Charlotte Swift
11 May 2021 · Coroner Penelope Schofield · West Sussex
This report repeats 2 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of inpatient beds for eating disorder patients
“[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. 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.”
2. untreated mental health conditions
“[the deceased] had been struggling with her mental health since the age of 22 when she was disgnosed with gender dysphoria and she went on to develop an eating disorder”
3. delayed inpatient admission
“real concerns were raised about her weight loss and it was clear that she needed an urgent inpatient bed at a specialist unit”
Linked reports
Identical hazardConfidence 0.96 · high
Earlier report
“There remains still a national lack of provision of inpatient beds for mentally il! children and adolescents including those who suffer from eating disorders.”
This report
“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.”
Identical hazardConfidence 0.92 · high
Earlier report
“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.”
This report
“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.”
Closely relatedConfidence 0.90 · high
This report
“[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.”
Later report
“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.”