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recurance

Jonathan Harris

20 Mar 2024 · Coroner Anna Crawford · Surrey

This report repeats 2 earlier warnings, and was raised again 2 times later. See the linked reports.

The coroner's concerns

  1. 1. vacant consultant psychiatrist post in community mental health team

    “The court heard that a Consultant [name redacted] post in the community mental health team that treated Mr [name redacted] has been vacant with no suitable applicants since 1 May 2022”
  2. 2. shortage of inpatient psychiatric beds in Surrey

    “there is an ongoing shortage of available inpatient psychiatric beds in Surrey”
  3. 3. risk of future deaths from mental health service gaps

    “both of these matters present a risk of future deaths”

Linked reports

Repeats an earlier warningAnthony Watson12 Feb 2019 · 5 years 1 month earlier
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.”
Original on judiciary.uk ↗

This report

“The court also heard that there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds.”
Full chain: Delayed transfer of acute mental health prisoners to secure units
Repeats an earlier warningStephen Richardson22 Jun 2023 · 9 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds”
Original on judiciary.uk ↗

This report

“there is an ongoing shortage of available inpatient psychiatric beds in Surrey”
Full chain: Delayed transfer of acute mental health prisoners to secure units
Raised again laterMatthew Sheldrick (2)16 Dec 2024 · 9 months later
Identical hazardConfidence 0.90 · high

This report

“there is an ongoing shortage of available inpatient psychiatric beds in Surrey”

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 · 11 months later
Closely relatedConfidence 0.92 · high

This report

“there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds.”

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

2024-0155-Response-from-NHS-England.pdf ↗· NHS England

Stated action · 2036/37

“NHS England is working at a national level to deliver the Long Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic”
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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