Timothy Reading

Legal Department 
Uffculme Centre 
52 Queensbridge Road 
Moseley 
   Birmingham  
B13 8QY  

Date: 

    13 January 2026      

Mr J Puzey, 
HM Assistant Coroner, 
Coroner’s Court 
Martins Way 
STOURPORT ON SEVERN  
DY13 8UN 

Dear Mr Puzey, 

Prevention of Future Death report into the death of Timothy Thomas Reading 

Thank you for the Prevention of Future Deaths (PFD) Report dated 21 November 2025 in relation to the 
death of Mr Reading. I would like to take this opportunity to offer my sincere condolences to the family 
of Mr Reading at this very sad time. I would like to begin by offering assurances that the Trust is a learning 
organisation and when we identify care which could have been improved, we take actions to improve 
care for other patients in the future.  

I note from your PFD report there were two aspects of care you have raised concern with, one relating 
to the trust. We will therefore aim to respond to the issue raised below: 

The absence of a formal documented s.117 plan agreed by all those responsible for a patient’s 
care and treatment upon discharge into the Community from a lengthy inpatient stay creates a 
risk of disjointed, disorganized and inadequate support for vulnerable people suffering serious 
mental health conditions. This, in turn, may cause them to feel unsupported and helpless. 

The Trust has now looked at the inpatient care and CMHT care around the s.117 plan on the back of 
your concerns. Section 117 of the Mental Health Act 1983 places a joint duty on the NHS Integrated Care 
Board and local authority to provide aftercare services for individuals detained under certain sections of 
the Act following discharge. 

This duty is not automatic; it only applies where there are ongoing health or social care needs arising 
from the mental disorder and aimed at reducing the risk of relapse or readmission. The Trust has a form 
within  Rio  which  clearly  sets  out  the  relevant  areas  for  the  s.117  meeting  and  ensures  that  both 
healthcare  and  social  care  are  signed  up  to  the plan. I attach  for ease a  copy  of  a blank  form  which 
shows all the relevant areas in one place and will ensure comprehensive plans in an easily accessible 
and shareable document. All staff in Acute care have been reminded to use this form in the future and 
this has also been discussed at team meetings.   

In respect of the CMHT transfer to the new CMHT,  the Clinical Directors for CMHTs will be raising the 
case and reminding staff of the need to provide verbal and written handover to external Trusts receiving 
service user subject to  s.117 aftercare at the Community  Clinical Governance Committee on 27th Jan 

8

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                               
 
 
 
 
 
 
 
 
 
 
 2026. They will also be formally writing to all the Consultant Psychiatrists outlining that this must be done, 
to ensure that receiving teams are fully aware of the s.117 requirements during the handover period and 
there is therefore consistency in care.  

I hope that you will now be assured that the s.117 process is now robust within the organisation. If you 
require any further information, please do not hesitate to contact us.  

Yours sincerely 

Chief Executive 
BSMHFT

Mr James Puzey 
HM Assistant Coroner for Worcestershire  
Worcestershire Coroner’s Court 
The Civic 
Martin’s Way 
Stourport-on-Severn 
Worcestershire 
DY13 8UN 

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

7 April 2026 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Timothy Thomas Reading 
who died on 9 January 2025.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  21 
November 2025 and received by NHS England on 24 February 2026, concerning the 
death of Timothy Thomas Reading on 9 January 2025. In advance of responding to 
the  specific  concerns  raised  in  your  Report,  I  would  like  to  express  my  deep 
condolences to Timothy’s family and loved ones. NHS England is keen to assure the 
family and yourself that the concerns raised about Timothy’s care have been listened 
to and reflected upon.   

Your Report raised concerns around the absence of formal documented Section 117 
plan  agreed  upon  by  all  those  responsible  for  a  patient’s  care  and  treatment  upon 
discharge  into  the  community  from  a  lengthy  inpatient  stay.  This  creates  a  risk  of 
disjointed,  disorganised  and  inadequate  support  for  vulnerable  people  suffering 
serious  mental  health  conditions  which  may  cause  them  to  feel  unsupported  and 
helpless. Your report also raised concerns around lack of national guidance from the 
NHS  or  other  sources  that  explain  what  a  Section  117  plan  should  address.  This 
represents a gap which gives rise to concern that mental health providers are unclear 
as  to  the  component  elements  for  a  Section  117  plan  and  the  degree  or  depth  of 
planning required for individual patients.  

NHS England Mental Health colleagues have advised that there is clear guidance set 
out in the Mental Health Act Code of Practice on Section 117 aftercare which includes 
planning  based  on  the  person’s  individual  needs.  It  includes  examples  such  as 
ensuring the person’s wider social, cultural and spiritual needs are met and specifies 
that after care should aim to support people in regaining or enhancing their skills, or 
learning new skills,  in order to  cope  with  life  outside  of hospital.  Before  deciding  to 
discharge or grant more than a very short-term leave of absence to a patient, or to 
place a patient onto a Community Treatment Order (CTO), the responsible clinician 
should  ensure  that  the  patient’s  needs  for  after-care  have  been  fully  assessed, 
discussed with the patient (and their carers, where appropriate) and addressed in their 
care  plan.  If  the  patient  is  being  given  leave  for  only  a  short  period,  a  less 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 comprehensive review may be sufficient, but the arrangements for the patient’s care 
should still be properly recorded 

In addition to this, the Community Mental Health Framework states that ‘every person 
who  requires  support,  care  and  treatment  in  the  community  should  have  a  co-
produced and personalised care plan that takes into account all of their needs, as well 
as  their  rights  under  the  Care  Act  and  Section  117  of  the  Mental  Health  Act  when 
required’.  

There is also statutory discharge guidance which covers Section 117 care. This states 
that  ‘a  personalised  care  and  support  plan,  as  a  result  of  a  ‘what  matters  to  me’ 
conversation with the patient, should be prepared and available to support discharge 
with  input,  where  relevant,  from  family  members,  chosen  carers  and  relevant 
professionals.’ This is underpinned by the NHS England guidance on comprehensive 
model  of  personalised  care.  NHS  bodies  and  local  authorities  in  England  have  a 
statutory duty to have regard to the statutory discharge guidance as well as the Mental 
Health Act Code of Practice.  

We  note  that  your  report  has  also  been  addressed  to  the  Trust  who  will  be  better 
placed  to  respond  to  the  concerns  raised  around  the  absence  of  Section  117  plan 
provided by the Trust despite it being requested.   

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 
Timothy, 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,  

National Medical Director 
NHS England