Anthony Card

Police Headquarters, Martlesham Heath, Ipswich IP5 3QS
Telephone: 101 or 999 in an emergency Fax: 01473 613737 (24 hrs) 
Calls may be monitored for quality control, security and training purposes.   

OFFICIAL - SENSITIVE

Mr Peter TAHERI
HM Assistant Coroner in Suffolk
Suffolk Coroner’s Court
Beacon House
Ipswich
IP1 5PB

Dear Mr Taheri

5 February 2026

Regulation 28 Response – Chief Constable of Suffolk Constabulary 
Inquest touching on the death of Mr Anthony Robert Card

I am writing in response to your Regulation 28 Report to Prevent Future Deaths dated 7 
November  2025  following  the  conclusion  of  the  inquest  touching  on  the  death  of  Mr 
Anthony Robert Card on 6 November 2025.

Suffolk  Constabulary  has  taken  this  incident,  and  your  findings,  very  seriously  and  is 
committed to continuing to improve awareness and training for frontline staff in relation to 
adult mental health, including in relation to the established mechanisms available to officers 
to  communicate  Medium  risk  to  self  from  mental  ill-health  where  statutory  safeguarding 
thresholds are not met. 

On 21 November 2023, Mr Card presented to police during a period of significant mental 
health deterioration. Officers determined that neither section 136 of the Mental Health Act 
1983 powers, nor section 42 of the Care Act 2014 safeguarding thresholds, were met and 
transported  him  back  to  his  accommodation.  A  Protecting  Vulnerable  Persons  (“PVP”) 
report was submitted by attending officers describing a Medium risk to self from mental ill-
health.  Both  frontline  officers  believed  that  the  PVP  would  be  automatically  shared  with 
adult  mental  health  services  via  the  Multi-Agency  Safeguarding  Hub  (“MASH”)  in  “slow 
time”. On 22 November 2023, Mr Card died by suicide, a conclusion reached by the jury 
on 6 November 2025. 

Evidence heard at the inquest established that the frontline officers’ belief regarding PVPs 
being automatically shared with adult mental health services via MASH was incorrect and 
that there is no facility for adult mental health to be reviewed by MASH unless there are 
other concerning factors, in which case Adult Social Services would be involved. 

Detective  Chief  Inspector 
provided  a  statement  detailing  the  current  MASH 
referral  process  confirming  that  MASH  does  not  process  adult  mental  health  referrals 
unless the section 42 Mental Health Act criteria are met. All referrals that do not meet this 
threshold are BRAG–rated ‘Blue’ and are retained solely for audit, with no onward sharing 
with partner agencies. This has been the case since 5 April 2022.

Making Suffolk a safer place to live, work, travel and invest

www.suffolk.police.uk

 The central concern, as set out in your Regulation 28 Report, is that there is currently no 
mechanism available to enable frontline police officers who wish, of their own volition and 
with the subject’s consent, to communicate risk information, arising out of an interaction 
with an adult at Medium risk to self from mental ill-health, to medical or mental health care 
providers where statutory safeguarding thresholds are not met. 

Suffolk Constabulary is committed to addressing your concerns and is doing so through 
existing  clinical  pathways  as  opposed  to  by  way  of  new  structures  which  would  create 
operational  difficulties  and  would  require  a  full  multi-agency  process  change.  This  is 
explained in more detail below. 

1. Statutory division of responsibilities 

Your Regulation 28 Report is addressed to both Suffolk Constabulary and Suffolk County 
Council  (Adult  Social  Care),  however  is  not  addressed  to  Norfolk  and  Suffolk  NHS 
Foundation Trust (“NSFT”). It is important to note that NSFT hold both the statutory and 
operational responsibility for adult mental health care across Suffolk. 

A multi–agency meeting convened by the Suffolk Safeguarding Partnership on 20 January 
2026 has since considered your concerns and the appropriate remit of responsibilities as 
amongst partner agencies in regard to adult mental health. Although agencies will respond 
individually,  a  shared  position  was  reached  on  what  is  deliverable,  proportionate,  and 
feasible given current statutory frameworks, workforce constraints and the national ‘Right 
Care Right Person’ requirements.

2. Practical limitations of creating a new MASH pathway 

A  new  MASH  referral  pathway  for  adult  mental  health  concerns  is  not,  in  our  respectful 
submission, viable. Creating a pathway for Medium–risk adult mental health referrals falling 
short of section 42 of the Mental Health Act would generate an estimated 500 additional 
referrals  per  month,  creating  substantial  operational  impact  across  the  police  and  Adult 
Social Care. This would require a structural redesign of MASH which, in our view, would 
not lead to improved outcomes due to adult mental health sitting wholly within the remit of 
NSFT as opposed to within MASH. As addressed below, NHS 111 Option 2 already exists 
as  the  appropriate  clinical  route  for  sharing  concerns  falling  outside  of  the  statutory 
framework. 

It is important to note that Suffolk Constabulary is not sufficiently resourced to be able to 
assist with mental health referrals which fall short of the current legislative thresholds. A 
shift in this approach would go against the recent policy of ‘Right Care Right Person’ and 
place undue pressure and expectation upon police officers to make an assessment of an 
individual’s mental health needs where they are not qualified mental health professionals. 
This would in turn raise the risk to officers should they make the incorrect decision whether 
by omission of filing an adequate PVP or by way of initiating a PVP that results in further 
intervention that may ultimately be viewed as interference. 

PVPs for adult mental health incidents are not currently mandatory however should this be 
revised,  this  would  have  the  effect  of  increasing  the  already  heavy  burden  on  frontline 
officers,  as  well  as  increasing  the  need  for  officers  to  make  a  judgement  call  as  to  an 
individual’s mental health needs which is not the role of the police. 

3. The role and function of NHS 111 Option 2

 NHS 111 Option 2 is a 24-hour, 7 day a week NSFT-operated clinical triage service. It has 
the benefit of providing real-time assessment and provides a route to correctly referring 
individuals to primary, secondary or crisis mental health services. 

Should frontline officers wish to raise a concern in relation to adult mental health which falls 
short of their powers, and where there is no additional social care concern, NHS 111 Option 
2 is the appropriate mechanism. It provides clinical oversight, immediate triage and relevant 
follow-on referral for those with mental health concerns. This is in contrast to MASH which 
does not process adult mental health referrals in the absence of section 42 safeguarding 
thresholds having been met. Attempting to use MASH for Medium risk concerns regarding 
adult mental health would add delay, provide no clinical value and divert MASH from its 
statutory safeguarding purpose. 

4. Addressing knowledge gaps within frontline policing 

Suffolk  Constabulary  accepts  that  staff  awareness  of  the  role  and  function  of  NHS  111 
Option 2 requires strengthening. Officers are routinely expected to direct individuals to NHS 
111  Option  2  however  there  appears  to  be  inconsistency  in  the  understanding  and 
appropriate application of this. 

Suffolk Constabulary is therefore committed to addressing knowledge gaps within frontline 
policing to reinforce officers’ understanding in relation to: 

• How MASH processes adult mental health referrals (including that MASH does not 
review adult mental health PVPs unless there are other social care concerns); 

• Who holds adult mental health responsibility; and 
• The role and function of NHS 111 Option 2. 

Suffolk Constabulary commit to: 

• Reinforcing guidance through internal communications; 
• Updating officer briefing materials; and 
• Ensuring the Contact and Control Room (“CCR”) confirms that NHS 111 Option 2 

has been signposted or contacted before CAD closure. 

 disclosed as part of your 
The statement from Detective Chief Superintendent 
investigation  provides  reassurance  that  training  in  respect  of  adult  mental  health  as 
delivered to frontline officers and operational staff is ongoing and adequate. This includes:

• Mental  health  training  delivered  as  part  of  initial  officer  training  –  this  is  a 

comprehensive training package covering:

o Powers  and  policies  for  officers  dealing  with  individuals  who  suffer  from 

mental ill-health or who may lack capacity;

o Mental Health Act 1983;
o Mental Capacity Act 2005;
o Role and jurisdiction of the Office of the Public Guardian; 
o Mental health illness, initial response and the support available;
o Force policy and protocol concerning mental health; and 
o Right Care Right Person. 

• Mental health training is provided to staff members joining the Contact and Control 

Room. 

 • Public  and  Personal  Safety  Training  (“PPST”),  as  approved  by  the  College  of 
Policing – mental health forms an integral part of this training delivered by PPST 
trainers. 

• Vulnerability training – this is scheduled for Autumn/Winter 2026 and will include a 

refresher on mental health training. 

• Enhanced  training  is  delivered  to  Armed  Response  Officers  and  the  Negotiator 

cohort. 

• Training  materials  are  held  on  the  Learning  Management  System  for  officers  to 

readily access.  

5. Suffolk Constabulary’s commitment to a multi–agency audit of NHS 111 Option 2

The Suffolk Safeguarding Partnership is to commission an audit to evaluate as follows: 

• How NHS 111 Option 2 functions in practice;
• How reliably it captures and routes police and partner–initiated concerns; and 
• Whether improvements are needed in staff knowledge and public messaging case–

study based testing of the pathway. 

This audit is already underway and we aim for this to be complete in the next quarter. 

Suffolk  Constabulary  is  committed  to  continuing  to  consult  with  partner  agencies  to 
encourage a multi-agency approach to evaluating the operability and reliability of NHS 111 
Option  2  and  whether  improvements  can  be  made  to  strengthen  staff  knowledge  and 
training. It is respectfully submitted that the existing clinical pathways provide an adequate 
mechanism for raising mental health concerns in circumstances where statutory thresholds 
are not met. It is important to consider alongside this the limitations of police powers, the 
role of Adult Social Care and the statutory role of NSFT in dealing with adult mental health 
concerns across Suffolk as addressed above. 

Yours sincerely, 

Demand Reduction & Safeguarding

OFFICIAL-SENSITIVE PERSONAL 

Date:02nd February 2026  

PRIVATE AND CONFIDENTIAL 
Suffolk Coroners Court 
FAO Coroner Taheri 
Beacon House 
IP1 5PB 

Dear Coroner Taheri, 

Suffolk County Council (“SCC”) writes in response to your Regulation 28 Report dated 07th  
November 2025 and further to our previous letter dated 23rd December 2025. 

SCC acknowledges it is a recipient organisation of the Report, however SCC wishes to 
clarify its statutory and operational remit in relation to the specific issue raised. 

The responsibility for adult mental health provision and clinical pathways as identified by 
the report rests predominantly with NHS commissioners and NHS mental health providers 
(this is without prejudice to SCC’s distinct statutory responsibilities in respect of mental 
health social care, including Care Act functions and, where applicable, joint aftercare 
duties under the Mental Health Act). 

SCC Adult Social Care’s role in this context (and generally) is concerned with statutory 
functions under the Care Act, including safeguarding where the section 42 duty is engaged 
(i.e. where there is reasonable cause to suspect the adult has needs for care and support, 
is experiencing or at risk of abuse or neglect, and as a result is unable to protect 

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themselves) and social care assessment/support for eligible care and support needs, 
which may co-exist with mental ill-health 

Where information relates solely to adult mental health concerns and does not meet 
statutory adult safeguarding criteria and/or does not otherwise engage adult social care 
functions, SCC is not the appropriate recipient for clinical triage or onward clinical referral 
into adult mental health pathways. Where a contact nonetheless indicates an appearance 
of care and support needs, SCC will consider whether Care Act assessment duties are 
engaged. 

For that reason, creating a new MASH pathway for adult mental health-only referrals that 
fall short of section 42 safeguarding criteria would not sit appropriately with MASH’s 
purpose and would not, of itself, ensure that clinically relevant risk information is triaged 
and acted upon within a clinically led NHS mental health pathway. 

SCC has participated in multi-agency discussions convened following the inquest, 
including a meeting chaired through Suffolk Safeguarding Partnership arrangements in 
January 2026 to support consistency across agencies’ responses and identify feasible and 
deliverable actions. 

While each organisation must respond to the Regulation 28 Report individually, SCC 
supports the partnership approach being taken to ensure the right agencies implement the 
correct solutions, and to ensure frontline staff have clarity about routes available to secure 
timely clinical triage and support. Notwithstanding the above SCC can confirm the 
following. 

SCC will issue an internal briefing note to relevant SCC services (including Adult Social 
Care operational teams, Emergency Duty Service and Customer First) clarifying the 
purpose and limits of MASH in relation to adult mental health-only referrals, when Care Act 
section 42 duties apply and appropriate routes for signposting/referral to clinically-led 
NHS mental health triage services (including use of NHS 111 Option 2). 

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SCC will also update relevant internal guidance and intranet pages used by Customer First 
/ ASC to reflect the above, including out-of-hours signposting. 

SCC will continue to support and will participate in a Suffolk Safeguarding Partnership led 
multi- agency audit to examine current processes and make recommendations to improve 
staff understanding and consistent system use. 

SCC will support consistent multi-agency messaging explaining what happens when the 
NHS 111 Option 2 pathway is used, and why it is the appropriate clinically led route for 
adult mental health triage outside safeguarding criteria. SCC will incorporate partner 
provided wording into SCC-facing guidance and disseminate to relevant staff. 

SCC recognises and supports the underlying safety aim of ensuring relevant risk 
information reaches the right services. However, it is not proposed to establish a new 
MASH pathway for “medium risk mental health-only” for the reasons outlined above. 

SCC is committed to working with partners to reduce the risk identified in your Report. 
While SCC is not the correct lead body to create adult mental health referral mechanisms 
outside safeguarding criteria, SCC will: 

1.  Participate in and support the SSP-led multi-agency audit and recommendations; 

2.  Strengthen internal understanding and clarity across Adult Social Care, Customer 
First and out-of-hours teams about the function of MASH and the correct routes for 
adult mental health concerns; 

3.  Support consistent partnership messaging and signposting to clinically led NHS 

pathways, including NHS 111 Option 2. 

SCC will continue to co-operate with other partner agencies and share relevant 
information in accordance with applicable information-sharing arrangements, to support 
timely access to clinically led crisis assessment where suicide risk is identified 

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Yours sincerely, 

Suffolk County Council Legal Services (on behalf of SCC) 

OFFICIAL-SENSITIVE PERSONAL