George Taylor
2 Feb 2015 · Coroner Andrew Cox · Cornwall
A similar concern from this report was raised again 4 times later. See the linked reports.
The coroner's concerns
1. lack of acute psychiatric beds
“It was established in evidence that Mr [name redacted] death was not caused by the lack of an acute psychiatric bed”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“It was established in evidence that Mr [name redacted] death was not caused by the lack of an acute psychiatric bed.”
Later report
“One continuing difficulty was the "lack of acute psychiatric beds" in Cornwall.”
Closely relatedConfidence 0.90 · high
This report
“It was established in evidence that Mr [name redacted] death was not caused by the lack of an acute psychiatric bed.”
Later report
“To review the availability of beds for psychiatric patients in Cornwall.”
Identical hazardConfidence 0.90 · high
This report
“It was established in evidence that Mr [name redacted] death was not caused by the lack of an acute psychiatric bed.”
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
“It was established in evidence that Mr [name redacted] death was not caused by the lack of an acute psychiatric bed.”
Later report
“Despite recognising Mr [name redacted] needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT' RCA report identified no remedial action.”
Responses
2015-0044-Response-by-Department-of-Health.pdf ↗· Department of Health and Social Care
Stated action
“I have made NHS England aware of your report.”
2015-0044-Response-by-Kernow-CCG.pdf ↗· Kernow Clinical Commissioning Group
Stated action · rolled out across the County
“This pathway includes services to support the health and well-being of the individual through a variety of 3rd sector services, employment support, ethnic minority group support, befriending services and community groups as per the Living Well model, which is being rolled out across the County and has national Pioneer status.”