Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of inpatient mental health beds
The earlier warning
Andrew Farrow · 20 Apr 2015 · Peter Hatvany, Wiltshire & Swindon
“no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014”
judiciary.uk/prevention-of-future-death-reports/andrew-farrow
What was promised
Stated action 1 · response to Andrew Farrow (20 Apr 2015) · stated timescale: none stated
“The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”
judiciary.uk/…/2015-0147-Response-by-Avon-and-Wiltshire-NHS-Tru…
What recurred
- 7 Aug 2016 · Rohan Fitzsimons · Peter Harrowing · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Andrew Farrow · 20 Apr 2015
“no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014”
Later · Rohan Fitzsimons · 7 Aug 2016
“provision of in-patient beds is subject fo the funding provided by the Bristol Clinical Commissioning Group (CCG).”
What happened next
No evidence found either way · stated action 1
“Inappropriate out of area placements (IOAPs) have a significant emotional, economic and health impact on patients and carers, and negatively impact patient outcomes.”
Bringing care closer to home:reducing inappropriate out of area placements in mental health services · thenhsalliance.org/…/bringing-care-closer-to-home-reducing-inap…
No evidence found does not mean the action did not happen.