days or sometimes weeks for a bed.  

We note that your Report has also been directed to EPUT, who will be best placed to 
address concerns 1 and 2 listed above.  

In  relation  to  concern  3  above  and  the  issue  of  bed  availability,  NHS  England  is 
currently  rolling  out  dedicated  24/7  neighbourhood  mental  health  centres  to  better 
support the community, including 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 and will run until July 2026. This will be followed by an Implementation 
Support Programme which will roll out to sites from March 2026.  

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
  
 NHS  England  is  aware  of  the  issues  in  some  healthcare  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.  

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.  

NHS England’s 2025/26 priorities and operational planning guidance reinforces this 
focus on improving patient flow as a key priority – with systems directed to reduce the 
average  length  of  stay  in  adult  acute  mental  health  wards  in  order  to  deliver  more 
timely  access  to  local  beds.  NHS  England  is  taking  steps  to  address  current 
operational pressures driving these issues.  

If local beds are not available, Out of Area Placements are currently used to ensure 
patient care is delivered in an inpatient setting if needed. However, NHS England plans 
to reduce and eliminate the use of Out of Area Placements as they can result in poorer 
outcomes for patients and provide additional risk to patient safety.  

NHS England was not a party to the inquest, however we consider EPUT would also 
be  best  placed  to  comment  upon  the  evidence  referred  to  under  concern  3,  that 
patients can be waiting in the open reception area for days or sometimes weeks for a 
bed. 

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 
Martin, 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,  

 
 
 
 
 
 
 
  
  
 MRCGP  
National Medical Director  
NHS England