Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
George Werb · 19 Nov 2014 · Lydia Brown, Exeter & Greater Devon
“The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed.”
What was promised
Stated action 1 · response to Emma Carpenter (14 Jul 2015) · stated timescale: 8 September 2015
“The Trust has now set up a specialist Eating Disorder Service for children and adolescents, and reports that although this service now has good professional links with named paediatricians at Kings Mill Hospital and Queen's Medical Centre, there are no equivalent links with Bassetlaw Hospital.”
judiciary.uk/wp-content/uploads/2015/10/Carpenter-2015-0276a.pdf
Stated action 2 · response to Emma Carpenter (14 Jul 2015) · stated timescale: none stated
“We have an identified Consultant and will actively engage with the services provided by Nottinghamshire Healthcare Trust as the need arises and will monitor these arrangements through the paediatric clinical governance team.”
judiciary.uk/…/2015-0276-Response-by-Doncaster-and-Bassettlaw-H…
Stated action 3 · response to Emma Carpenter (14 Jul 2015) · stated timescale: 2017-18
“Admission into hospital, in the majority of cases, ought to be the result of all community interventions being exhausted. Since NHS England became responsible for commissioning inpatient services in 2013, we have invested financial resources and increased the capacity of inpatient beds both in the East Midlands and across the country to enable greater access to beds at time of clinical need. Working with expert clinicians and service managers, NHS England has developed national service specifica”
21 further stated actions are listed on the full chain page.
What recurred
- 14 Jul 2015 · Emma Carpenter · Stephanie Haskey
- 14 Nov 2016 · David Knight · Emma Carlyon
- 4 Oct 2018 · William Edge · Emma Brown
- 4 Oct 2018 · Michael Cooper · Emma Brown
- 30 Nov 2018 · Thomas Nicol · Geoffrey Sullivan
- 19 Dec 2018 · Kirsty Walker · Anna Crawford
- 12 Feb 2019 · Anthony Watson · James Bennett
- 11 May 2021 · Charlotte Swift · Penelope Schofield · Identical hazard · confidence 0.96 (high)
- 27 Apr 2023 · Ben Shipley · Ian Pears · Closely related · confidence 0.86 (high)
- 22 Jun 2023 · Stephen Richardson · Andre Rebello · Identical hazard · confidence 0.90 (high)
- 20 Mar 2024 · Jonathan Harris · Anna Crawford · Identical hazard · confidence 0.90 (high)
- 21 May 2024 · Emma Morris · Sarah Murphy · Closely related · confidence 0.90 (high)
- 7 Aug 2024 · Martyn Stringer · Nicholas Graham · Closely related · confidence 0.80 (moderate)
- 26 Sept 2024 · Charne Petit · Caroline Topping · Identical hazard · confidence 0.90 (high)
- 4 Nov 2024 · Jagjeet Singh · Melanie Lee · Identical hazard · confidence 0.90 (high)
- 16 Dec 2024 · Matthew Sheldrick (2) · Penelope Schofield · Identical hazard · confidence 0.92 (high)
- 5 Feb 2025 · Sapphire Bernard · Penelope Scofield · Identical hazard · confidence 0.96 (high)
- 24 Nov 2025 · Diana Grant · Richard Travers · Identical hazard · confidence 0.97 (high)
- 19 Jan 2026 · Martin Bryant · Rebecca Mundy · Closely related · confidence 0.90 (high)
- 3 Feb 2026 · Ellame Ford-Dunn · Joanne Andrews · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Thomas Nicol · 30 Nov 2018
“the length of time taken to transfer prisoners in acute mental health crisis to a suitable secure hospital potentially puts lives at risk”
Later · Diana Grant · 24 Nov 2025
“Detention in prison of persons requiring mental health unit admission raises a concern for risk of death”
What happened next
No evidence found either way · stated action 1
The Trust described a specialist eating disorder service for children and adolescents with professional links to paediatricians at Kings Mill Hospital and Queen's Medical Centre but no equivalent links with Bassetlaw Hospital.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“The recommendation of assurance from the Executive team.”
10 Date of meeting: 20 May 2026 Report to the: Trust Board ... · eastofenglandcommunityhealthandcare.nhs.uk/…/100-trust-board-in…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“The case for intensive community and day treatments for eating disorders CONTENTS Executive summary Introduction What are intensive community and day treatments?”
[PDF] THERE'S NO PLACE LIKE HOME · beat.contentfiles.net/…/The_case_for_intensive_community_and_da…
“Adult eating disorders: community, inpatient and intensive day patient care Guidance for commissioners and providers Publishing approval number: 000957 Version number: 1 First published: August 2019”
Adult Eating Disorders: Community, Inpatient and Intensive ... · england.nhs.uk/wp-content/uploads/2019/08/aed-guidance.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Undertakes a monthly contract review of its providers. Since February 2018, following an 'inadequate' rating by the Care Quality Commission of FTB, the CCG has led the development of a Quality Improvement Board to oversee and provide assurance on a CQC improvement Action Plan and a System Improvement Plan.”
“we will ensure that the papers are still published and we will catch up on any outstanding matters at our following public board meeting”
NHS England Board Meeting – 1 October 2026 · youtube.com/watch?v=EFSi5gzU1Jg&xstg=CAMSBhUDze3xHw%3D%3D
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Proactively manages demand with a series of initiatives to reduce unnecessary admissions and avoid delayed transfers of care, such that capacity can be optimally managed.”
“Page 22 under community care models, a sentence about those living with frailty has been amended. The change is highlighted. Page 22 community care models- information about virtual wards has been amended to read 40-50 virtual beds per 100,000 population. The change is highlighted.”
2022/23 priorities and operational planning guidance · england.nhs.uk/…/20211223-B1160-2022-23-priorities-and-operatio…
“These findings show the NHS could reduce avoidable use of health services, including the number of emergency admissions and A&E attendances, by supporting”
Reducing-Emergency-Admissions-long-term-conditions- ... · health.org.uk/…/Reducing-Emergency-Admissions-long-term-conditi…
“Process Area teams will seek to invite GP practices to participate in this enhanced 3.1 service by 31 May 2014. GP practices wishing to participate will be required to sign up to it by no later than 30 June 2014.”
Avoiding unplanned admissions: proactive case finding ... · england.nhs.uk/…/avoid-unplanned-admissions.pdf
No evidence found does not mean the action did not happen.
Evidence found · stated action: “Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).In 2018/19 the CCG provided additional investment in BSMHFT amounting to £3,117,000 (2.4% increase) and FTB amounting to £2,881,000 (9.3% increase). Further”
“We are investing at least £2.3 billion of additional funding a year by March 2024 to expand and transform mental NHS health services, so an extra two million people can get mental health support.”
How we are supporting mental health services in England – Department of Health and Social Care Media Centre · healthmedia.blog.gov.uk/…/how-we-are-supporting-mental-health-s…
“We invested an additional £500 million in mental health and developed a one-year cross-government action plan to support recovery.”
Mental health and wellbeing plan: discussion paper - GOV.UK · gov.uk/…/mental-health-and-wellbeing-plan-discussion-paper
“The government has announced a £343m investment to expand community mental health services across England through the delivery of 159 new NHS facilities.”
£343m investment to fund 159 new community mental health facilities across England · buildingbetterhealthcare.com/…/343m-investment-to-fund-159-new-…
No evidence found either way · stated action: “Undertakes mortality and incident review seriously and in line with national policy. The coroners' letters have prompted a comprehensive review of mortality and incident governance which will result in improved care quality and learning from incidents.”
“We use some essential cookies to make this website work.”
Review of patient safety across the health and care landscape - GOV.UK · gov.uk/…/review-of-patient-safety-across-the-health-and-care-la…
“Learning, candour and accountability A review of the way NHS trusts review and investigate the deaths of patients in England DECEMBER 2016 b LEARNING, CANDOUR AND ACCOUNTABILITY Our purpose The Care Quality Commission is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high”
Learning, candour and accountability · cqc.org.uk/…/files?file=20161213-learning-candour-accountabilit…
“The aim of the 3-year programme is to introduce a standardised methodology for reviewing case records of adult patients who have died in acute general hospitals in England and Scotland.”
Using the structured judgement review method · healthinnowest.net/…/NMCRR-clinical-governance-guide-Final.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Oversight of strategic and operational issues: the CCG will lead the establishment of an oversight group which involved all stakeholders . The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis.”
“The Board is invited to: - Note the functions, processes and governance in place across the organisation, and how we work across NHS England in order to take action; and - Note our work with NHSI and other ALBs to strengthen improvement capabilities across the NHS”
PRIVATE BOARD PAPER · england.nhs.uk/…/03_CB_28_03_2018-system-quality.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Risk assessment: this needs to be available and of high quality 24 hours a day, 7 days a week. We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care.”
“We've put some small files called cookies on your device to make our site work. We'd also like to use analytics cookies. These send information about how our site is used to a service called Google Analytics. We use this information to improve our site. Let us know if this is OK. We'll use a cookie to save your choice. You can[read more about our cookies](https://www.england.nhs.uk/privacy-policy/”
NHS England » Principles for assessing and managing risks across integrated care systems · england.nhs.uk/…/principles-for-assessing-and-managing-risks-ac…
“Stop Copying the Copyrighted Material!”
RISK ASSESSMENT IN QUALITY IMPROVEMENT IN HEALTHCARE · qualityleadersacademy.com/risk-assessment-in-quality-improvement
“We use some essential cookies to make this website work.”
Review of patient safety across the health and care landscape - GOV.UK · gov.uk/…/review-of-patient-safety-across-the-health-and-care-la…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The CCG is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment.”
The sources discuss mental health care access challenges and system gaps but do not confirm or deny the specific promise about establishing a mental health system with timely inpatient access.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “the CCG will lead the establishment of an oversight group which involved all stakeholders . The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis.”
“We use essential cookies to make our site work. We'd like to use additional cookies to understand how you use the site and improve our services. You can find details of these and all other cookies in our [cookie policy”
Government oversight of underperforming NHS trusts · commonslibrary.parliament.uk/research-briefings/cbp-12201
“The Board is asked to give its approval for NHS Improvement to start overseeing providers using the Single Oversight Framework (Appendix 1) on 1 October and at the same point to stop overseeing NHS foundation trusts using Monitor's Risk Assessment Framework and NHS trusts using NHS Trust Development Authority's (NHS TDA's) Accountability Framework, subject to any final comments from the sector on”
NHS Improvement's Single Oversight Framework · england.nhs.uk/…/BM1687_Single_Oversight_Framework_.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The CCG has taken the opportunity, as part of this investigation, to review its broader quality assurance processes and identify any learning outside the scope of the Regulation 28 reports.”
“A primary goal of the policy review was to identify and discuss the main policy levers that can enhance process quality and provide countries with concrete examples of policies.”
Quality assurance and improvement in the early education ... · oecd.org/…/774688bf-en.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “NHS. England has committed to eliminating. the practice. of sending people out of-area for non-specialist acute inpatient:care due to”
“The Government pledged to eliminate adult mental health out of area (OOA) placements by the end of March 2021, but it still hasn't happened yet.”
NHS out of area placements: challenges and solutions | Grant Thornton · grantthornton.co.uk/…/nhs-out-of-area-placements-challenges-and…
“Guidance # Out of area placements in mental health services for adults in acute inpatient care”
Out of area placements in mental health services for adults in acute inpatient care - GOV.UK · gov.uk/…/out-of-area-placements-in-mental-health-services-for-a…
“Inappropriate out of area placements (IOAPs) have a significant emotional, economic and health impact on patients and carers, and negatively impact patient outcomes.”
Bringing care closer to home:reducing inappropriate out of area placements in mental health services · thenhsalliance.org/…/bringing-care-closer-to-home-reducing-inap…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “NHS England is also investing £36m over three years to improve the quality of mental health, learning disabilities and autism inpatient settings. This includes a culture of care improvement programme which is being co-produced with patients, carers and families with lived experience.”
“Advancing mental health equalities .........................................................................................................”
NHS Mental Health Implementation Plan 2019/20 – 2023/24 · england.nhs.uk/…/nhs-mental-health-implementation-plan-2019-20-…
“Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings”
Mental health inpatient settings · hssib.org.uk/…/mental-health-inpatient-settings
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “NHS England is working at a national level to deliver the Long Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic”
“We are already growing the workforce and there are almost 67,300 more staff compared to a year ago, including over 6,800 more doctors and over 17,600 more nurses.”
NHS Long Term Workforce Plan fact sheet – Department of Health and Social Care Media Centre · healthmedia.blog.gov.uk/…/nhs-long-term-workforce-plan-fact-she…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The number of mental health beds required to support a local population is dependent on both local mental health need, and the effectiveness of the whole local mental health system1 in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary”
“5 Planning approach .................................................................................................................................... 8 'Fixed', 'flexible' and 'targeted' approaches to delivering mental health commitments in the NHS Long Term Plan ....................................................................................................................................”
NHS Mental Health Implementation Plan 2019/20 – 2023/24 · england.nhs.uk/…/nhs-mental-health-implementation-plan-2019-20-…
“Sustainability and transformation plans (STPs) provide the local vehicle for strategic planning, implementation at scale and c”
Implementing the Five Year Forward View for Mental Health · england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf
“Bed reductions were a constant feature, with important differences betwe”
Long term trends in NHS inpatient bed provision in England, 1960–2020 · pmc.ncbi.nlm.nih.gov/articles/PMC12396719
No evidence found does not mean the action did not happen.
Evidence found · stated action: “The NHS LTP saw an additional £2.3 billion of funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to allow people to get faster access to the care they need and prevent deterioration and hospital admission where it is avoidable.”
“Mental health funding will increase at a faster pace than the wider NHS budget, which is positive news for private providers of mental health services”
Understanding the priorities of the NHS Long-term Plan · marwoodgroup.com/…/2019-01-10-NHS-Long-Term-Plan-Mental-Health-…
“We are investing at least £2.3 billion of additional funding a year by 2023-24 to expand and transform mental health services in England so that two million”
The #NHSLongTermPlan sets aside funding for mental health ... · facebook.com/…/2084301925144978
“the NHS Long Term Plan for Mental Health (2019) included a commitment to create a new ringfenced local investment fund worth at least £2.3 billion a year in real terms by 2023/24”
Mental health pressures data analysis · bma.org.uk/…/mental-health-pressures-data-analysis
No evidence found either way · stated action: “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the 'flow' of patients being discharged or moving to another setting.”
“Trusts are increasingly looking to electronic bed management systems to improve patient flow and increase capacity by providing visibility to flow bottlenecks and helping staff identify available beds as early as possible.”
How electronic bed management can improve patient flow and capacity management in hospitals - Teletracking · teletracking.com/…/how-electronic-bed-management-can-improve-pa…
“Ensure your patients receive the right care, at the right time, in the right location. Bed and Capacity Management Systems are an important part of NHS England's Urgent and Delivery Care Plan.”
The right care, at the right time, in the right location · go.alterahealth.com/en-gb/patientflow
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements.”
“NHS key statistics: England Summary: NHS pressures before and after the pandemic 1 Emergency care: A&E and emergency admissions 2 Waiting times for hospital treatment 3 Cancer waiting times 4 Ambulance response times and demand 5 Diagnostic tests 6 Workforce levels and vacancies 7 Bed availability and discharges 8 GP appointments NHS key statistics: England”
CBP-7281.pdf · researchbriefings.files.parliament.uk/…/CBP-7281.pdf
“For the first time since February 2026, more than 10% of all patients attending A&E waited over 12 hours to be admitted, transferred, or discharged.”
NHS performance dashboard | Nuffield Trust · nuffieldtrust.org.uk/qualitywatch/nhs-performance-dashboard
No evidence found does not mean the action did not happen.