Delayed mental health bed allocation leading to patient deterioration

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2013 → 2016Rohan Fitzsimons2 years 8 months after Stephanie Daniels · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight the risk that patients needing inpatient mental health care experience delays or cannot get a bed when required. They both call for systemic action to guarantee bed availability at the point of need.

  Stephanie Daniels · 13 Dec 2013

  “MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed”

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  Rohan Fitzsimons · 7 Aug 2016

  “The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment.”

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  Stated action in the response to the earlier report

  “A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported by the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.”

  Earlier report in the app · Later report in the app