Ben Shipley
27 Apr 2023 · Coroner Ian Pears · West Yorkshire Western
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delay in completing s2 assessment leading to inability to legally detain patient
“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”
2. inability to lawfully detain patient under Mental Health Act
“[the deceased] cannot be legally detained as the section 2 is not complete until there is a bed”
3. risk of fatal injury from train collision in rural area
“[the deceased] was struck by a train in a rural area of Huddersfield”
4. death resulting from train collision
“His life was pronounced extinct at 14:14hrs”
Linked reports
Closely relatedConfidence 0.86 · high
Earlier report
“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.”
This report
“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.”
Identical hazardConfidence 0.90 · high
This report
“[the deceased] cannot be legally detained as the section 2 is not complete until there is a bed.”
Later report
“patients who have been assessed by 2 s12 consultant psychiatrists to require detention after a mental health act assessment are being effectively detained in general hospitals without a section, awaiting a bed”
Identical hazardConfidence 0.90 · high
This report
“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”
Later report
“In [the deceased]'s case a bed was not found for her within a 19-day period”
Responses
No published response was found on judiciary.uk.