Stephen Richardson
22 Jun 2023 · Coroner Andre Rebello · Liverpool and Wirral
This report repeats 5 earlier warnings, and was raised again 4 times later. See the linked reports.
The coroner's concerns
1. national shortage of acute psychiatric beds
“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”
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
“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”
Closely relatedConfidence 0.92 · high
Earlier report
“One continuing difficulty was the "lack of acute psychiatric beds" in Cornwall.”
This 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
Earlier report
“there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment”
This 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
Earlier report
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
This 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 0.95 · high
Earlier report
“There were no beds available and as a result he had further episodes of self-harm and suicide attempts. The availability of acute beds is a serious concern.”
This 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
“at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds”
Later report
“there is an ongoing shortage of available inpatient psychiatric beds in Surrey”
Identical hazardConfidence 0.90 · high
This 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”
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.”
Identical hazardConfidence 0.92 · high
This 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”
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”
Identical hazardConfidence 0.95 · high
This report
“It was clear from the investigation that at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds”
Later report
“There appear to be insufficient beds available in psychiatric units to meet patient demand.”
Responses
2023-0209-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2023-0209-Response-from-NHS-England-.pdf ↗· NHS England
Stated action
“NHS England is also investing £36m over three years to improve the quality of mental health, learning disabilities and autism inpatient settings. This includes a culture of care improvement programme which is being co-produced with patients, carers and families with lived experience.”