Philip Malone
23 Nov 2023 · Coroner James Bennett · Birmingham and Solihull
This report repeats 6 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of psychiatric bed capacity
“no bed was available in August 2022”
2. lack of psychiatric bed capacity
“lack of psychiatric bed capacity remains an ongoing problem”
3. lack of psychiatric bed capacity
“no bed was available in December 2021”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“It was established in evidence that Mr [name redacted] death was not caused by the lack of an acute psychiatric bed.”
This 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.”
Identical hazardConfidence 0.90 · high
Earlier 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.”
This report
“no bed was available in August 2022”
Closely relatedConfidence 0.90 · high
Earlier report
“Between the 16th March 2019 and the 25th April 2019, a bed could not be found for the Deceased even though he had been assessed and fit for detention.”
This report
“My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable.”
This 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.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“I am therefore concerned in relation to the overall bed capacity for those patients like [the deceased] seeking informal admission”
This report
“My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate”
Identical hazardConfidence 0.90 · high
Earlier report
“Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU.”
This report
“Despite recognising Mr [name redacted] needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity”
Closely relatedConfidence 0.90 · high
This 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.”
Later report
“The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”
Responses
2023-0469-Response-from-Birmingham-and-Solihull-Integrated-Care-Board.pdf ↗· Birmingham and Solihull Integrated Care Board
2023-0469-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
2023-0469-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · 12-month project
“The Trust initiated a 12- month project with Grant Thornton Consultancy to address local bed shortages and reduce reliance on out-of-area hospital beds”