Health leaders in Staffordshire and Stoke-on-Trent are re-evaluating their approach to crisis mental health care following mounting concerns that the “Right Care, Right Person” (RCRP) policy may have contributed to fatal gaps in support.
The move comes after multiple trusts within the integrated care system (ICS) raised alarms about unclear responsibilities between police and health services, with evidence suggesting that confusion over the policy’s application played a role in the deaths of four individuals.
Coroners’ warnings highlight systemic risks
The RCRP model, introduced nationally in 2023, aims to reduce police involvement in mental health incidents by ensuring patients are supported by appropriate health services instead. However, coroners across England have repeatedly warned that the policy may be creating dangerous ambiguity at the frontline. Reports into several deaths have pointed to instances where police declined to attend welfare checks involving individuals in acute mental distress. In one case, a coroner noted there had been “a refusal” for police attendance despite a “real and immediate risk to life”.
Coroners also highlighted structural limitations within health services, including the inability of crisis teams to enter locked premises, raising concerns that redirecting responsibility away from police without adequate safeguards leaves critical gaps in emergency response. By late 2025, at least 17 Prevention of Future Death (PFD) reports had been linked to RCRP-related incidents, with further inquests ongoing, indicating the scale of concern across the system.
Local confusion and fragmented responsibilities
Within Staffordshire and Stoke-on-Trent, NHS trusts and system partners have flagged “confusion” over roles and thresholds as a key issue in implementing RCRP. The policy relies on multi-agency coordination between police, NHS providers, local authorities and voluntary services. However, local governance documents show that responsibilities are still being actively negotiated, with partners required to agree “what is the remit of health services… and the police” in crisis situations.
This lack of clarity has been compounded by the phased rollout of RCRP, which introduced changes incrementally across different types of incidents, from welfare checks to missing persons and mental health detentions. Health leaders have acknowledged that inconsistent understanding at operational level may have contributed to delayed or absent responses in high-risk cases.
ICB rethinks crisis care pathways
In response, Staffordshire and Stoke-on-Trent Integrated Care Board (ICB) is now reviewing its crisis care pathways and escalation protocols. Local plans already emphasise the need for improved data sharing, clearer escalation routes, and better real-time decision-making across agencies. This includes developing integrated triage systems and expanding access to 24/7 mental health advice via NHS 111, intended to reduce reliance on police call-outs.
However, internal assessments have also identified “system delays” and situations where individuals remain under police care because appropriate health services are not immediately available, precisely the issue RCRP was designed to address. The ICB is now working with partners to refine accountability frameworks and ensure that no agency withdraws from a case without a clear handover of responsibility.
Technology, data and the accountability gap
The controversy has also exposed broader challenges around digital coordination in urgent care pathways. Effective implementation of RCRP depends heavily on interoperable data systems, shared risk assessments, and real-time communication between agencies, areas where gaps remain.
Local system leaders have begun exploring enhanced data collection and analytics to monitor outcomes and identify risks earlier. This includes tracking how RCRP affects different patient groups and whether certain populations are disproportionately impacted. At a national level, the policy continues to face scrutiny from patient safety groups, who argue it was rolled out without sufficient evaluation or infrastructure to support the shift in responsibilities.
Balancing demand with patient safety
The original rationale behind RCRP was to relieve pressure on policing, which had become a default responder to mental health crises. Yet both police and NHS services remain under strain, raising questions about whether the system has the capacity to safely absorb these changes.
For Staffordshire and Stoke-on-Trent, the deaths have become a catalyst for reassessment. Health leaders now face the challenge of clarifying responsibilities, strengthening inter-agency coordination, and ensuring that policy ambitions do not outpace operational reality. As the review progresses, the central issue remains clear: in crisis care, ambiguity can be fatal, and resolving it will require not just policy alignment, but robust systems, shared accountability, and sustained investment in mental health services.
