Robert Day

Parliamentary Under-Secretary of State for   
Women’s Health and Mental Health 

39 Victoria Street  
London  
SW1H 0EU  

HM Coroner Ian Potter 
Kent and Medway Jurisdiction 

22 May 2026 

Dear Mr Potter,    

Thank you for the Regulation 28 report of 24th March 2026 sent to myself and the 
Secretary of State for Department of Health and Social Care about the death of Mr Robert 
Joseph Day.  I am replying as 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 Mr Day’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.  

In your report, you state you heard compelling evidence from the Head of Mental Health at 
South East Coast Ambulance Service NHS Foundation Trust regarding the difficulties 
faced by emergency services generally in situations and must accept that frontline 
paramedics and police officers are not specialists in the provision of mental health care.  

A capacity assessment was undertaken and the responders reasonably believed that the 
deceased did have capacity to make the decision to refuse treatment even in the 
knowledge that, without it, his death within the coming hours was highly likely. You also 
heard that the police could not have deployed section 136 of the Mental Health Act 1983 to 
take Mr Day to a place of safety because, at that time, the hotel room was his home. In 
any event, section 136 would not allow for treatment. Further, in the circumstances of Mr 
Day’s case, the process of applying for a warrant under section 135 of the Mental Health 
Act 1983 was also likely inappropriate given the critical nature and timing of Robert's 
situation.  

While not hearing specific and detailed evidence on other provisions of the Mental Health 
Act 1983, the witness was clear that these matters would likely be beyond the scope of 
understanding of most frontline emergency workers.  

The fundamental issue was considered to be 'what can the frontline crew actually do' in 
such complex situations. You acknowledged the complex interplay between the various 
agencies and services involved but highlighted your concern that the absence of any 
national guidance/advice to frontline emergency crews risks the lives of others who are 
found to be at time critical risk as a result of underlying mental health concerns. 

   
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
 I understand that this report has also been sent to the Home Office.  

In preparing this response, my officials have made enquiries with NHS England and the 
Care Quality Commission to ensure we adequately address your concerns. Upon 
reviewing your report, our NHSE colleagues felt it was more appropriate to reply directly to 
you given concerns around the absence of any national guidance/advice to frontline 
emergency crews.  You may want to address your report to NHSE, so that they can also 
address your concerns. For CQC, you will see that their response to your concerns is 
highlighted in this letter below.    

While I cannot comment on the applicability of section 135 and 136 of the Mental Health 
Act in this case, it may be helpful to say that the Government have committed to carrying 
out a consultation to explore the powers available to different professionals in different 
situations and settings, in particular but not limited to the operation of sections 135 and 
136. 

The consultation will seek views on powers and joint working approaches to ensure health 
and social care professionals and police have the appropriate powers to act in order to 
protect people from harm to themselves and to others when in a mental health crisis. 

While the exact scope of the consultation is not yet defined, we are working closely with 
the police, health and care representative groups and people with lived experience, to 
define the scope for the consultation and will set out further details in due course. 

Whilst NHS England will reply directly to your concern about guidance, it may be helpful if I 
describe some of the other actions being taken to improve overall care for people in 
mental health crisis. To supplement the NHS 111 mental health crisis triage service, we 
are also deploying mental health professionals in 999 call emergency operation centres 
and clinical assessment services to ensure people experiencing a mental health crisis are 
directed towards appropriate services.  

We continue to increase mental health expertise for ambulance services including 
ensuring that mental health professionals are embedded in all emergency operation 
centres and improve training for ambulance staff to enable effective responses to those in 
mental health crisis. 

Substantial progress has been achieved in building a more robust crisis care pathway 
across all ages ensuring that people in mental health crisis have access 
to timely and appropriate support. Key developments include the introduction of the NHS 
111 ‘select mental health’ option alongside hundreds of alternative crisis services, 
including crisis cafes, sanctuaries and crisis houses which provide a supportive 
environment outside of traditional clinical settings. Work is underway with all Integrated 
Care Boards to roll out crisis text services across England by March 2026.  

NHS England has successfully completed the delivery phase of the Mental Health 
Response Vehicles programme, with 88 vehicles now built and handed over to local 
systems. These vehicles are providing on-scene support for individuals in crisis and 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 reducing attendance in A&E for mental health concerns by delivering care directly in the 
community. 

There is also full national coverage of 24/7 liaison mental health teams providing mental 
health assessments and care in general acute hospitals, as well as high fidelity crisis 
teams in a community.  

We are also investing up to £120m to bring the number of mental health emergency 
departments up to 85. Mental Health Emergency Departments (MHEDs) provide rapid 
assessment and support in a therapeutic setting, helping those with mental health needs 
get the right care quickly and reducing reliance on Emergency Departments. Early 
evidence shows that MHEDs can improve patient experience and outcomes, while also 
easing pressure on wider urgent and emergency services.  

Alongside this, NHS England is also developing new core standards of care for community 
mental health services. These will set out the ‘must dos’ for all services to ensure that at 
least a minimum quality of care is being provided in all areas for all people with serious 
mental illness. By providing better care for all people sooner, fewer people will require the 
highest levels of intensive and assertive community treatment.    

CQC response 

CQC have shared the following information regarding Mr Day’s death: 

Mr Day was a person receiving support from Kent and Medway Mental Health NHS Trust 
at the time of his sad death.  We note that it was his community psychiatric nurse who 
alerted emergency service following the disclosure that he had taken an overdose.  

We inspected the trust’s community mental health services for working age adults in 
March 2025. This inspection was completed as part of CQC's Adult Community Mental 
Health Programme. We also inspected crisis services and health-based places of safety 
as part of the programme. The programme of inspections contributes to CQC's 
commitment to inspect the standard of care in community mental health services across 
the country. We undertook a short-notice, announced comprehensive inspection of this 
service. You can read the report here:   

https://www.cqc.org.uk/provider/RXY/inspection-summary#Community-based-mental-
health-services-for-adults-of-working-age 

At this inspection we rated the service as requires improvement. We found 4 breaches of 
regulation in relation to safe care and treatment, buildings and premises, governance, and 
staffing. We served a warning notice on the trust for failing to meet the regulations related 
to risk assessment and management of service users accessing community mental health 
services.  

We have since carried out a follow up inspection in December 2025 and we are satisfied 
that the Warning Notice has been met, but the report from this inspection has yet to be 
published.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

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

Minister of State for Policing and 
Crime  

2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

Ian Potter 
Kent and Medway Coroners' Service  
Oakwood House  
Oakwood Park  
Maidstone  
Kent  
ME16 8AE 

2 June 2026 

Dear Mr Potter, 

Thank you for your letter of 27 March 2026 enclosing a copy of the Regulation 28 Report 
to Preventing Future Deaths, following the inquest into the death of Robert Joseph Day. I 
am responding as the Minister for Policing and Crime. 

I would first like to express my deepest condolences to Robert’s family for their loss in 
what must be a truly difficult time for them. 

The Mental Capacity Act 2005 is designed to protect individuals who may lack the mental 
capacity to make their own decisions about care or treatment.  The legislation states that a 
person lacks capacity in relation to a matter if they are unable to make a decision for 
themselves on that matter due to an impairment of, or a disturbance in the functioning of, 
the mind or brain.  Further, a person is unable to make a decision for themselves if they 
are unable to understand relevant information; to retain that information, to use or weight 
the information to make a decision or to communicate their decision. A person is to be 
assumed to have capacity unless it is established otherwise and making what might be 
considered to be an unwise or irrational decision is not by itself, proof that someone lacks 
capacity.  Where a person is deemed to lack capacity, others, including police, may 
intervene in certain vital or imminent circumstances such as to enable them to receive life 
sustaining treatment.    

The College of Policing’s Authorised Professional Practice 
(https://www.college.police.uk/app/mental-health/mental-capacity), which is the official, 
evidence-based guidance for policing in England and Wales, is clear that where an issue 
of capacity has arisen and “where health or social care professionals are on the scene, 
police should defer to their expertise and provide support as appropriate and in 
accordance with local protocols” which was the case in this event with the attendance of 
paramedics. 

There are limited powers which are available to the police in these types of circumstances. 
I see that you have acknowledged that Section 136 of the Mental Health Act could not be 
used as Mr Day was not in a public space, which is of course correct, and your view that 
section 135 was inappropriate given the critical timing of the situation. In order for section 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 135 to have been used, an approved mental health practitioner (AMHP) would have 
needed to be involved as they are the only professional who is able to apply for the 
warrant needed (although as you note, it may be unlikely that a warrant could have been 
granted and executed swiftly enough given the urgency of an overdose.) 

Further to this and the case law of R (Sessay) v South London and Maudsley NHS 
Foundation Trust & Anor [2011] EWHC 2617 (QB) 
(https://www.bailii.org/ew/cases/EWHC/QB/2011/2617.html), suggests the police would 
not have been able to remove Mr Day from the premises as the judge in that case gave 
clear direction that intervention of this kind must be conducted under the Mental Health 
Act, either admission under s4 MHA or the execution of a s135(1) MHA warrant. The 
judgement highlights that the MCA and common law doctrine of necessity cannot be used 
by the police to remove a person from a private premises as an alternative to using the 
MHA 1983 s135 (where a warrant must be obtained) or s136 (where the power can only 
be used in a place to which the public has access).  

Unfortunately, there was little that the police could have legally done in this particular sad 
situation where Mr Day lost his life, as the officers must have regard to that person’s rights 
and freedom of action, which he was deemed to have under the mental capacity act; an 
unwise decision does not amount to an automatic lack of capacity – people are entitled to 
make unwise decisions and decline medical treatment, where they have legal capacity to 
do so. 

Thank you again for your letter. 

Very best wishes, 

Minister of State for Policing and Crime

Mr. Ian Potter  

Kent and Medway Coroners' Service  

Oakwood House  

Oakwood Park  

Maidstone  

Kent 

ME16 8AE 

Chief Executives Office 

Priority House 

Hermitage Lane 

Maidstone 

Kent 

ME16 9PH 

15 May 2026 

Dear Mr Potter 

Inquest into the death of Mr Robert Day  

Kent and Medway Mental Health Trust Response to the Regulation 28 Report to 

Prevent Future Death 

I write in response to the Regulation 28 Report dated 24 March 2026, sent to Kent and Medway 

Mental Health NHS Trust (the Trust) following the conclusion of the inquest into the very sad 

death of Mr Robert Day on 15 January 2025.  

In your report to the Trust, you raised the following matters of concern: 

1.  Professional Curiosity 

I heard evidence that led me to conclude that in the weeks prior to Robert's death some 

of the mental health professionals from the Trust that were involved in his care did not 

display sufficient professional curiosity. This included, but was not limited to: 

•  Conducting what should have been 'home visits' in public places, which denied 

the  clinician(s)  the  opportunity  to  fully  and  holistically  assess  Robert  and  his 

needs; 

•  Overly strict adherence to the Trust's Did Not Attend (DNA) policy, which lacked 

any  meaningful  thought  being  given  as  to  the  reason(s)  why  an  appointment 

 
 
 
 
 
 might not have been attended. One witness considered that the policy itself was 

an issue; 

•  Robert's sister raised concerns about him to the Trust on 2 January 2025. Later 

that  day,  two  mental  health  nurses  from  Medway  and  Swale  MHT+  team 

conducted a 'cold call' visit to Robert. They documented a plan as a result of that 

visit, but I heard in evidence that this plan was "not reasonable" at that time and 

that a referral to the Rapid Response team would have been expected; and 
•  Some  staff  appear  to  have  looked  at  Robert's  presentation  on  one  given  day, 

without  looking  at  his  previous  presentation,  which  I  was  told  in  evidence 

showed a "lack of professional curiosity". 

Trust Response 

The  Trust  accept  that  opportunities  were  missed  to  demonstrate  an  appropriate  level  of 

professional curiosity. Even though the plan to meet Mr Day at a public place was eventually 

changed  to  the  local  Community  Mental  Health  Team  based  at  Sittingbourne  Memorial 

Hospital,  there  was  insufficient  clinical  probing  that  would  have  helped  clinicians  in 
recognising, querying, and escalating emerging concerns from Mr Day’s presentation before 

discharging  him.  In  line  with  the  Patient  Safety  Incident  Response  Framework  (PSIRF) 

principles, a learning response was undertaken through a multidisciplinary case conference 

with the local Community Mental Health Team on the 20th January, 2026. The focus was on 

understanding the care context, identifying contributory system factors, and agreeing shared 

learning to inform service improvement. 

In  regards  to the application of  the  Trust  Did  Not  Attend  (DNA) policy,  it  is  expected  that 
patients’ vulnerabilities, care and support needs, symptoms, safeguarding concerns, risks, 

the  Mental  Health  Act  (1983)  and  Mental  Capacity  Act  (2005)  will  be  considered  in  the 

implementation of this policy and not in isolation. The Trust   has introduced a daily DNA 

huddle within the local Community Mental Health Team to allow for consideration of risk   of 

patients and instigate relevant action required to maintain patient safety. 

Following  the  concerns  raised  by  Mr  Day’s  sister  on  the  2nd  January  2025,  we  have 

acknowledged there was inadequate challenge of assumptions, limited triangulation of care, 

and a lack of proactive questioning that may have contributed to a failure to fully appreciate 

the level of risk presented by  Mr Day at the time. A referral to the Home Treatment Team 

(HTT) should have follow to allow for a more intensive treatment and follow up. 

 
 
 
 
 
 We also recognise that professional curiosity is essential in mental health care, particularly 

where presentation may be complex, fluctuating, or  influenced by multiple factors such as 

lack of appropriate housing, social isolation as in the case of Mr Day. We regret that this was 
not consistently demonstrated in this case. In response to the coroner’s findings therefore, 

the organisation has taken the following actions: 

Strengthening Training and Awareness regarding professional curiosity  

•  Professional curiosity is being strengthened by focusing on developing a culture that 
supports personalised care and informed clinical decision-making. This is reinforced by 
senior clinical leaders through daily safety huddles, ward rounds, and team meetings. It 
will also be an agenda item at clinical summits, senior nursing leadership forum (June 
2026) and the annual nursing conference (October 2026).  

•  Case based learning will be introduced, using real clinical scenarios to support staff 

in recognising when to question, probe, and escalate concerns as part of directorate 

leadership learning. 

Clinical Supervision and Reflective Practice  

•  Supervision  frameworks  will  be  refreshed  to  ensure  professional  curiosity  and 

reflective questioning are routinely addressed. 

•  This will provide a focus on patient case discussion, supporting wider MDT and team 

decision making, personalised care planning and formulation that forms part of the 

Trust wider quality plan. 

Leadership and Oversight 

•  Senior clinical leaders, including Matrons and lead nurses are providing enhanced 

oversight and visible support, focusing on curiosity, challenge, and risk escalation. 

They  do  this  by offering  visible professional oversight  of nursing  and  Allied  Health 

Professionals (AHP) practice, setting clear expectations for standards of assessment, 
care  planning,  acting  as  a  point  of  escalation  in  managing  high‑risk  and 
high‑complexity cases. 

Policy and Documentation 

 
 
 
 
 
 
 
 
 
 
 • 

In  January  2026,  the  Trust  introduced  and  is  embedding  the  Collaborative  Risk 

Assessment and Management (CRAM) risk assessment framework. The quality of 

the  CRAM  is  routinely  being  audited  in  respect  of  patient/carer  involvement, 

formulation and a safety plan is present to support effective reassessment, challenge 

of assumptions, and clear clinical reasoning. 

•  The Trust is in the process of comprehensively refining the model of care within the 

Community Mental Health Teams with clinical pathways escalations to be clarified 

and  clinical  leadership  reinforced.  The  Trust  has  also  recognised  that  Curiosity  is 

fundamental to effective care delivery as it enables understanding of the person, not 
just the presentation and has consequently adopted ‘curiosity’ as one of its values. 

Work is now being undertaken  to  embed this to ensure a change of culture within 

the organisation. 

Ongoing Monitoring and Assurance  

We will continue to monitor the effectiveness of these actions through: 

•  CRAM Quality audits – 10 patients per month for each team. These audits focus on 

the quality of the risk assessment, formulation and plan and are overseen by senior 

nursing colleagues. 

• 

Incident reviews are undertaken in line with the Trust’s Patient Safety Incident Response 
Framework  (PSIRF)  to  ensure  learning  is  identified,  followed  through,  and  effectively 
embedded following patient safety incidents. 

•  Progress against the Trust Quality Improvement Plan is being strengthened through 
a  revised  governance  structure  implemented  during  May–June  2026.  Four  Senior 
Responsible Officers at Deputy level have been identified to provide assurance on delivery 
of quality milestones, including discharge and care planning. Each milestone is supported 
by defined key performance indicators to monitor impact. 

2.  Record Keeping (the '836 line') 

I  received  compelling  evidence  in  the  form  of  contemporaneous  notes  by  both  the 

paramedic and police officer that attended the 999 call to assist Robert on 14 January 

2025 (following his taking of an overdose), which led me to conclude that the paramedic 

 
 
 
 
 
 
 
 
 
 had sought advice from the Trust's so-called '836 line'. There was no record of the call 

or the advice given within Robert's electronic notes. 

I concluded that, in this particular case, the lack of record keeping did not contribute to 

death. However, record keeping in healthcare is a fundamental basic of patient care and 

is a central part of keeping patients safe. Again, it is not difficult to see circumstances 

in which a lack of clinical record-keeping would contribute to a death. As such, I raise 

my concern that ongoing record-keeping issues will contribute to future deaths. 

Trust Response 

Actions that are completed and in place as business as usual:  

•  All calls received by the 836-line are now recorded.  

•  A monthly meeting takes place with the Trust, British Transport Police, Kent Police and 

SECAMB they review 10 calls with the support of  the Trust Information Governance 

team. These are then triangulated with the progress notes on Rio (the electronic patient 

notes system).  

•  The information governance team listen to 10 calls a month separate to the meeting 

for quality purposes.  

Actions to be completed and monitored weekly by the Acute Directorate Clinical 

Governance Team: 

•  The Trust Information Governance Team is undertaking a review to verify that all staff 
within the 836-line team hold an in-date licence, ensuring all calls are appropriately 
recorded. Where a valid licence is not in place, calls will not be recorded. This action is 
being led by the General Manager for the 836-line. 

•  A monthly audit of 10 patients will be undertaken within the directorate to review call 
recordings and associated progress notes for quality and safety. This action is being led 
by the Clinical Governance Lead for the Acute Directorate. 

Thank you for bringing your concerns to my attention and I am sincerely sorry for the shortfalls 

in the care of Mr Day. 

Yours sincerely 

 Chief Executive