“In light of the failings I identified, I invited evidence to be filed in relation to any…”

The coroner’s concerns

In light of the failings I identified, I invited evidence to be filed in relation to any improvements that have been put in place to ameliorate these matters. Evidence was provided by Epsom General Hospital, Surrey and Borders Partnership Trust and South East Coast Ambulance Service. The organisations have taken the matters that led to Ms Ostler’s death seriously. However, some of the matters I have raised have not been capable of resolution since the inquest concluded, and proposed improvements could therefore not be evidenced, although some are being planned. I therefore remain concerned as follows: Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital : , Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care 1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed. 2. I remain concerned that there in no plan to stop this practice and that therefore: a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based 4 care under a multi-disciplinary psychiatric team. b.) One to one nursing is meant to be provided by mental health nurses however, they are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients. c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients. d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician. e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area. f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement. g.) There is an acknowledged risk that psychiatric patents being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient. Training for Paramedics to undertake Capacity Assessments. Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service 3. I found that the paramedics who attended Ms Ostler on the 16 th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her. 4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately. 5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed. 6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments. South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions. Addressed to the South East Coast Ambulance Service 5 7. The Trusts policy on Mental Capacity is being reviewed to improve articulation of how to assess mental capacity in life threatening circumstances. It is not yet available. I regarded the current policy as inadequate and remain concerned about this because I have not been able to review the revised document. Multi Agency Safeguarding Plans Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service 8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacitous decisions about her own care. 9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for

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

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judiciary.uk, Prevention of Future Deaths reports, 2025-0416

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8 Oct 2026

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