“Department of Health and NHS England 1”

The coroner’s concerns

- Department of Health and NHS England 1. In 2023 the National Suicide Prevention Strategy 2023 for England highlighted the critical role of 24/7 crisis text services.  The roll out of crisis text services across the country in 2024/25 was a key action and commitment in the Strategy, funded by an allocation of £7million to ICBs included in the NHSE Urgent and Emergency Care recover Plan. (a) The NHSE indicated in their April 2024 Crisis Text Support Guidance and Specification document that they will oversee the rollout of these services which was expected to be rolled out by the end of March 2025. This has now been extended to March 2026.As of to date the evidence indicates only 10 have set up such a service with another 11 in the process of doing so. Some ICBs have indicated that they have no plans to do so. (b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide.  The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service users’ life. Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities. In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services. Greater Manchester Integrated Care Board 2. Within the Greater Manchester Area there is no commissioned crisis text mental health support service.  Whilst GM residents can message national services, often the location of an individual texter will not be known. Th court heard from Greater Manchester Police that they receive a significant number of referrals which have been sent by this crisis service to the Metropolitan Police, almost one a day where there has been a real and immediate risk to a person’s life identified.  All of these referrals require an immediate police response (they are outside of Right Care Right Person).  If there was a GM commissioned service, it is likely that any search for the location of the individual would be done by GMP and would shorten the timeframe in which they could respond to the risk. In addition, a GM commissioned service would have a greater understanding of local pathways in order to refer people who may have a deteriorating mental health before they reached the point of crisis.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0415

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0