Delayed transfer of acute mental health prisoners to secure units
NHS England received 21 coroners' reports about this hazard between 19 Nov 2014 and 3 Feb 2026.
They came from 18 different coroners in 14 coroner areas. A similar concern was raised again 20 times after the first warning.
A published response was found for 19 of the 20 earlier reports, stating 24 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“Since August 2013, NHS England has implemented a situation report (SITREP) process each Friday which requires all Child and Adolescent Mental Health Services (CAMHS) inpatient providers to submit numbers of available beds to a national database. This data is Used to produce a report that is available from lunch time on a Friday indicating available capacity at each of the inpatient services commissioned. . The report is circulated via the Area Teams to all Tier 3/Community CAMHS so. they can '”
Stated timescale: each Friday
- 8 months later
“There remains still a national lack of provision of inpatient beds for mentally il! children and adolescents including those who suffer from eating disorders.”
Original on judiciary.uk ↗ NHS England responded, stating 3 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“The Trust has now set up a specialist Eating Disorder Service for children and adolescents, and reports that although this service now has good professional links with named paediatricians at Kings Mill Hospital and Queen's Medical Centre, there are no equivalent links with Bassetlaw Hospital.”
Stated timescale: 8 September 2015
Web search (Tavily): No evidence found either way
“We have an identified Consultant and will actively engage with the services provided by Nottinghamshire Healthcare Trust as the need arises and will monitor these arrangements through the paediatric clinical governance team.”
Web search (Tavily): No evidence found either way
10 Date of meeting: 20 May 2026 Report to the: Trust Board ... ↗1 more stated action in the Promises tab.
- 1 year 4 months later
“there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗
- 1 year 11 months later
“The Coroner is aware, although not from evidence obtained in respect of Mr. [name redacted] case as the inquest is yet to take place, that inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available.”
Original on judiciary.uk ↗ NHS England responded, stating 7 specific actions.Response (PDF) ↗Response (PDF) ↗
“Undertakes a monthly contract review of its providers. Since February 2018, following an 'inadequate' rating by the Care Quality Commission of FTB, the CCG has led the development of a Quality Improvement Board to oversee and provide assurance on a CQC improvement Action Plan and a System Improvement Plan.”
Stated timescale: February 2018
Web search (Tavily): No evidence found either way
NHS England Board Meeting – 1 October 2026 ↗“Proactively manages demand with a series of initiatives to reduce unnecessary admissions and avoid delayed transfers of care, such that capacity can be optimally managed.”
Web search (Tavily): No evidence found either way
2022/23 priorities and operational planning guidance ↗5 more stated actions in the Promises tab.
- 0 months later
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
Original on judiciary.uk ↗ NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“the CCG will lead the establishment of an oversight group which involved all stakeholders . The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis.”
Stated timescale: November 14 2018
Web search (Tavily): No evidence found either way
Government oversight of underperforming NHS trusts ↗“The CCG has taken the opportunity, as part of this investigation, to review its broader quality assurance processes and identify any learning outside the scope of the Regulation 28 reports.”
Web search (Tavily): No evidence found either way
Quality assurance and improvement in the early education ... ↗ - 2 months later
“the length of time taken to transfer prisoners in acute mental health crisis to a suitable secure hospital potentially puts lives at risk”
Original on judiciary.uk ↗ NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“NHS England is also reviewing the current prison transfer and remission guidance, published by the Department of Health and Social Care in 20113. In particular, the review is looking at whether the timescales within the guidance take into account clinical urgency and need. The revised guidance will be subject to full, public consultation in due course.”
Stated timescale: due course
“Since 2016, NHS England and respective stakeholders have been engaged in various multi-faceted programmes of work with the specific intention of improving the mental health pathway and is focused on ensuring timely referral, assessment and access to high quality care, and similarly ensuring that remission back to prison also takes place without delay to enable good throughput.”
Stated timescale: 28 February 2019
- 1 month later
“The court heard that where a prisoner is assessed as being detainable under the Mental Health Act 1983, they ought to be transferred to hospital within 14 days, pursuant to the recommendations in the 2009 Bradley Report.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“The next audit is currently underway, based on a census date of 28 February 2019. It is anticipated that the report will be available by the end of May 2019.”
Stated timescale: end of May 2019
- 2 months later
“Mr [name redacted] was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“NHS. England has committed to eliminating. the practice. of sending people out of-area for non-specialist acute inpatient:care due to”
Stated timescale: 2021
Web search (Tavily): No evidence found either way
NHS out of area placements: challenges and solutions | Grant Thornton ↗ - 2 years 3 months laterIdentical hazardConfidence 0.96 · higha different coroner
“Evidence heard at the Inquest indicated that there was a national shortage of placements/beds and this was putting individuals at risk of serious harm and possible death.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗
- 2 years laterClosely relatedConfidence 0.86 · higha different coroner
“there are about 12 hours of delay following a 22.00 s2 Mental Health Act assessment built into the system if there is no bed.”
Original on judiciary.uk ↗ Repeated from the earlier report:MentalHealth
No published response from NHS England was found for this report.
- 2 months laterIdentical hazardConfidence 0.90 · higha different coroner
“at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient”
Original on judiciary.uk ↗ Repeated from the earlier report:nationalshortageacutebedspatientsmental
NHS England responded, stating 1 specific action.Response (PDF) ↗
“NHS England is also investing £36m over three years to improve the quality of mental health, learning disabilities and autism inpatient settings. This includes a culture of care improvement programme which is being co-produced with patients, carers and families with lived experience.”
Web search (Tavily): No evidence found either way
NHS Mental Health Implementation Plan 2019/20 – 2023/24 ↗ - 9 months laterIdentical hazardConfidence 0.90 · higha different coroner
“there is an ongoing shortage of available inpatient psychiatric beds in Surrey”
Original on judiciary.uk ↗ Repeated from the earlier report:shortagebeds
NHS England responded, stating 1 specific action.Response (PDF) ↗
“NHS England is working at a national level to deliver the Long Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic”
Stated timescale: 2036/37
Web search (Tavily): No evidence found either way
NHS Long Term Workforce Plan fact sheet – Department of Health and Social Care Media Centre ↗ - 2 months laterClosely relatedConfidence 0.90 · higha different coroner
“The gatekeeping assessment included a mental health state examination, where it was the clinical opinion of the mental health practitioner from the Crisis Resolution Home Treatment Team, that Ms [name redacted] required an inpatient hospital admission to a mental health ward as there was an immediate risk to her safety as she was found to be a high risk of walking in front of a car.”
Original on judiciary.uk ↗ Repeated from the earlier report:Treatmentinpatient
NHS England responded, stating 1 specific action.Response (PDF) ↗
“The number of mental health beds required to support a local population is dependent on both local mental health need, and the effectiveness of the whole local mental health system1 in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary”
Web search (Tavily): No evidence found either way
NHS Mental Health Implementation Plan 2019/20 – 2023/24 ↗ - 3 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to [the deceased].”
Original on judiciary.uk ↗ Repeated from the earlier report:HealthSafetyavailable
NHS England responded.Response (PDF) ↗
- 2 months laterIdentical hazardConfidence 0.90 · higha different coroner
“Evidence given by the court appointed expert consultant psychiatrist was that Ms [name redacted] was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital. Her response to treatment needed to be observed.”
Original on judiciary.uk ↗ Repeated from the earlier report:treatmentmentalhealth
NHS England responded.Response (PDF) ↗Response (PDF) ↗
- 1 month laterIdentical hazardConfidence 0.90 · higha different coroner
“I heard that a bed on the mental health ward should have been available for Mr [name redacted] when he was discharged from the medical wards but that there is a chronic shortage of mental health beds and not just in London but nationally.”
Original on judiciary.uk ↗ Repeated from the earlier report:mentalhealthbeds
NHS England responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“The number of mental health beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary.”
Stated timescale: 2024/25
- 1 month later
Raised again · 16th time
Matthew Sheldrick (2)↗
16 Dec 2024 · Penelope Schofield · West Sussex, Brighton and Hove
Identical hazardConfidence 0.92 · higha different coroner“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
Original on judiciary.uk ↗ NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The NHS LTP saw an additional £2.3 billion of funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to allow people to get faster access to the care they need and prevent deterioration and hospital admission where it is avoidable.”
Stated timescale: 2023/24
Web search (Tavily): Evidence found that the action was carried out
Understanding the priorities of the NHS Long-term Plan ↗“I expect individual trusts and local health systems to effectively assess and manage bed capacity, the 'flow' of patients being discharged or moving to another setting.”
Web search (Tavily): No evidence found either way
How electronic bed management can improve patient flow and capacity management in hospitals - Teletracking ↗ - 2 months later
Raised again · 17th time
Sapphire Bernard↗
5 Feb 2025 · Penelope Scofield · West Sussex, Brighton and Hove
Identical hazardConfidence 0.96 · higha different coroner“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds.”
Original on judiciary.uk ↗ Repeated from the earlier report:lackinpatientbeds
NHS England responded, stating 1 specific action.Response (PDF) ↗
“We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements.”
Stated timescale: Winter 2024/25
Web search (Tavily): No evidence found either way
CBP-7281.pdf ↗ - 10 months laterIdentical hazardConfidence 0.97 · higha different coroner
“Detention in prison of persons requiring mental health unit admission raises a concern for risk of death”
Original on judiciary.uk ↗ Repeated from the earlier report:mentalhealthrisk
NHS England responded.Response (PDF) ↗Response (PDF) ↗
- 2 months laterClosely relatedConfidence 0.90 · higha different coroner
“The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed.”
Original on judiciary.uk ↗ Repeated from the earlier report:lackbedsmentalhealth
NHS England responded.Response (PDF) ↗Response (PDF) ↗
- 0 months later
Raised again · 20th time
Ellame Ford-Dunn↗
3 Feb 2026 · Joanne Andrews · West Sussex, Brighton and Hove
Closely relatedConfidence 0.90 · higha different coroner“I heard from clinicians at University Hospitals Sussex NHS Foundation Trust that they continued to have on acute paediatric wards a number of children and young people who have no physical medical needs for which they requirement treatment in an acute hospital but do not have packages of care in the community in place or a Tier 4 Paediatric Mental Health bed available to be admitted to.”
Original on judiciary.uk ↗ Repeated from the earlier report:medicaltreatmenthospitalMentalHealth
NHS England responded.Response (PDF) ↗
- All reports to NHS England
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.
2015 → 2021Charlotte Swift5 years 10 months after Emma Carpenter · different coronerIdentical hazardConfidence 0.96 · high
Identical hazardConfidence 0.96 · highBoth reports highlight a national shortage of inpatient beds for children and adolescents with eating disorders. The later case describes a specific instance where a needed bed was unavailable, reflecting the ongoing lack of provision noted earlier.
Emma Carpenter · 14 Jul 2015
“There remains still a national lack of provision of inpatient beds for mentally il! children and adolescents including those who suffer from eating disorders.”
Original on judiciary.uk ↗ Charlotte Swift · 11 May 2021
“Evidence heard at the Inquest indicated that there was a national shortage of placements/beds and this was putting individuals at risk of serious harm and possible death.”
Original on judiciary.uk ↗ 2018 → 2021Charlotte Swift2 years 7 months after Michael Cooper · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight that a shortage of inpatient beds puts patients at risk of serious harm or death. The earlier report concerns general mental health bed availability, while the later report concerns specialist eating disorder beds, but the core hazard is the same.
Michael Cooper · 4 Oct 2018
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
Original on judiciary.uk ↗ Charlotte Swift · 11 May 2021
“Although she had been accepted for such a placement a bed did not become available before she died. Evidence heard at the Inquest indicated that there was a national shortage of placements/beds and this was putting individuals at risk of serious harm and possible death.”
Original on judiciary.uk ↗ 2019 → 2023Ben Shipley4 years 2 months after Anthony Watson · different coronerClosely relatedConfidence 0.86 · high
Closely relatedConfidence 0.86 · highBoth reports highlight that a shortage of inpatient mental health beds prevents timely admission or leads to dangerous delays. The earlier case concerns immediate admission being impossible due to no local bed, while the later case describes a built‑in delay after assessment when no bed is available.
Anthony Watson · 12 Feb 2019
“Mr [name redacted] was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area.”
Original on judiciary.uk ↗ Ben Shipley · 27 Apr 2023
“there are about 12 hours of delay following a 22.00 s2 Mental Health Act assessment built into the system if there is no bed.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“NHS. England has committed to eliminating. the practice. of sending people out of-area for non-specialist acute inpatient:care due to”
2016 → 2023Stephen Richardson6 years 7 months after David Knight · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a national shortage of acute mental health psychiatric beds that forces patients to receive care outside their local area or without adequate inpatient provision. The core concern is the insufficient bed capacity leading to unsafe patient management.
David Knight · 14 Nov 2016
“there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment”
Original on judiciary.uk ↗ Stephen Richardson · 22 Jun 2023
“at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient”
Original on judiciary.uk ↗ 2018 → 2023Stephen Richardson4 years 9 months after Michael Cooper · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the danger posed by insufficient psychiatric inpatient beds, noting that shortages increase the risk of death for patients needing acute care.
Michael Cooper · 4 Oct 2018
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
Original on judiciary.uk ↗ Stephen Richardson · 22 Jun 2023
“at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient”
Original on judiciary.uk ↗ 2023 → 2024Jonathan Harris9 months after Stephen Richardson · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a shortage of inpatient psychiatric beds as a risk factor for future deaths. The earlier report notes a national shortage of acute psychiatric beds in 2019, while the later report describes an ongoing shortage of such beds in Surrey within the same national context.
Stephen Richardson · 22 Jun 2023
“at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds”
Original on judiciary.uk ↗ Jonathan Harris · 20 Mar 2024
“there is an ongoing shortage of available inpatient psychiatric beds in Surrey”
Original on judiciary.uk ↗ 2019 → 2024Jonathan Harris5 years 1 month after Anthony Watson · different coronerClosely relatedConfidence 0.86 · high
Closely relatedConfidence 0.86 · highBoth reports highlight an insufficient supply of inpatient psychiatric beds leading to risks for patients needing admission. The earlier report focuses on local bed shortages and distant out‑of‑area options in Birmingham, while the later report notes an ongoing bed shortage in Surrey within a national context.
Anthony Watson · 12 Feb 2019
“Mr [name redacted] was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area.”
Original on judiciary.uk ↗ Jonathan Harris · 20 Mar 2024
“The court also heard that there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“NHS. England has committed to eliminating. the practice. of sending people out of-area for non-specialist acute inpatient:care due to”
2021 → 2024Emma Morris3 years after Charlotte Swift · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a national shortage of inpatient mental health beds that prevents timely admission when clinically needed. The earlier case concerned an eating disorder specialist unit, while the later case involved a general mental health ward.
Charlotte Swift · 11 May 2021
“[the deceased] was in urgent need of medical treatment by way of an inpatient bed at a specialist unit for those with eating disorders. Although she had been accepted for such a placement a bed did not become available before she died.”
Original on judiciary.uk ↗ Emma Morris · 21 May 2024
“The gatekeeping assessment included a mental health state examination, where it was the clinical opinion of the mental health practitioner from the Crisis Resolution Home Treatment Team, that Ms [name redacted] required an inpatient hospital admission to a mental health ward as there was an immediate risk to her safety as she was found to be a high risk of walking in front of a car.”
Original on judiciary.uk ↗ 2019 → 2024Emma Morris5 years 3 months after Anthony Watson · different coronerClosely relatedConfidence 0.86 · high
Closely relatedConfidence 0.86 · highBoth reports highlight that patients assessed as needing immediate inpatient mental health admission cannot be admitted because no beds are available. The earlier report notes local bed shortages and distant out‑of‑area options, while the later report describes a nationwide lack of beds.
Anthony Watson · 12 Feb 2019
“Mr [name redacted] was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area.”
Original on judiciary.uk ↗ Emma Morris · 21 May 2024
“The gatekeeping assessment included a mental health state examination, where it was the clinical opinion of the mental health practitioner from the Crisis Resolution Home Treatment Team, that Ms [name redacted] required an inpatient hospital admission to a mental health ward as there was an immediate risk to her safety as she was found to be a high risk of walking in front of a car. Whilst Ms [name redacted] agreed to an informal admission, this was not possible at the time of assessment as there were no beds”
Original on judiciary.uk ↗ 2019 → 2024Martyn Stringer5 years 6 months after Anthony Watson · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight insufficient inpatient mental health bed availability leading to denied admissions. The earlier case cites local bed shortage and distant out‑of‑area options; the later case notes a bed that existed but was withheld due to anticipated demand.
Anthony Watson · 12 Feb 2019
“Mr [name redacted] was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area.”
Original on judiciary.uk ↗ Martyn Stringer · 7 Aug 2024
“It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to [the deceased].”
Original on judiciary.uk ↗ 2019 → 2024Charne Petit5 years 7 months after Anthony Watson · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that a shortage of mental health inpatient beds prevents patients who need immediate admission from receiving appropriate hospital care. This leads to either no admission or placement in unsuitable settings.
Anthony Watson · 12 Feb 2019
“Mr [name redacted] was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety.”
Original on judiciary.uk ↗ Charne Petit · 26 Sept 2024
“Evidence given by the court appointed expert consultant psychiatrist was that Ms [name redacted] was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital. Her response to treatment needed to be observed.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“NHS. England has committed to eliminating. the practice. of sending people out of-area for non-specialist acute inpatient:care due to”
2018 → 2024Jagjeet Singh6 years 1 month after Michael Cooper · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a shortage of inpatient mental health beds leading to unsafe discharges or inability to admit patients. This bed shortage creates a risk to life by leaving patients without appropriate care.
Michael Cooper · 4 Oct 2018
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
Original on judiciary.uk ↗ Jagjeet Singh · 4 Nov 2024
“I heard that a bed on the mental health ward should have been available for Mr [name redacted] when he was discharged from the medical wards but that there is a chronic shortage of mental health beds and not just in London but nationally.”
Original on judiciary.uk ↗ 2024 → 2024Matthew Sheldrick (2)7 months after Emma Morris · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight that a shortage of inpatient mental health beds prevents timely admission, forcing patients to wait in unsuitable settings such as A&E or remain in the community. This creates a risk of harm due to delayed care.
Emma Morris · 21 May 2024
“this was not possible at the time of assessment as there were no beds available nationally within the NHS or privately.”
Original on judiciary.uk ↗ Matthew Sheldrick (2) · 16 Dec 2024
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
Original on judiciary.uk ↗ 2015 → 2024Matthew Sheldrick (2)9 years 5 months after Emma Carpenter · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a national shortage of inpatient mental‑health beds causing delays in care. The earlier report focuses on children/adolescents with eating disorders, while the later report notes the shortage leads to prolonged A&E waits for all mental‑health patients, especially autistic and transgender individuals.
Emma Carpenter · 14 Jul 2015
“There remains still a national lack of provision of inpatient beds for mentally il! children and adolescents including those who suffer from eating disorders.”
Original on judiciary.uk ↗ Matthew Sheldrick (2) · 16 Dec 2024
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
Original on judiciary.uk ↗ 2016 → 2024Matthew Sheldrick (2)8 years 1 month after David Knight · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify a national shortage of mental health beds as a core problem. The earlier report focuses on the shortage leading to out‑of‑county placements, while the later report highlights the shortage specifically affecting autistic and transgender patients needing mixed wards.
David Knight · 14 Nov 2016
“there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment”
Original on judiciary.uk ↗ Matthew Sheldrick (2) · 16 Dec 2024
“There being a national shortage of mental health beds in particular for Autistic patients and those who are transgender requiring a mixed ward”
Original on judiciary.uk ↗ 2024 → 2024Matthew Sheldrick (2)9 months after Jonathan Harris · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a shortage of inpatient psychiatric beds as a safety concern. The earlier report notes the shortage in Surrey, while the later report describes how that shortage causes prolonged A&E waits for mental health patients.
Jonathan Harris · 20 Mar 2024
“there is an ongoing shortage of available inpatient psychiatric beds in Surrey”
Original on judiciary.uk ↗ Matthew Sheldrick (2) · 16 Dec 2024
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
Original on judiciary.uk ↗ 2023 → 2024Matthew Sheldrick (2)1 year 6 months after Stephen Richardson · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a national shortage of inpatient mental health beds that leads to delayed care and prolonged waiting times. The core concern is the insufficient availability of beds for patients needing acute psychiatric treatment.
Stephen Richardson · 22 Jun 2023
“at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient”
Original on judiciary.uk ↗ Matthew Sheldrick (2) · 16 Dec 2024
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
Original on judiciary.uk ↗ 2018 → 2024Matthew Sheldrick (2)6 years 2 months after William Edge · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight insufficient inpatient mental‑health bed availability as a core safety issue. The earlier report links bed over‑occupancy to stretched home‑treatment teams, while the later report ties the shortage to prolonged A&E waits.
William Edge · 4 Oct 2018
“inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available”
Original on judiciary.uk ↗ Matthew Sheldrick (2) · 16 Dec 2024
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
Original on judiciary.uk ↗ 2018 → 2024Matthew Sheldrick (2)6 years 2 months after Michael Cooper · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports identify a shortage of inpatient mental‑health beds as a safety concern. The earlier report links the shortage to delayed admission and reliance on home treatment, while the later report links it to prolonged A&E waits.
Michael Cooper · 4 Oct 2018
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust”
Original on judiciary.uk ↗ Matthew Sheldrick (2) · 16 Dec 2024
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds”
Original on judiciary.uk ↗ 2015 → 2025Sapphire Bernard9 years 7 months after Emma Carpenter · different coronerIdentical hazardConfidence 0.96 · high
Identical hazardConfidence 0.96 · highBoth reports highlight a national shortage of inpatient psychiatric beds causing prolonged waits in emergency departments.
Emma Carpenter · 14 Jul 2015
“There remains still a national lack of provision of inpatient beds for mentally il! children and adolescents including those who suffer from eating disorders.”
Original on judiciary.uk ↗ Sapphire Bernard · 5 Feb 2025
“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds.”
Original on judiciary.uk ↗ 2024 → 2025Sapphire Bernard9 months after Emma Morris · different coronerIdentical hazardConfidence 0.96 · high
Identical hazardConfidence 0.96 · highBoth reports highlight the shortage of inpatient mental health beds causing extended waits in emergency departments for patients needing psychiatric admission.
Emma Morris · 21 May 2024
“there were no beds available nationally within the NHS or privately. As an inpatient admission was not possible, the option was to attend the Accident and Emergency Department”
Original on judiciary.uk ↗ Sapphire Bernard · 5 Feb 2025
“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds.”
Original on judiciary.uk ↗ 2024 → 2025Sapphire Bernard11 months after Jonathan Harris · different coronerClosely relatedConfidence 0.92 · high
Closely relatedConfidence 0.92 · highBoth reports identify a shortage of inpatient psychiatric beds as a core problem affecting patient safety. They differ in focus: the earlier report emphasizes the overall bed shortage, while the later report highlights resulting prolonged A&E waits and unsuitable holding environments.
Jonathan Harris · 20 Mar 2024
“there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds.”
Original on judiciary.uk ↗ Sapphire Bernard · 5 Feb 2025
“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds.”
Original on judiciary.uk ↗ 2023 → 2025Sapphire Bernard1 year 8 months after Stephen Richardson · different coronerIdentical hazardConfidence 0.92 · high
Identical hazardConfidence 0.92 · highBoth reports highlight a shortage of inpatient psychiatric beds that forces patients needing urgent mental‑health care to wait inappropriately long periods, often in emergency departments.
Stephen Richardson · 22 Jun 2023
“at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community”
Original on judiciary.uk ↗ Sapphire Bernard · 5 Feb 2025
“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds”
Original on judiciary.uk ↗ 2018 → 2025Sapphire Bernard6 years 4 months after Michael Cooper · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports identify the shortage of inpatient psychiatric beds as a core problem that leads to dangerous delays in care. They link this bed shortage to increased risk of death while patients wait for appropriate treatment.
Michael Cooper · 4 Oct 2018
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
Original on judiciary.uk ↗ Sapphire Bernard · 5 Feb 2025
“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds.”
Original on judiciary.uk ↗ 2018 → 2025Sapphire Bernard6 years 4 months after William Edge · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify insufficient inpatient mental‑health beds as the core problem. They differ in the downstream impact described – one stresses overflow to home‑treatment teams, the other stresses prolonged A&E waits.
William Edge · 4 Oct 2018
“The Coroner is aware, although not from evidence obtained in respect of Mr. [name redacted] case as the inquest is yet to take place, that inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available.”
Original on judiciary.uk ↗ Sapphire Bernard · 5 Feb 2025
“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds.”
Original on judiciary.uk ↗ 2023 → 2025Sapphire Bernard1 year 9 months after Ben Shipley · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that a shortage of psychiatric inpatient beds causes excessively long waits for patients in emergency departments. The core issue is the same: bed unavailability leading to prolonged A&E stays.
Ben Shipley · 27 Apr 2023
“there are about 12 hours of delay following a 22.00 s2 Mental Health Act assessment built into the system if there is no bed”
Original on judiciary.uk ↗ Sapphire Bernard · 5 Feb 2025
“In [the deceased]'s case a bed was not found for her within a 19-day period”
Original on judiciary.uk ↗ 2014 → 2025Sapphire Bernard10 years 3 months after George Werb · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that insufficient psychiatric bed availability leads to dangerous delays in care. The earlier report focuses on clinicians wasting time searching for beds, while the later report describes patients waiting excessively in A&E for a bed.
George Werb · 19 Nov 2014
“The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed.”
Original on judiciary.uk ↗ Sapphire Bernard · 5 Feb 2025
“In [the deceased]'s case a bed was not found for her within a 19-day period.”
Original on judiciary.uk ↗ 2018 → 2025Diana Grant7 years after Thomas Nicol · different coronerIdentical hazardConfidence 0.97 · high
Identical hazardConfidence 0.97 · highBoth reports highlight that delays in transferring prisoners with acute mental health needs to secure mental health units result in prolonged prison detention, increasing mortality risk.
Thomas Nicol · 30 Nov 2018
“the length of time taken to transfer prisoners in acute mental health crisis to a suitable secure hospital potentially puts lives at risk”
Original on judiciary.uk ↗ Diana Grant · 24 Nov 2025
“Detention in prison of persons requiring mental health unit admission raises a concern for risk of death”
Original on judiciary.uk ↗ 2018 → 2025Diana Grant6 years 11 months after Kirsty Walker · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that insufficient secure mental health bed capacity leads to prolonged delays in transferring individuals needing secure care, creating a risk of death.
Kirsty Walker · 19 Dec 2018
“The court heard that where a prisoner is assessed as being detainable under the Mental Health Act 1983, they ought to be transferred to hospital within 14 days, pursuant to the recommendations in the 2009 Bradley Report.”
Original on judiciary.uk ↗ Diana Grant · 24 Nov 2025
“The evidence I received established that, despite changes made since the Deceased's death, including the recent introduction of NHS England's "Mental Health Crisis Care for Londoners: London's Section 136 Pathway and Health Based Place of Safety Specification", it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit.”
Original on judiciary.uk ↗ 2024 → 2025Diana Grant1 year 4 months after Martyn Stringer · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight insufficient secure mental health bed capacity leading to inappropriate detention of individuals needing such care. The earlier report focuses on a specific decision not to offer an available bed, while the later report describes systemic restrictions causing delayed transfers.
Martyn Stringer · 7 Aug 2024
“It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to [the deceased].”
Original on judiciary.uk ↗ Diana Grant · 24 Nov 2025
“it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate”
Original on judiciary.uk ↗ 2024 → 2026Martin Bryant1 year 1 month after Matthew Sheldrick (2) · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a shortage of mental health inpatient beds causing patients to wait extended periods in unsuitable settings. The earlier report cites A&E waits, while the later report notes waits in an open reception area.
Matthew Sheldrick (2) · 16 Dec 2024
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”
Original on judiciary.uk ↗ Martin Bryant · 19 Jan 2026
“The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“I expect individual trusts and local health systems to effectively assess and manage bed capacity, the 'flow' of patients being discharged or moving to another setting.”
2025 → 2026Martin Bryant11 months after Sapphire Bernard · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight insufficient mental‑health inpatient beds causing prolonged waits for patients needing admission. They differ in the setting described—A&E versus an open reception area—but the core hazard is the same.
Sapphire Bernard · 5 Feb 2025
“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health”
Original on judiciary.uk ↗ Martin Bryant · 19 Jan 2026
“The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area”
Original on judiciary.uk ↗ 2024 → 2026Ellame Ford-Dunn1 year 4 months after Charne Petit · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a shortage of appropriate mental health inpatient beds, leading to patients being held in unsuitable settings.
Charne Petit · 26 Sept 2024
“Evidence given by the court appointed expert consultant psychiatrist was that Ms [name redacted] was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital.”
Original on judiciary.uk ↗ Ellame Ford-Dunn · 3 Feb 2026
“I heard from clinicians at University Hospitals Sussex NHS Foundation Trust that they continued to have on acute paediatric wards a number of children and young people who have no physical medical needs for which they requirement treatment in an acute hospital but do not have packages of care in the community in place or a Tier 4 Paediatric Mental Health bed available to be admitted to.”
Original on judiciary.uk ↗
Stated action · timescale: each Friday
“Since August 2013, NHS England has implemented a situation report (SITREP) process each Friday which requires all Child and Adolescent Mental Health Services (CAMHS) inpatient providers to submit numbers of available beds to a national database. This data is Used to produce a report that is available from lunch time on a Friday indicating available capacity at each of the inpatient services commissioned. . The report is circulated via the Area Teams to all Tier 3/Community CAMHS so. they can '”
Stated action · timescale: 8 September 2015
“The Trust has now set up a specialist Eating Disorder Service for children and adolescents, and reports that although this service now has good professional links with named paediatricians at Kings Mill Hospital and Queen's Medical Centre, there are no equivalent links with Bassetlaw Hospital.”
What happened next: No evidence found either way
The Trust described a specialist eating disorder service for children and adolescents with professional links to paediatricians at Kings Mill Hospital and Queen's Medical Centre but no equivalent links with Bassetlaw Hospital.
No evidence found does not mean the action did not happen.
Stated action
“We have an identified Consultant and will actively engage with the services provided by Nottinghamshire Healthcare Trust as the need arises and will monitor these arrangements through the paediatric clinical governance team.”
What happened next: No evidence found either way
The organisation stated it would engage with Nottinghamshire Healthcare Trust as needed and monitor arrangements via the paediatric clinical governance team, but no source confirms this action was carried out.
“The recommendation of assurance from the Executive team.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2017-18
“Admission into hospital, in the majority of cases, ought to be the result of all community interventions being exhausted. Since NHS England became responsible for commissioning inpatient services in 2013, we have invested financial resources and increased the capacity of inpatient beds both in the East Midlands and across the country to enable greater access to beds at time of clinical need. Working with expert clinicians and service managers, NHS England has developed national service specifica”
What happened next: No evidence found either way
NHS England's statement on inpatient capacity investment lacks a specific timeframe, and no source confirms the 2017-18 timescale.
“The case for intensive community and day treatments for eating disorders CONTENTS Executive summary Introduction What are intensive community and day treatments?”
“Adult eating disorders: community, inpatient and intensive day patient care Guidance for commissioners and providers Publishing approval number: 000957 Version number: 1 First published: August 2019”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
Stated action · timescale: February 2018
“Undertakes a monthly contract review of its providers. Since February 2018, following an 'inadequate' rating by the Care Quality Commission of FTB, the CCG has led the development of a Quality Improvement Board to oversee and provide assurance on a CQC improvement Action Plan and a System Improvement Plan.”
What happened next: No evidence found either way
The NHS England board meeting transcript from October 2026 mentions a shortened session due to a fire drill and references future agenda items, but does not confirm or deny any specific action related to monthly contract reviews or the February 2018 Quality Improvement Board setup.
“we will ensure that the papers are still published and we will catch up on any outstanding matters at our following public board meeting”
No evidence found does not mean the action did not happen.
Stated action
“Proactively manages demand with a series of initiatives to reduce unnecessary admissions and avoid delayed transfers of care, such that capacity can be optimally managed.”
What happened next: No evidence found either way
The NHS England document outlines priorities and planning guidance for 2022/23, including updates to community care models and virtual ward capacity targets, but does not specify a timescale for implementing initiatives to reduce unnecessary admissions.
“Page 22 under community care models, a sentence about those living with frailty has been amended. The change is highlighted. Page 22 community care models- information about virtual wards has been amended to read 40-50 virtual beds per 100,000 population. The change is highlighted.”
“These findings show the NHS could reduce avoidable use of health services, including the number of emergency admissions and A&E attendances, by supporting”
“Process Area teams will seek to invite GP practices to participate in this enhanced 3.1 service by 31 May 2014. GP practices wishing to participate will be required to sign up to it by no later than 30 June 2014.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2017/18 and 2018/19
“Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).In 2018/19 the CCG provided additional investment in BSMHFT amounting to £3,117,000 (2.4% increase) and FTB amounting to £2,881,000 (9.3% increase). Further”
What happened next: Evidence found that the action was carried out
The Department of Health and Social Care states that the NHS is investing at least £2.3 billion annually by March 2024 to expand mental health services, which includes funding increases referenced in the promised actions.
“We are investing at least £2.3 billion of additional funding a year by March 2024 to expand and transform mental NHS health services, so an extra two million people can get mental health support.”
“We invested an additional £500 million in mental health and developed a one-year cross-government action plan to support recovery.”
“The government has announced a £343m investment to expand community mental health services across England through the delivery of 159 new NHS facilities.”
Stated action
“Undertakes mortality and incident review seriously and in line with national policy. The coroners' letters have prompted a comprehensive review of mortality and incident governance which will result in improved care quality and learning from incidents.”
What happened next: No evidence found either way
The NHS England statement about undertaking mortality and incident reviews is not explicitly confirmed or denied in the provided sources.
“We use some essential cookies to make this website work.”
“Learning, candour and accountability A review of the way NHS trusts review and investigate the deaths of patients in England DECEMBER 2016 b LEARNING, CANDOUR AND ACCOUNTABILITY Our purpose The Care Quality Commission is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high”
“The aim of the 3-year programme is to introduce a standardised methodology for reviewing case records of adult patients who have died in acute general hospitals in England and Scotland.”
No evidence found does not mean the action did not happen.
Stated action · timescale: November 14 2018
“Oversight of strategic and operational issues: the CCG will lead the establishment of an oversight group which involved all stakeholders . The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis.”
What happened next: No evidence found either way
The document outlines NHS England's quality functions and governance but does not specify a November 14 2018 timeline for establishing an oversight group as described in the promise.
“The Board is invited to: - Note the functions, processes and governance in place across the organisation, and how we work across NHS England in order to take action; and - Note our work with NHSI and other ALBs to strengthen improvement capabilities across the NHS”
No evidence found does not mean the action did not happen.
Stated action
“Risk assessment: this needs to be available and of high quality 24 hours a day, 7 days a week. We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care.”
What happened next: No evidence found either way
The NHS England webpage does not contain any statement confirming or denying the availability of a 24/7 high-quality risk assessment service.
“We've put some small files called cookies on your device to make our site work. We'd also like to use analytics cookies. These send information about how our site is used to a service called Google Analytics. We use this information to improve our site. Let us know if this is OK. We'll use a cookie to save your choice. You can[read more about our cookies](https://www.england.nhs.uk/privacy-policy/”
“Stop Copying the Copyrighted Material!”
“We use some essential cookies to make this website work.”
No evidence found does not mean the action did not happen.
Stated action
“The CCG is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment.”
What happened next: No evidence found either way
The sources discuss mental health care access challenges and system gaps but do not confirm or deny the specific promise about establishing a mental health system with timely inpatient access.
No evidence found does not mean the action did not happen.
Stated action · timescale: November 14 2018
“the CCG will lead the establishment of an oversight group which involved all stakeholders . The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis.”
What happened next: No evidence found either way
No source confirms the CCG established an oversight group by November 14 2018 or that it met monthly as promised.
“We use essential cookies to make our site work. We'd like to use additional cookies to understand how you use the site and improve our services. You can find details of these and all other cookies in our [cookie policy”
“The Board is asked to give its approval for NHS Improvement to start overseeing providers using the Single Oversight Framework (Appendix 1) on 1 October and at the same point to stop overseeing NHS foundation trusts using Monitor's Risk Assessment Framework and NHS trusts using NHS Trust Development Authority's (NHS TDA's) Accountability Framework, subject to any final comments from the sector on”
No evidence found does not mean the action did not happen.
Stated action
“The CCG has taken the opportunity, as part of this investigation, to review its broader quality assurance processes and identify any learning outside the scope of the Regulation 28 reports.”
What happened next: No evidence found either way
The organisation reviewed its broader quality assurance processes as part of an investigation, but no specific timeframe was provided for completing this review.
“A primary goal of the policy review was to identify and discuss the main policy levers that can enhance process quality and provide countries with concrete examples of policies.”
No evidence found does not mean the action did not happen.
Stated action · timescale: due course
“NHS England is also reviewing the current prison transfer and remission guidance, published by the Department of Health and Social Care in 20113. In particular, the review is looking at whether the timescales within the guidance take into account clinical urgency and need. The revised guidance will be subject to full, public consultation in due course.”
Stated action · timescale: 28 February 2019
“Since 2016, NHS England and respective stakeholders have been engaged in various multi-faceted programmes of work with the specific intention of improving the mental health pathway and is focused on ensuring timely referral, assessment and access to high quality care, and similarly ensuring that remission back to prison also takes place without delay to enable good throughput.”
Stated action · timescale: end of May 2019
“The next audit is currently underway, based on a census date of 28 February 2019. It is anticipated that the report will be available by the end of May 2019.”
Stated action · timescale: 2021
“NHS. England has committed to eliminating. the practice. of sending people out of-area for non-specialist acute inpatient:care due to”
What happened next: No evidence found either way
The NHS England commitment to eliminate out-of-area placements for non-specialist acute inpatient care was set for 2021, but no source confirms the action was completed by that date.
“The Government pledged to eliminate adult mental health out of area (OOA) placements by the end of March 2021, but it still hasn't happened yet.”
“Guidance # Out of area placements in mental health services for adults in acute inpatient care”
“Inappropriate out of area placements (IOAPs) have a significant emotional, economic and health impact on patients and carers, and negatively impact patient outcomes.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No published response from NHS England was found for this report.
Stated action
“NHS England is also investing £36m over three years to improve the quality of mental health, learning disabilities and autism inpatient settings. This includes a culture of care improvement programme which is being co-produced with patients, carers and families with lived experience.”
What happened next: No evidence found either way
The NHS England plan mentions a culture of care improvement programme co-produced with patients, carers and families, but no source confirms that this specific programme has been implemented.
“Advancing mental health equalities .........................................................................................................”
“Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2036/37
“NHS England is working at a national level to deliver the Long Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic”
What happened next: No evidence found either way
The NHS Long-Term Workforce Plan outlines ambitions to expand the workforce by 2036/37, including increased training places and recruitment targets.
“We are already growing the workforce and there are almost 67,300 more staff compared to a year ago, including over 6,800 more doctors and over 17,600 more nurses.”
No evidence found does not mean the action did not happen.
Stated action
“The number of mental health beds required to support a local population is dependent on both local mental health need, and the effectiveness of the whole local mental health system1 in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary”
What happened next: No evidence found either way
The NHS England document outlines planning approaches and commitments for mental health services but does not specify a fixed timescale for implementing the described mental health bed strategy.
“5 Planning approach .................................................................................................................................... 8 'Fixed', 'flexible' and 'targeted' approaches to delivering mental health commitments in the NHS Long Term Plan ....................................................................................................................................”
“Sustainability and transformation plans (STPs) provide the local vehicle for strategic planning, implementation at scale and c”
“Bed reductions were a constant feature, with important differences betwe”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
Stated action · timescale: 2024/25
“The number of mental health beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary.”
Stated action · timescale: 2023/24
“The NHS LTP saw an additional £2.3 billion of funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to allow people to get faster access to the care they need and prevent deterioration and hospital admission where it is avoidable.”
What happened next: Evidence found that the action was carried out
The NHS Long-Term Plan commits to £2.3bn annual investment in mental health services by 2023/24, with a focus on expanding community and crisis care to reduce hospital admissions.
“Mental health funding will increase at a faster pace than the wider NHS budget, which is positive news for private providers of mental health services”
“We are investing at least £2.3 billion of additional funding a year by 2023-24 to expand and transform mental health services in England so that two million”
“the NHS Long Term Plan for Mental Health (2019) included a commitment to create a new ringfenced local investment fund worth at least £2.3 billion a year in real terms by 2023/24”
Stated action
“I expect individual trusts and local health systems to effectively assess and manage bed capacity, the 'flow' of patients being discharged or moving to another setting.”
What happened next: No evidence found either way
The sources discuss electronic bed management systems and their role in improving patient flow and capacity management within hospitals, but do not specify any promised action by an organisation regarding assessment and management of bed capacity.
“Trusts are increasingly looking to electronic bed management systems to improve patient flow and increase capacity by providing visibility to flow bottlenecks and helping staff identify available beds as early as possible.”
“Ensure your patients receive the right care, at the right time, in the right location. Bed and Capacity Management Systems are an important part of NHS England's Urgent and Delivery Care Plan.”
No evidence found does not mean the action did not happen.
Stated action · timescale: Winter 2024/25
“We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements.”
What happened next: No evidence found either way
The NHS England statement references national monitoring of patients waiting over 72 hours for mental health beds in emergency departments, but no source confirms this monitoring was introduced by winter 2024/25.
“NHS key statistics: England Summary: NHS pressures before and after the pandemic 1 Emergency care: A&E and emergency admissions 2 Waiting times for hospital treatment 3 Cancer waiting times 4 Ambulance response times and demand 5 Diagnostic tests 6 Workforce levels and vacancies 7 Bed availability and discharges 8 GP appointments NHS key statistics: England”
“For the first time since February 2026, more than 10% of all patients attending A&E waited over 12 hours to be admitted, transferred, or discharged.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2021 | 0.74 | 0.26 | Identical · 0.96 | different |
| 2018 → 2021 | 0.69 | 0.23 | Identical · 0.92 | different |
| 2019 → 2023 | 0.69 | 0.15 | Closely related · 0.86 | different |
| 2016 → 2023 | 0.72 | 0.26 | Identical · 0.90 | different |
| 2018 → 2023 | 0.66 | 0.27 | Identical · 0.90 | different |
| 2023 → 2024 | 0.75 | 0.20 | Identical · 0.90 | different |
| 2019 → 2024 | 0.71 | 0.06 | Closely related · 0.86 | different |
| 2021 → 2024 | 0.65 | 0.12 | Closely related · 0.90 | different |
| 2019 → 2024 | 0.78 | 0.17 | Closely related · 0.86 | different |
| 2019 → 2024 | 0.78 | 0.09 | Closely related · 0.80 | different |
| 2019 → 2024 | 0.73 | 0.13 | Identical · 0.90 | different |
| 2018 → 2024 | 0.80 | 0.24 | Identical · 0.90 | different |
| 2024 → 2024 | 0.74 | 0.17 | Identical · 0.92 | different |
| 2015 → 2024 | 0.74 | 0.26 | Closely related · 0.90 | different |
| 2016 → 2024 | 0.67 | 0.33 | Closely related · 0.90 | different |
| 2024 → 2024 | 0.78 | 0.17 | Identical · 0.90 | different |
| 2023 → 2024 | 0.72 | 0.21 | Identical · 0.90 | different |
| 2018 → 2024 | 0.76 | 0.18 | Closely related · 0.85 | different |
| 2018 → 2024 | 0.72 | 0.37 | Closely related · 0.80 | different |
| 2015 → 2025 | 0.74 | 0.25 | Identical · 0.96 | different |
| 2024 → 2025 | 0.74 | 0.17 | Identical · 0.96 | different |
| 2024 → 2025 | 0.78 | 0.28 | Closely related · 0.92 | different |
| 2023 → 2025 | 0.74 | 0.28 | Identical · 0.92 | different |
| 2018 → 2025 | 0.70 | 0.38 | Identical · 0.90 | different |
| 2018 → 2025 | 0.73 | 0.17 | Closely related · 0.90 | different |
| 2023 → 2025 | 0.77 | 0.10 | Identical · 0.90 | different |
| 2014 → 2025 | 0.76 | 0.25 | Closely related · 0.85 | different |
| 2018 → 2025 | 0.79 | 0.12 | Identical · 0.97 | different |
| 2018 → 2025 | 0.79 | 0.15 | Identical · 0.90 | different |
| 2024 → 2025 | 0.70 | 0.16 | Closely related · 0.80 | different |
| 2024 → 2026 | 0.85 | 0.19 | Closely related · 0.90 | different |
| 2025 → 2026 | 0.85 | 0.12 | Closely related · 0.80 | different |
| 2024 → 2026 | 0.66 | 0.10 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for NHS England
- Delayed referral for neurosurgical care2 reports · 2017–2026
- Inadequate medical documentation oversight2 reports · 2024–2026
- Patients treated in ED corridor due to lack of clinical space3 reports · 2024–2026
- Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff3 reports · 2015–2026
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.