David Knight
14 Nov 2016 · Coroner Emma Carlyon · Cornwall and the Isles of Scilly
This report repeats 1 earlier warning, and was raised again 5 times later. See the linked reports.
The coroner's concerns
1. out of county placement of mental health patients
“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”
2. lack of communication with community mental health team
“no communication with the local community mental health team and Home Treatment Team in Cornwall notifying them of the leave”
3. treatment of mental health patients out of county
“it was not best practice to treat patients out of county”
4. inadequate statutory function performance by nearest relative and responsible medical officer
“difficulties of the "nearest relattve' and the Responsible Medical Officer to adequately carry out their statutory function at such distances”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“One continuing difficulty was the "lack of acute psychiatric beds" in Cornwall.”
This report
“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”
Closely relatedConfidence 0.90 · high
This report
“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”
Later report
“In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts.”
Identical hazardConfidence 0.90 · high
This report
“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”
Later report
“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”
Identical hazardConfidence 0.90 · high
This report
“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”
Later report
“a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual”
Closely relatedConfidence 0.80 · moderate
This report
“national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization”
Later report
“there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”
Closely relatedConfidence 0.90 · high
This report
“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”
Later report
“There being a national shortage of mental health beds in particular for Autistic patients and those who are transgender requiring a mixed ward”
Responses
2016-0414-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action · 2020/21
“We will eliminate clinically unnecessary out of area placements for adult acute mental health care by 2020/21 and will reduce significantly delayed transfers of care.”
2016-0414-Response-by-NHS-England.pdf ↗· NHS England