Kallum Reed

From Baroness Gillian Merron 
Parliamentary Under-Secretary of State for   
Women’s Health and Mental Health
39 Victoria Street 
London 
SW1H 0EU 

19 March 2026 

Our ref: PFD-26-02-05 REED 

HM Coroner Mrs. Lydia Brown
Senior Coroner, West London 
Coroner Service 
25 Bagleys Lane, Fulham, London, SW6 2QA 
By email: HMCoroner@lbhf.gov.uk  

Dear Mrs Brown, 

Thank you for the Regulation 28 report of 5 February sent to the Secretary of State / the 
Department of Health and Social Care about the death of Kallum Josh Reed. I am replying 
as the Parliamentary Under-Secretary of State for Women's Health and Mental Health.  

Firstly,  I  would  like  to say  how saddened I was  to  read of  the  circumstances of  Kallum’s 
death and I offer my sincere condolences to his 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. 

The report raises concerns over: 

(1) the  "unacceptably  long  wait"  for  referrals,  assessments  and  diagnoses  of  ASD  and
ADHD,  impacting  the  provision  of  care,  appropriate  medication,  individual  insight  and
professional support.

(2) the fact that the "crisis team" gate-keep referrals into their service, notwithstanding that
referral requests can often arise from psychiatry liaison and/or the community psychiatric
team  who  have  deep  knowledge  of  the  patient  and  have  conducted  their  own  detailed
assessments and highlighting the challenges faced by patients seeking crisis care as the
Trust's own professionals were not in agreement or working collaboratively to find a safe
solution.

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

I am deeply sorry to hear of the significant delays that Kallum experienced with regard to 
referral, assessment and diagnosis of ASD and ADHD.  

The National Institute for Health and Care Excellence (NICE) guideline for the diagnosis of 
autism recommends the length of time between referral and first appointment should be no 
more than 13 weeks. We know that this is not happening routinely across the country.  The 
government has recognised that, nationally, demand for assessments for autism has 
grown significantly in recent years and that people are experiencing severe delays for 

 
 
 
 
 
 accessing such assessments. The government’s 10 Year Health Plan seeks to make the 
NHS fit for the future and recognises the need for early intervention and support. 

It is the responsibility of integrated care boards (ICBs) to make available appropriate 
provision to meet the health and care needs of their local population, including provision of 
autism services, in line with relevant National Institute for Health and Care Excellence 
(NICE) guidelines.     

Through the NHS Medium-term planning framework, published 24 October 2025, NHS 
England has set clear expectations for local ICBs and trusts to improve access, 
experience, and outcomes for autism services over the next three years, focusing on 
improving quality and productivity.  

While I acknowledge that there is still more to do, I can report that waiting times for 
assessment for potential autism in adults have fallen in the past twelve months nationally 
across ICB catchment areas. We believe that this progress has been aided by the ‘Right to 
Choose’ pathway provided by ICBs which gives patients in England the right to choose 
which NHS‑commissioned provider they are referred to for a first outpatient appointment 
for ASD (and ADHD) diagnostic assessment, allowing people to access providers offering 
shorter waiting times. Over the last 2 years NHSE has also invested in training a range of 
professionals in diagnostic assessment. In addition, there is on-going work on considering 
alternatives to diagnostic assessment where the current needs of the person are assessed 
and options offered to meet the needs without the necessity of having a diagnostic 
assessment prior to a needs assessment. It is my deep hope that such work and 
innovations will contribute to fewer people waiting for diagnostic assessments. 

The Secretary of State announced on 4th December the launch of an Independent Review 
into Prevalence and Support for Mental Health Conditions, ADHD and Autism. This 
independent review will inform our approach to enabling people with ADHD and autistic 
people to have the right support in place to enable them to live well in their communities.  

In terms of the specific local issues that resulted in Kallum slipping between the gaps and 
not receiving the potentially life-saving care he needed, I understand that West London 
NHS Trust has undertaken a Patient Safety Incident Investigation to learn important 
lessons from this event, which I welcome. I believe that they are responding separately to 
your report.  

More widely Government has been working to build more robust crisis care pathways 
across all ages ensuring that people in mental health crisis have access to timely and 
appropriate support. Key developments include:  

• Urgent mental health helplines, which are now universally accessible via NHS111
'select mental health option' alongside hundreds of alternative crisis services,
including crisis cafes, sanctuaries and crisis houses – that provide supportive
environment outside of traditional clinical settings.

•

transformation to ensure that crisis support is also available via text enhancing
options for those who may find it challenging to engage through voice calls.

 • Roll out of Mental Health Response Vehicles across the country.

• Full national coverage of 24/7 liaison mental health teams in general acute

hospitals.

• As part of the £150million of capital investment made available in recent years for
urgent and emergency care mental health pathways, there are now 33 new or
improved health-based places of safety providing a safe space for people detained
by the police and supporting timely handovers from police to healthcare staff.

•

Investing up to £120m to bring the number of mental health emergency
departments up to 85. Mental Health Emergency Departments will provide reactive,
short term intensive support for people in acute MH crisis as an alternative to
A&E. Mental Health Emergency Departments, or Crisis Assessment Centres, are
specialist NHS services that operate alongside emergency departments to provide
access to high quality, safe and compassionate care for those in mental health
crisis. Crisis Assessment Centres will be usually accessed via self-referral, direct
referral from other UEC mental health services, or ‘a walk-in’ where patients choose
to do so. Services are led by a consultant / nurse consultant, in easy-to-access
locations, in close vicinity to emergency department(s), ideally co-located with other
mental health services, including crisis teams, inpatient facilities and community
mental health teams. Crisis Assessment Centres should operate as part of a
networked model of urgent and emergency care, with referral pathways into
emergency departments and mental health services as required

To help ensure that fewer people reach a point of crisis, the government is transforming 
mental health services into community-based mental health centres, building on existing 
pilots. These centres will bring together a range of community mental health services 
under one roof, including crisis services and short-stay beds, improving continuity of care. 
This reduces fragmentation in service delivery and patient experience, which contributes to 
longer waiting times and lower patient satisfaction.   

I hope this response is helpful. Thank you for bringing these concerns to my attention and 
once again I would like to express my sincere condolences to the family and loved ones of 
Kallum.   

Yours sincerely, 

 BARONESS GILLIAN MERRON 

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR 
WOMEN’S HEALTH AND MENTAL HEALTH

Mrs Lydia Brown 

Senior Coroner for West London 

West London Coroner's Court,  

25 Bagley's Lane,        

Fulham,  

London  

SW6 2QA 

Dear Mrs Lydia Brown 

Chief Executive 

West London NHS Trust 

1 Armstrong Way 

SOUTHALL 

Middlesex 

UB2 4SD 

Tel: 

Web: www.westlondon.nhs.uk 

Date: 27th March 2026 

Inquest touching upon the death of Mr Kallum Josh Reed (Deceased) 

Response to Regulation 28 Report to Prevent Future Deaths dated 5th February 2026 

I am writing further to your report dated 5th February 2026 issued under paragraph 7, 

Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the 

Coroners (Investigations) Regulations 2013 as directed to West London NHS Trust (“the 

Trust”).   

I am aware that during the inquest hearing in January 2026 you heard evidence pertaining 

to delays for referral, assessment and diagnosis of autism spectrum disorder (ASD) and 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 attention deficit hyperactivity disorder (ADHD) for adults along with evidence pertaining to 

access to the Crisis, Assessment and Home Treatment Team (CAHTT) and that as a result 

of this evidence, a Regulation 28 report was issued to the Trust. 

The purpose of this letter is to provide you with a full response to these concerns as set 

out in your report in so far as these are issues that can be addressed by the Trust. Below I 

have set out your concerns and the Trust responses. 

Your concern regarding the "unacceptably long wait" for referrals, assessments and 

diagnoses of ASD and ADHD, which you raised with the Minister for the Department of 

Health and Social Care and with the Trust.  

Our response:  

The Trust is the provider for adult ASD assessments in Ealing. This service has had a 

significant number of patients waiting for an assessment, with the longest wait being 2 

years. When this service was established in 2021, it was modelled upon historical trends in 

activity referred to providers outside North West London, and commissioned and 

resourced by North West London ICB to complete 86 assessments per year. In the last 

three full financial years against this target, we delivered 547 assessments (212%), 

however demand continued to grow leading to a considerable backlog of patients 

awaiting diagnostic assessment experiencing unacceptable delays.  

Having successfully obtained additional interim funding we have commissioned a private 

partner provider to provide additional autism diagnostics capacity, and we are on 

schedule to reduce our waiting list to under twelve months by the end of March 2026 and 

to reduce this further to under six months by the summer of 2026. Robust monitoring and 

quality assurance measures are in place to track delivery and monitor waiting lists. In 

tandem with this we are working on our internal pathways, to ensure that these are more 

streamlined and productive. Finally, whilst we have received non-recurrent resources, we 

 
 
 
 
 
 have also now agreed with commissioners that the previously commissioned service was 

insufficient and will be augmented. The commitment of our commissioners to expand the 

service will be critical if we are to deliver shorter waiting times on a sustainable footing.  

The Trust is not the commissioned provider for adult ADHD assessments in any of our 

boroughs and therefore cannot respond on this matter. This would best be addressed to 

the NW London Integrated Care Board as the commissioner.  

Your concern regarding the ‘crisis team’ gatekeeping referrals into their service and the 

failure of pathway in Kallum’s case; regarding the Trust’s internal report conclusion that 

Kallum should have been assessed in person by the ‘crisis team’ contested in court by the 

service manager, re-emphasising  the challenges faced by patients seeking crisis care; and 

regarding no route to access the ‘half-way house’ provisions of care unless via the ‘crisis 

team’. You raised this concern with the Trust. 

Our response:  

From April 2025, the Trust moved from a service-line to a borough-based structure. This 

means that all mental health services are now managed within the borough rather than 

the previous model which saw all inpatient, all community, all liaison and talking therapies 

teams managed across the three directorates based on functional similarities. This change 

ensures that the organisation’s structure better supports integration of care and aims to 

reduce fragmentation for individuals whose care pathways previously spanned multiple 

service lines. The new structure supports more joined-up working within boroughs and 

stronger relationships with partners (both internal and external to the organisation) in 

place-based systems within the local areas. 

As part of the work flowing from this reorganisation, and to maximise benefits arising 

from this organisational change, the Trust decided that integrated pathways and whole 

person care would be a key element of the Trust Quality Priorities for 2025-2028 

(supporting a refreshed Clinical Strategy). As part of this work and directly linked to your 

 
 
 
 concern, Ealing borough mental health services are undertaking a pilot testing the 

implementation of ‘trusted assessments’. This means that services are ‘trusted’ to have 

conducted a thorough assessment for the purposes of being accepted by the CAHTT (or 

‘crisis team’).  In Kallum’s case, this would have meant that the recommendation from the 

psychiatric liaison team in the Accident & Emergency unit that he should be admitted 

either to the Recovery House with CAHTT support, or for home treatment with the CAHTT 

team, would not require a further assessment by the CAHTT team and this referral would 

be automatically accepted for onward support. The CAHTT team will then continue to 

undertake their own ongoing assessment to validate current presentation, risk, protective 

factors, required interventions and onward care, but this will determine acceptance to the 

team nor affect timelines.  

To fully support this roll-out, we have adjusted the management portfolios in Ealing and 

brought the Psychiatry Liaison and CAHTT teams together under a single new senior 

manager with previous experience of working within a trusted assessment framework. We 

have also recruited a new Clinical Lead who will work across the same portfolio to support 

the new service manager and implement all necessary changes and improvements 

supporting the medical staff. This interface and smooth transition remain a priority for the 

Clinical and Associate Directors within the borough.  

Notwithstanding these recent changes, the Trust notes that Kallum did receive a timely 

follow-up and input from the Mental Health Integrated Network Team, mitigating delays 

caused by the decision of the CAHTT team to decline his referral.  

You also raised a concern about the disagreement expressed by a Service Manager, when 

attending as a witness, with the conclusions of the Patient Safety Incident Investigation 

(PSII). The Trust places a very strong emphasis on the independence of the PSII Panel and 

acknowledges that staff may hold differing clinical views regarding specific decisions and 

findings. The learning from our PSII reports and learning events clarifies that it remains 

imperative that the findings of a PSII are treated as a true record of events and 

 
 
 
 recommendations are given the status necessary to implement required changes. We 

continue to work across services to promote the understanding that change and learning 

following a PSII is a fundamental part of being an evolving, learning and improving 

organisation. 

Your concern has highlighted a need to strengthen our processes at the point where 

investigators provide feedback to involved teams, ensuring that any concerns or 

disagreements are identified and addressed before the report and recommendations are 

finalised. This improvement work is already being implemented and will include a focus on 

the implementation of learning and the significance of the service flexibility and openness 

to change. We anticipate completion of the first tranche of this learning by May 2025 but 

appreciate it is an ongoing learning need. 

I hope that this letter sets out the current and planned actions from the Trust to ensure 

that the concerns you have raised are being addressed and mitigated.  

I would like to take this opportunity to further offer my deepest condolences to the family 

and friends of Kallum for their loss.  

Yours sincerely 

Chief Executive