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recurance

Emma Carpenter

14 Jul 2015 · Coroner Stephanie Haskey · Nottinghamshire

A similar concern from this report was raised again 4 times later. See the linked reports.

The coroner's concerns

  1. 1. lack of long term funding for specialist eating disorder service

    “there is only short term funding in place for this" service and a lack of commitment from Commissioners for its long term future”
  2. 2. lack of inpatient beds for mentally ill children and adolescents

    “still a national lack of provision of inpatient beds for mentally il! children and adolescents including those who suffer from eating disorders. 3.”
  3. 3. irregular attendance of school nurses in multidisciplinary meetings

    “it was important for school nurses to attend Multi Disciplinary Meetings to understand and assist with care planning, this does not happen on a regular, reliable basis due to lack of funding for school nurses”
  4. 4. lack of clear connections between mental health professionals and education staff

    “Inthe absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents”

Linked reports

Raised again laterCharlotte Swift11 May 2021 · 5 years 10 months later
Identical hazardConfidence 0.96 · high

This 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.”

Later 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.”
Original on judiciary.uk ↗
Full chain: Delayed transfer of acute mental health prisoners to secure units
Raised again laterAlfie Nicholls14 Feb 2024 · 8 years 7 months later
Closely relatedConfidence 0.90 · high

This report

“Inthe absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents”

Later report

“The Inquest heard that the school nurse service could play a vital role in identifying health issues and supporting other professionals.”
Original on judiciary.uk ↗
Full chain: Insufficient school nurse staffing weakens health education link
Raised again laterMatthew Sheldrick (2)16 Dec 2024 · 9 years 5 months later
Closely relatedConfidence 0.90 · high

This 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.”

Later report

“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 ↗
Full chain: Delayed transfer of acute mental health prisoners to secure units
Raised again laterSapphire Bernard5 Feb 2025 · 9 years 7 months later
Identical hazardConfidence 0.96 · high

This 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.”

Later report

“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 ↗
Full chain: Delayed transfer of acute mental health prisoners to secure units

Responses

2015-0276-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care

2015-0276-Response-by-Doncaster-and-Bassettlaw-Hospitals-NHS-Trust.pdf ↗· Department of Health and Social Care

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.”

2015-0276-Response-by-NHS-England.pdf ↗· NHS England

Stated action · 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”

Carpenter-2015-0276a.pdf ↗· NHS England

Stated action · 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.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error