Patricia Genders: Prevention of future deaths report
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Date of report: 28/10/2025
Ref: 2025-0551
Deceased name: Patricia Genders
Coroner name: Nick Armstrong
Coroner Area: West Sussex, Brighton and Hove
Category: Community health care and emergency services related deaths
This report is being sent to: Department for Health and Social Care | NHS England & NHS Improvement
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 Secretary of State for Health and Social Care 2 NHS England & NHS Improvement ( reg 28 reports) | |
| 1 | CORONER I am Nick ARMSTRONG, Assistant Coroner for the coroner area of West Sussex, Brighton and Hove |
| 2 | INVESTIGATION and INQUEST Patricia’s mental health declined leading to extended periods of time in hospital from August 2020 after demonstrating suicidal ideation and a preoccupation with cliffs. Following a short period of home leave over Christmas 2023, Patricia was discharged in January 2024. Whilst the discharge on 2nd January was the least restrictive option, it was not an appropriate or safe decision given that she was actively non-compliant with medication and the timing of her discharge with regard to the anniversary of her husband’s death and the fact that there was a known delay before the package of care was to be provided. Additionally, Christmas was not an appropriate period to judge the success of home leave, given it is not an accurate reflection of everyday life and likely to involve substantially more social interaction and support than usual. This decision to discharge Patricia possibly contributed to her death. The allocated 5-hour package of care was intended to run alongside the Home First help. This 5-hour package did not materialise, which led to greater social isolation. The absence of the package of care possibly contributed to Patricia’s death. It is worth noting that Home First did not provide cover for the two Occupational Therapists who took annual leave from 12th February. Despite agreed protocols that Police should call the Blue Light Line before conveying patients under Section 136, Patricia was taken straight to the A&E department at the Royal Sussex County Hospital, which was not the most appropriate location. This possibly contributed to Patricia’s death. Having contacted Blue Light Line, the Police were told a place was available for Patricia at Eastbourne Haven and that she should be taken there. The Police should not have refused to transport her. The Haven would have provided a more therapeutic environment, and she would have been under the protection of the Police/Secure Care, both of which can restrain patients under Section 136. This contrasts with the Enhanced Observation Unit which is an unsuitable environment for patients detained under the Mental Health Act. It is also noted that the Eastbourne Haven is not close to any cliffs. The decision not to transport Patricia to Eastbourne Haven probably contributed to her death. Following a failed attempt to abscond during the early hours of 22nd February, Patricia absconded from the EOU later that morning. She was able to walk through the door that was supposed to be secure with ease. Whilst a call was made immediately to Security, communication between ward staff and Security was insufficient to locate Patricia with the necessary urgency. The nurse allocated to Patricia that morning made appropriate attempts to deter her from leaving the hospital site at which point he did not follow her. Had Patricia been followed, it is possible the Police could have prevented her from reaching the cliffs and therefore preventing her death. This would have made up for the fact that hospital staff were unable to provide police with adequate information to help locate Patricia, partially caused by the fact that staff hadn’t had the opportunity to read Patricia’s notes following handover. It appears that there was, at the time, a general and widespread lack of understanding of the RSCH policy pertaining to absconding patients and staff leaving the site boundary. These factors relating to the response to Patricia absconding possibly contributed to her death. |
| 3 | CIRCUMSTANCES OF THE DEATH Patricia Genders died on 22 February 2024 [REDACTED] This followed lengthy periods in hospital for mental ill-health, starting from August 2020. Her final discharge was on 2nd January 2024 and the intention was for this to be supported by an agreed package of home care which was absent. A period of worsening mental ill-health followed this discharge. On 21st February 2024, Patricia was detained [REDACTED] under section 136 of the Mental Health Act 1983 to facilitate conveyance to a place of safety for mental health assessment. She was admitted to the A&E Department at the Royal Sussex County Hospital and detained under Section 3 of the Mental Health Act and then admitted to the Enhanced Observation Unit and placed under one-to-one arms- length observation. She absconded at about 8:00am on the morning of 22nd February and was subsequently found by a member of the public on the coastal side of the safety fence [REDACTED] . Following the arrival of Police, Paramedics and the Fire & Rescue Service, there was an attempt by the Fire & Rescue Service to rescue Patricia. [REDACTED] She was taken to A&E and shortly after arrival was pronounced dead at 10:12am. Her mental ill-health means that her capacity and, therefore, her intention when stepping off the ledge cannot be ascertained. |
| 4 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Please also refer to the jury’s findings of fact, which accompany this report and contain the circumstances of Tricia Genders’ death, and Section 4 of the Record of Inquest (the narrative conclusion). My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long. This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury’s conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around. Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and firemen at the cliffs. All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation. I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern. The evidence I heard is that three things are required of those responsible for commissioning these services: 1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment. 2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions. 3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds. Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur. |
| 5 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. |
| 6 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by December 23, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. |
| 7 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons · [REDACTED] · Care Quality Commission · West Sussex County Council Adult Safeguarding · Brighton and Hove City Council · Sussex Partnership NHS Foundation Trust (SPFT) · University Hospitals Sussex NHS Foundation Trust · Sussex Police who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. They may send a copy of this report to any person who they believe may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. |
| 8 | 28/10/2025 Nick ARMSTRONG KC Assistant Coroner for West Sussex, Brighton and Hove |