Louis Saunders

Ms Laura Bradford 
Senior Coroner  
East Sussex Coroner's Court and Office 
Westfield House 
St Anne's Crescent 
Lewes 
BN7 1UE 

Medical Director for Mental Health & 
Neurodiversity
NHS England 
Wellington House
133-155 Waterloo Road 
London
SE1 8UG

17th April 2026

Dear Coroner, 

Re:  Regulation 28 Report  to  Prevent  Future Deaths  –  Louis Robert  Saunders, 
who died on 10 October 2024 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  27 
February 2026 concerning the death of Louis Robert Saunders on 10 October 2024. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my sincere condolences to Louis’ family and loved ones. NHS England are 
keen to assure the family and the coroner that the concerns raised about Louis’ care 
have been listened to and reflected upon. 

ADHD  services  are  a  complex  landscape.  They  are  commissioned  locally  by 
Integrated Care Boards (ICBs) with significant national variation existing in pathways 
and  provision,  including  independent  sector  providers  operating  under  the  Right  to 
Choose framework.   

Your report highlights the potentially serious patient safety risk created by ineffective 
sharing of clinical information between care providers, in this case between a private 
care provider and NHS primary care. I note your reference to a shared care agreement 
(SCA) being put into place between the private provider and Louis’ GP, following his 
diagnosis in October 2022 (“his care was transferred to his NHS GP under a shared 
care agreement”).  

SCAs are formal arrangements supporting the safe sharing or transfer of elements of 
a patient’s ongoing care between, or from, a specialist provider to primary care, where 
this  is  clinically  appropriate  and  agreed  by  all  parties.  Their  purpose  is  to  enable 
patients  to  receive  continuing  care  in  the  community,  while  ensuring  appropriate 
specialist  oversight  is  maintained.  Under  an  SCA,  the  specialist  (in  this  case  the 
private provider) initiates treatment and remains responsible for the overall treatment 
plan, including diagnosis, treatment initiation, and specialist review. The primary care 
prescriber  (in  this  case  Louis’  GP)  may  agree  to  take  on  responsibility  for  routine 
prescribing  and  agreed  monitoring  requirements,  in  line  with  locally  agreed 
arrangements and any national guidance. 

Effective shared care relies on clear communication between the specialist and the 
primary  care  prescriber. The  specialist  is  responsible  for  providing  sufficient  clinical 
information to support safe prescribing and for promptly communicating any changes 

 
 
 
 
 
 
 
 
 to the treatment plan, including the outcome of scheduled reviews. The primary care 
prescriber  may  seek  specialist  advice  as  required,  including  where  concerns  arise 
regarding treatment efficacy or adverse effects. 

For medications that require ongoing specialist oversight, such as those used in the 
management of ADHD, SCAs are typically time-limited and subject to regular specialist 
review. Overall clinical accountability for the patients care remains with the specialist, 
while  specific  elements  of  care  are  delivered  under  shared  care  arrangements:  the 
specialist retains responsibility for diagnosis, treatment initiation, specialist review and 
any material changes to the treatment plan, and the GP undertakes agreed aspects 
of prescribing and monitoring in line with the SCA. The patient therefore remains under 
the  care  of both the  specialist  and  the GP throughout.  Where  a material  change to 
treatment is proposed, a revised or new SCA would normally be required, subject to 
the agreement of the GP. 

I  understand  from  your  report  that  the  SCA  was  established  for  the  provision  of 
Lisdexamfetamine  (30mg)  to  Louis,  and  the  first  prescription  issued  by  his  GP,  in 
November 2023. However, concurrently, Louis was reviewed by his specialist and his 
pharmacological treatment changed to Dexamfetamine (5mg, 3 times daily), resulting 
in simultaneous prescriptions. It is not unusual for a brief overlap in prescribing to exist 
when a treatment change occurs in the background of an existing SCA. Normally we 
would anticipate that the private provider (as the responsible specialist) would have 
discussed with Louis that this change of medication meant he should no longer take 
the  Lisdexamfetamine  prescribed  previously  and  communicated  the  change  in 
treatment  plan  to  Louis’  GP,  in  order  that  they  could  discontinue  the  existing 
Lisdexamfetamine prescription.  

We understand the concern that has arisen relates to continuity of care and robustness 
of process between private providers and the NHS once a patient has been diagnosed 
with ADHD,  commenced  on  medication,  and  subsequently  transferred  to  GP  care. 
However, I want to reassure you that it is entirely appropriate for a patient receiving 
ADHD medication via an SCA to remain under the care of their responsible specialist 
alongside their primary care prescriber, due to the need for the responsible specialist 
to retain oversight and manage treatment in line with the evolving needs of the patient. 
I  have  fed  your  concerns  back  to  NHS  England’s  National ADHD  Programme  and 
Primary  Care  Teams,    who  will  ensure  that  the  risks  you  have  raised  of  duplicate 
prescriptions and confusion between current and previous medication regimes,  and 
actions you have identified, including the need for continuity of care and timely and 
effective  communication  of  treatment  changes,  are  highlighted  to  both  specialist 
providers and primary care prescribers wherever possible in their ongoing work.  

NHS England is committed to working with system partners, including commissioners 
and providers of ADHD support, to improve health-related experience and outcomes 
for those with ADHD. We recently published non-mandatory guide prices for ADHD 
assessments  and  treatment  pathways,  alongside  detailed  commissioning  guidance, 
that  will  set  clear  expectations  for  assessment  standards,  data  quality,  clinical 
governance, shared care and follow-up.  

More fundamentally, the government has commissioned an Independent review into 
mental  health  conditions,  ADHD  and  autism to  look  at  the  issues  relating  to 
assessment  and  diagnosis  you  have  raised.  In  parallel  to  the  Review,  we  are also 

 
 
 
 
 
 conducting  an  internal exercise to  understand  current NHS clinical  and  operational 
practice  and  spend  on  mental  health, autism and  ADHD  services. In  addition 
to identifying unwarranted  variation  in  service  models,  we  will  explore  how  we  can 
improve access, productivity and quality of NHS services with a range of experts. To 
inform local commissioning and provision of care, we will use our findings to set out 
clear proposals for the future of mental health, autism and ADHD services. 

It  is  also  important  to  reaffirm  the  national  commitment  to  suicide  prevention.  NHS 
England  and  the  Department  of  Health  and  Social  Care  continue  to  prioritise 
improvements in early identification of suicide risk, safe prescribing, timely access to 
psychological  support  and  joined-up  communication  across  organisations.  These 
priorities  are  reflected  in  the  national  suicide  prevention  strategy,  which  places 
particular  focus  on  young  adults  and  people  with  neurodevelopmental  conditions, 
groups recognised as facing disproportionately high risks.  

Regional Response 

The South East Regional NHS England Team have liaised with the NHS GP practice 
and the private ADHD clinic regarding this case.  

The NHS GP practice have held multiple practice meetings looking at their in-house 
systems  around  SCAs  for  their  patients  with  ADHD.  Through  this  they  identified 
difficulties  with  communication  between  themselves  and  the  private  provider  which 
meant that the practice were not fully aware of what treatment Louis was receiving. 
They also noted difficulties in being able to contact the private clinics due to problems 
both with finding a point of contact and receiving a response. 

The NHS GP practice highlighted that with SCAs used for other medications there is 
a clear standardisation of what is expected from general practice and secondary care. 
They  would  welcome  improved  communication  with  private  providers  and  greater 
clarity around the specifics of an ADHD shared care agreement. 

The Region have liaised with the private ADHD clinic who have advised that they have 
held a formal preventing future deaths review meeting for this case. The result of the 
review  was  that  they  did  not  identify  any  deficiencies  in  their  processes,  nor  any 
changes  required  to  their  current  clinical  practice.  They  highlighted  their  current 
systems ensure continuity of care and safer prescribing which included that following 
every  clinical  interaction,  including  titration,  medication  reviews,  and  shared  care 
reviews,  detailed  written  correspondence  is  issued  to  the  patient’s  GP  to  ensure 
continuity,  transparency,  and  clarity  of  care.  They  clarified  that  they  do  not  initiate 
medication  without  first  obtaining  a  Summary  Care  Record  or  equivalent  clinical 
information from the patient’s GP.  

The Region will be sharing the responses from the NHS GP with the private provider 
and the private providers response with the NHS GP so they are aware of each other’s 
response. If you have any further questions we would advise you address those to the 
private provider directly.   

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 Louis, 
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,  

Medical Director for Mental Health and Neurodiversity 

NHS England