Madeleine Savory
15 Nov 2023 · Coroner Darren Stewart · Suffolk
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of Tier 4 beds
“The availability, nationally, of Tier 4 beds in paediatric mental health facilities to allow for the timely allocation to children in need of care in such facilities such as [the deceased].”
2. lack of coordinated measures
“measures which that organisation had undertaken in their area of responsibility to address my concern in relation to the availability and allocation of Tier 4 beds in a paediatric mental health facilities to children such as [the deceased]”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“The availability, nationally, of Tier 4 beds in paediatric mental health facilities”
Later report
“I heard that there are insufficient numbers of Tier 4 Paediatric Mental Health beds available for the children and young people who have been assessed as requiring this level of admission.”
Responses
2023-0452-Response-from-Department-of-Health-and-Social-Care.pdf ↗· NHS England
Stated action
“I note that you have received satisfactory evidence from East Suffolk and North Essex NHS Foundation Trust, the East of England Provider Collaborative and Northgate High School concerning the measures they have put in place to address the failures identified during the course of the Inquest.”
2023-0452-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 2022/23
“The NHS Planning Guidance 2022/23 outlined the need for Lead Provider Collaboratives (LPCs) and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive care Units to meet the needs of their local population.”