12 Mar 2026 Tania Louise JARMAN · Prevention of Future Deaths report Cheshire
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Concerns raised 1
Fewer mental health beds than patients assessed as needing them View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Tania Louise JARMAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Tania Louise JARMAN died aged 54 on 27 February 2024 at Park House, a non-clinical crisis placement, after tying a ligature with the probable intention of ending her life. Her mental health had worsened before her death, and her admission removed her from protective factors including her mother and home. The principal concerns were the longstanding shortage of mental health beds and the risk that this could lead to an artificially elevated threshold for referrals, potentially denying beds to patients with a clinical need.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Fewer mental health beds than patients assessed as needing them
Wider context from the report “1. There is a long standing and well publicised concern that there are fewer mental health beds than patients who are assessed as needing these . I draw your attention to the fact that this situation is ongoing and continues to pose a risk to life .
” Source location Tania Louise JARMAN · Prevention of Future Deaths report
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Concerns raised 2
Insufficient availability of Tier 4 paediatric mental health beds View source Unavailability of Tier 4 paediatric mental health beds for children and young people remaining on acute paediatric wards View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
NHS England
Publish implementation guidance defining a comprehensive 24/7 urgent and emergency mental health offer for children and young people.
View source
NHS England
Establish intensive home treatment services across Sussex as an alternative to hospital admission where safe.
View source
NHS England
Provide early discharge planning through intensive home treatment services to reduce prolonged hospital stays and dependence on inpatient admission.
View source
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Ellame FORD-DUNN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ellame FORD-DUNN, aged 16, was detained on an acute paediatric ward because no Tier 4 Paediatric Mental Health bed was available. She absconded from the ward during a toilet visit and died following her absconding. The principal concerns included insufficient Tier 4 beds, inadequate security and risk management, inconsistent handovers and unclear procedures for responding to absconsion, and poor coordination between agencies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient availability of Tier 4 paediatric mental health beds
Wider context from the report “1. 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 . I heard that the waiting time for a bed for those who are under the Kent and Sussex Child and Adolescent Mental Health Services (CAMHS) Inpatient Provider Collaborative is, on average, 8 days .
” Source location Ellame FORD-DUNN · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of Tier 4 paediatric mental health beds for children and young people remaining on acute paediatric wards
Wider context from the report “2. I heard from clinicians at University Hospitals Sussex NHS Foundation Trust that they continued to have on acute paediatric wards a number of children and young people who have no physical medical needs for which they requirement treatment in an acute hospital but do not have packages of care in the community in place or a Tier 4 Paediatric Mental Health bed available to be admitted to .
” Source location Ellame FORD-DUNN · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish implementation guidance defining a comprehensive 24/7 urgent and emergency mental health offer for children and young people.
Verbatim wording from the response “In 2024, NHS England published updated implementation guidance on urgent and emergency mental health care for children and young people, which set out the components of a comprehensive 24/7 offer that must be available to all children and young people experiencing mental health crisis. As well as a single point of access through NHS 111, the offer should include brief interventions in the community and intensive home treatment, avoiding admissions to hospital where these are not necessary and helping to ensure that beds are available for those who do need them.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish intensive home treatment services across Sussex as an alternative to hospital admission where safe.
Verbatim wording from the response “From a regional perspective, there has been substantial investment in Intensive Home Treatment Services (COAST) in Sussex, either directly via NHS England funded schemes or directly via the Lead Provider Trust and/or Sussex ICB and Sussex Partnership NHS Foundation Trust. These services have been co-produced with young people with lived experience and their parents, families and carers. These services, now established across all counties in the Sussex Integrated Care System (ICS) geography, currently provide:” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide early discharge planning through intensive home treatment services to reduce prolonged hospital stays and dependence on inpatient admission.
Verbatim wording from the response “From a regional perspective, there has been substantial investment in Intensive Home Treatment Services (COAST) in Sussex, either directly via NHS England funded schemes or directly via the Lead Provider Trust and/or Sussex ICB and Sussex Partnership NHS Foundation Trust. These services have been co-produced with young people with lived experience and their parents, families and carers. These services, now established across all counties in the Sussex Integrated Care System (ICS) geography, currently provide:” Source location Response from NHS England
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19 Jan 2026 Martin Douglas Bryant · Prevention of Future Deaths report Essex
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Concerns raised 1
Lack of locally and nationally available beds for mental health admissions View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Essex Partnership University NHS Foundation Trust NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
NHS England
Roll out 24/7 neighbourhood mental health centres, specialist mental health emergency departments and 24/7 psychiatric liaison teams.
View source
NHS England
Provide £75 million in additional capital for local systems to improve bed capacity and reduce out-of-area placements.
View source
NHS England
Consider providing more mental health beds within a whole-system transformation approach.
View source
NHS England
Issue operational planning guidance directing systems to reduce average adult acute mental health ward length of stay and improve access to local beds.
View source
NHS England
Reduce and eliminate the use of out-of-area placements.
View source
Essex Partnership University NHS Foundation Trust
Implement the Therapeutic acute Inpatient Operating Model to reduce length of stay and support purposeful admissions, flow and safe discharge planning.
View source
Essex Partnership University NHS Foundation Trust
Work with ICBs, NHS England and system partners to address admission and discharge bed pressures, including delayed community discharges.
View source See 4 more actions
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AI-generated summary
Martin Douglas Bryant · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Martin Douglas Bryant died by suicide on 19 January 2025 after presenting to the Mental Health Urgent Care Department following a suicide attempt. While awaiting informal admission and a bed, he was asked to wait in an open reception area from which he was free to come and go, and he subsequently left and did not return. The substantive concerns related to reliance on this waiting arrangement, the suitability of the waiting area, and shortages of mental health admission beds resulting in prolonged waits.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of locally and nationally available beds for mental health admissions
Wider context from the report “3. The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed .
” Source location Martin Douglas Bryant · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out 24/7 neighbourhood mental health centres, specialist mental health emergency departments and 24/7 psychiatric liaison teams.
Verbatim wording from the response “In relation to concern 3 above and the issue of bed availability, NHS England is currently rolling out dedicated 24/7 neighbourhood mental health centres to better support the community, including opening more specialist Mental Health Emergency Departments alongside general Emergency Departments and having a 24/7 psychiatric liaison team available. A pilot programme for these centres started in October 2025 and will run until July 2026. This will be followed by an Implementation Support Programme which will roll out to sites from March 2026.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £75 million in additional capital for local systems to improve bed capacity and reduce out-of-area placements.
Verbatim wording from the response “NHS England is aware of the issues in some healthcare systems around high bed occupancy and limited local bed availability. This is related to long lengths of stay and high numbers of patients clinically ready for discharge but unable to be discharged, leading to flow pressures across systems. To improve this, in 2025/26, NHS England made £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider providing more mental health beds within a whole-system transformation approach.
Verbatim wording from the response “Given increasing lengths of stay and the increased number of patients clinically ready for discharge, providing more beds will be considered as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue operational planning guidance directing systems to reduce average adult acute mental health ward length of stay and improve access to local beds.
Verbatim wording from the response “NHS England’s 2025/26 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds. NHS England is taking steps to address current operational pressures driving these issues.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce and eliminate the use of out-of-area placements.
Verbatim wording from the response “If local beds are not available, Out of Area Placements are currently used to ensure patient care is delivered in an inpatient setting if needed. However, NHS England plans to reduce and eliminate the use of Out of Area Placements as they can result in poorer outcomes for patients and provide additional risk to patient safety.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Therapeutic acute Inpatient Operating Model to reduce length of stay and support purposeful admissions, flow and safe discharge planning.
Verbatim wording from the response “As per the evidence provided to the Court, the Trust has implemented the Therapeutic acute Inpatient Operating Model for adults and older adults. The objective of this model is to reduce length of stay when a patient requires hospital admission. This model aligns with national guidance around purposeful admissions including capacity and flow, therapeutic benefit, proactive, safe and effective discharge/transfer planning and trauma informed care.” Source location Response from Essex Partnership University NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with ICBs, NHS England and system partners to address admission and discharge bed pressures, including delayed community discharges.
Verbatim wording from the response “We are also working closely with our integrated care boards (ICBs), NHSE and wider system partners re bed pressures for admission and discharge to and from EPUT beds. This has included a recent workshop with Essex county council to review delayed discharges from EPUT beds into the community where accommodation needs are delaying discharges.” Source location Response from Essex Partnership University NHS Foundation Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation EPUT is best placed to comment on evidence that patients may wait in the open reception area for days or weeks for a bed.
Verbatim wording from the response “3. The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for responding to concerns about the local and national shortage of mental health admission beds.
Verbatim wording from the response “Response:
We respectfully advise that this concern is for NHS England to respond to. However, in an effort to provide assurance on this point, the Trust provided assurance re: the availability of beds as part of our evidence at this Inquest, namely that this continues to be a challenge for the Trust / the NHS as a whole. Every effort is made to assess and manage patients in a safe and timely manner, again flow and capacity challenges remain, leading to patients having to wait to be seen in the UCD.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
24 Nov 2025 Diana Ocean Grant · Prevention of Future Deaths report Surrey
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Concerns raised 1
Insufficient capacity in the secure mental health unit estate View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS England
Review local causes of delays against the 28-day prison-to-hospital transfer target with providers, including guidance, escalation pathways, referral forms and contact lists.
View source
NHS England
Map emergency admission arrangements across adult forensic provider collaboratives, including out-of-hours access.
View source
NHS England
Develop a national adult forensic Access Assessment Services specification requiring emergency adult forensic bed admission arrangements, including out-of-hours access.
View source
NHS England
Launch and maintain a national database of adult forensic Access Assessment Services with referral and out-of-hours contact information.
View source
NHS England
Continue the national programme addressing delays in transfers from prison to mental health hospitals.
View source See 2 more actions
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AI-generated summary
Diana Ocean Grant · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Diana Ocean Grant, who was experiencing a relapse of paranoid schizophrenia and symptoms of psychosis, died in her prison cell after a foreign object became lodged in her upper airway. The report identified concerns about failures and delays in mental health assessment, treatment, information-sharing, observation and prison placement, as well as the limited availability of secure mental health beds for people requiring admission.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient capacity in the secure mental health unit estate
Wider context from the report “The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise.
The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit . This is principally because of the restricted capacity of the secure mental health unit estate , but also because of an expectation that some element of pre-planning will take place before such an admission occurs.
Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days .
Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison.
The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed.
” Source location Diana Ocean Grant · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review local causes of delays against the 28-day prison-to-hospital transfer target with providers, including guidance, escalation pathways, referral forms and contact lists.
Verbatim wording from the response “Locally, NHS England’s South East Health and Justice Commissioning team and Direct and Specialised Commissioning Quality team have engaged with the national programme of mental health improvements, along with working with local providers, to review areas that can cause delays to achieve the 28 day transfer target referred to within your Report, including looking at the Who Pays guidance, escalation pathways, referral forms and contact lists. There are also working groups with a focus on alternatives to custody.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Map emergency admission arrangements across adult forensic provider collaboratives, including out-of-hours access.
Verbatim wording from the response “NHS England’s Adult Forensic Services Team are currently mapping arrangements across all 15 Adult Secure Provider Collaboratives for emergency admissions to an adult forensic bed, including out of hours, to understand variation across England.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a national adult forensic Access Assessment Services specification requiring emergency adult forensic bed admission arrangements, including out-of-hours access.
Verbatim wording from the response “Using this information, and in collaboration with relevant stakeholders, we are developing a new national service specification for Access Assessment Services (for adult forensic services), that will include a requirement that arrangements are in place for emergency admissions to an adult forensic bed, including out of hours.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch and maintain a national database of adult forensic Access Assessment Services with referral and out-of-hours contact information.
Verbatim wording from the response “We have also created a database of Access Assessment Services (for adult forensic services) across England, that includes the direct contact information for referrals and urgent referrals, and out of hours contact information. This has now been launched and is accessible via the NHS Futures Collaboration Platform.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the national programme addressing delays in transfers from prison to mental health hospitals.
Verbatim wording from the response “There is also an ongoing significant national programme of work to address delays in transfers from prison to mental health hospitals.” Source location Response from NHS England
Open published response
Concerns raised 1
Insufficient availability of independent-sector mental health beds View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Patricia Genders · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Genders died on 22 February 2024 after absconding from the Enhanced Observation Unit at the Royal Sussex County Hospital while detained under the Mental Health Act. She was found on the coastal side of a safety fence, taken to A&E, and pronounced dead shortly afterwards. The concerns included the use of A&E for people in mental health crisis, the absence of an agreed home-care package, the decision not to transport Patricia to a more therapeutic setting, and shortcomings in hospital security, communication and responses to absconding.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient availability of independent-sector mental health beds
Wider context from the report “My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long.
This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around.
Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs.
All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation.
I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern.
The evidence I heard is that three things are required of those responsible for commissioning these services:
1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment.
2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions.
3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector . This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds.
Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur.
” Source location Patricia Genders · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £75 million of additional capital available to improve local mental health bed capacity and reduce Out of Area Placements.
Verbatim wording from the response “NHS England is aware of the issues in some systems around high bed occupancy and limited local bed availability. This is related to long lengths of stay and high numbers of patients clinically ready for discharge but unable to be discharged, leading to flow pressures across systems. To improve this, in 2025/26, NHS England made £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £2.3 billion in mental health services under the Long Term Plan, including funding for adult community, crisis and acute services.
Verbatim wording from the response “However, given increasing lengths of stay and the increased number of patients clinically ready for discharge, providing more beds will be considered as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts and local health systems are responsible for assessing and managing local mental health bed capacity.
Verbatim wording from the response “Regarding your concern on a need for an increase in the number of mental health beds available in the independent sector. Individual trusts and local health systems are responsible for effectively assessing and managing local bed capacity through the ‘flow’ of patients being discharged or moving to another setting. The NHS Operational Planning Guidance for 2025-26 contains fewer targets across the board to focus on the fundamentals of good care. It sets a requirement for Integrated Care Boards to take action to reduce the average length of stay in adult acute mental health beds, improving local bed availability and reducing the need for inappropriate out of area placement, and to reduce waits longer than 12 hours in A&E.” Source location Response from Department for Health and Social Care
Open published response
13 Oct 2025 Jack Mathew Peatling · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Lack of available mental health in-patient beds for very high-risk patients who cannot be safely managed in the community View source
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AI-generated summary
Jack Mathew Peatling · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jack Mathew Peatling, who had a very high risk of suicide, made further serious suicide attempts and was assessed as requiring urgent inpatient mental health care. No suitable inpatient bed was available for six days, during which he was managed in the community despite clinical recognition that his risk could not be safely managed there; he died by suicide on 5 June 2023. The report identified the chronic lack of available high-risk mental health inpatient beds as a principal concern.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of available mental health in-patient beds for very high-risk patients who cannot be safely managed in the community
Wider context from the report “(a) A highly vulnerable 20-year-old man, with a history of anxiety, depression and impulsive previous suicide attempts made two further serious attempts to take his own life and inflicted an extensive wound to his arm ████████ after those suicide attempts were frustrated by his mother. The subsequent formal MHA assessment determined Jack to be such a high risk of suicide that an immediate period of assessment and treatment as a (voluntary) in-patient on an MHAU was required as his high risk of suicide could not be safely managed in the community.
(b) No such bed was available over the six days between the MHA assessment and Jack’s suicide with still no indication, at the time of his death, as to if or when a bed would be available. By default, and notwithstanding point (a) above, the HTT, absent an in-patient bed, became responsible for his care in the community.
(c) In his evidence, it was further expressly recognised by the HTT psychiatrist who saw Jack on the 31st May that his “very, very high risk” of suicide at that time could not be managed safely in the community by the HTT and, further, that Jack was “untreatable” in the community.
(d) Nonetheless, and notwithstanding the unanimous clinical view, the non-availability of an EPUT MHAU in-patient bed meant that the HTT were required to attempt to mitigate this unmanageable level of risk in the community, something that the HTT was, as had been anticipated, unable to do.
(e) The evidence confirmed that a lack of available in-patient beds for high-risk mental health patients who, as was acknowledged at the time, cannot be managed safely in the community, is a chronic and on-going situation in Essex and, the inquest was told, nationally.
(f) Jack took his own life by deploying a ligature ████████
████████ on the sixth day awaiting the necessary, required in-patient bed. Had an in-patient bed been made available, he would probably not have died. Jack’s death was avoidable.
(g) Absent the provision of available mental health in-patient beds for very high-risk patients that formal Mental Health Act assessments have clinically determined cannot be managed safely in the community, then further avoidable deaths by suicide amongst this cohort of vulnerable patients appears inevitable.
” Source location Jack Mathew Peatling · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £75 million of additional capital available to improve local mental health bed capacity and reduce out-of-area placements.
Verbatim wording from the response “NHS England is aware of the issues in some systems around high bed occupancy and limited local bed availability. This is related to long lengths of stay and high numbers of patients clinically ready for discharge but unable to be discharged, leading to flow pressures across systems. To improve this, in 2025/26, NHS England made £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £2.3 billion in mental health services, including approximately £1.3 billion for adult community, crisis and acute services.
Verbatim wording from the response “However, given increasing lengths of stay and the increased number of patients clinically ready for discharge, providing more beds will be considered as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce and eliminate the use of out-of-area placements where local inpatient beds are unavailable.
Verbatim wording from the response “If local beds are not available, Out of Area Placements are currently used to ensure patient care is delivered in an inpatient setting if needed. NHS England plans to reduce and eliminate the use of Out of Area Placements as they can result in poorer outcomes for patients and provide additional risk to patient safety.” Source location Response from NHS England
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation When local beds are unavailable, existing out-of-area placements ensure inpatient care is delivered if clinically needed.
Verbatim wording from the response “If local beds are not available, Out of Area Placements are currently used to ensure patient care is delivered in an inpatient setting if needed. NHS England plans to reduce and eliminate the use of Out of Area Placements as they can result in poorer outcomes for patients and provide additional risk to patient safety.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation When admission capacity is insufficient, existing community safeguards and priority escalation arrangements manage risk or secure inpatient provision.
Verbatim wording from the response “Essex Partnership University NHS Foundation Trust (EPUT) has advised that when there is insufficient capacity to meet all hospital admission demands, the Chair of the twice-daily situation report meetings is mandated to seek assurance that sufficient community mitigation and safeguards are in place to continue with community intervention as an alternative to admission. Furthermore, Home Treatment Teams (HTTs) are instructed to raise as a priority for admission those individuals for whom the HTT is unable to provide adequate mitigation and/or where there is an escalating risk presentation.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local trusts and health systems are expected to assess and manage local mental-health bed capacity through patient flow.
Verbatim wording from the response “I expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from Department of Health and Social Care
Open published response
20 Aug 2025 Charles Andrew STONLEY · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1
Severe shortage of beds in mental health facilities View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Issue operational planning guidance requiring local systems to improve mental-health crisis flow and reduce emergency-department waits exceeding 12 hours.
View source
NHS England
Invest £75 million in 2025/26 capital funding to reduce mental-health out-of-area placements.
View source
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AI-generated summary
Charles Andrew STONLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Charles Andrew Stonley, who had severe depression with psychotic features, attended hospital with suicidal ideations and psychotic and paranoid symptoms while awaiting a mental health bed. After repeatedly leaving the Emergency Department, he was found deceased hanging in a wooded area. The report raises concerns about limited legal powers and resources for managing mental health patients in Emergency Departments and shortages of mental health beds, which can leave vulnerable patients at increased risk of self-harm and death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Severe shortage of beds in mental health facilities
Wider context from the report “2. The severe shortage and availability of beds in mental health facilities resulting in vulnerable patients being left in the Emergency Department for days increasing the risk of self harm and death.
” Source location Charles Andrew STONLEY · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue operational planning guidance requiring local systems to improve mental-health crisis flow and reduce emergency-department waits exceeding 12 hours.
Verbatim wording from the response “NHS England is also taking steps to address the current operational pressures driving these issues. The NHS operational planning guidance for this year tasks local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in EDs. In 2025/26, the NHS is also investing £75 million in capital funding to reduce mental health out-of-area placements, which pose an increased suicide risk and lead to longer stays away from the patients’ support networks.
At a local level, NHS Cheshire and Merseyside Integrated Care Board (ICB) is working with system partners to improve system flow for mental health inpatient beds. This” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £75 million in 2025/26 capital funding to reduce mental-health out-of-area placements.
Verbatim wording from the response “NHS England is also taking steps to address the current operational pressures driving these issues. The NHS operational planning guidance for this year tasks local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in EDs. In 2025/26, the NHS is also investing £75 million in capital funding to reduce mental health out-of-area placements, which pose an increased suicide risk and lead to longer stays away from the patients’ support networks.
At a local level, NHS Cheshire and Merseyside Integrated Care Board (ICB) is working with system partners to improve system flow for mental health inpatient beds. This” Source location Response from NHS England
Open published response
4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Lack of psychiatric hospital beds resulting in prolonged emergency department detention View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Epsom and St Helier University Hospitals NHS Trust NHS Southwest London Integrated Care Board Surrey and Borders Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Surrey and Borders Partnership NHS Foundation Trust
Increase the number of funded inpatient mental health beds for the Trust’s population.
View source
Surrey and Borders Partnership NHS Foundation Trust
Continue improving service flow, aligning operational processes and reducing unnecessary inpatient delays and length of stay.
View source
Surrey and Borders Partnership NHS Foundation Trust
Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
View source
Epsom and St Helier University Hospitals NHS Trust
Provide daily escalation and weekly executive oversight of patients awaiting psychiatric admission through collaboration with SABP and the ICB.
View source
NHS Southwest London Integrated Care Board
Maintain regular cross-boundary system calls and agreed escalation arrangements between Epsom General Hospital and mental health providers.
View source
NHS Southwest London Integrated Care Board
Work with the commissioned mental health trust to improve the urgent care pathway, maximise appropriate crisis alternatives, and reduce delays in accessing inpatient beds.
View source
NHS Southwest London Integrated Care Board
Use the assessment outputs to identify pathway gaps, support future commissioning and winter planning, and produce tailored improvement plans for mental healthcare delivery.
View source See 4 more actions
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AI-generated summary
Tracey Ostler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of psychiatric hospital beds resulting in prolonged emergency department detention
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds . The longest wait by such a patient in these circumstances has been 6 weeks . There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed .
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Source location Tracey Ostler · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the number of funded inpatient mental health beds for the Trust’s population.
Verbatim wording from the response “The Trust has taken steps to mitigate the demand for beds at a local level, including by embedding Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds for the Trust’s population, and improvement work aimed at reducing the length of inpatient stay.” Source location Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue improving service flow, aligning operational processes and reducing unnecessary inpatient delays and length of stay.
Verbatim wording from the response “The Trust has taken steps to mitigate the demand for beds at a local level, including by embedding Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds for the Trust’s population, and improvement work aimed at reducing the length of inpatient stay.” Source location Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
Verbatim wording from the response “Further improvement work continues through the Mind and Body Provider Collaborative, which is a programme of work chaired by our Chief Nursing Officer and undertaken with our acute care partners.” Source location Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide daily escalation and weekly executive oversight of patients awaiting psychiatric admission through collaboration with SABP and the ICB.
Verbatim wording from the response “The Trust works collaboratively with SABP to ensure that these delays are kept to a minimum. Every patient awaiting psychiatric admission is subject to daily escalation through Trust site meetings and concerns are raised with SABP and the ICB. Executive led weekly meetings between the Trust and SABP provides further oversight of plans for mental health patients at the Trust. The Trust continues to advocate for timely transfer to inpatient psychiatric units recognising that ED cannot provide the ward-based, multidisciplinary care these patients require.” Source location Response from Epsom General Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain regular cross-boundary system calls and agreed escalation arrangements between Epsom General Hospital and mental health providers.
Verbatim wording from the response “The cross-boundary arrangement at EGH requires coordination between the two mental health providers (SABP and SWLStG) and the two commissioners (SW London ICB and Surrey & Borders ICB). Routine actions underway include regular system calls and agreed escalation arrangements between EGH and mental health providers.” Source location Response from NHS South West London Integrated Care Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the commissioned mental health trust to improve the urgent care pathway, maximise appropriate crisis alternatives, and reduce delays in accessing inpatient beds.
Verbatim wording from the response “SW London works closely with SWLSTG to address delays in the urgent care pathway and minimise delays in access to beds. This work is focused on both improving the inpatient pathway and maximising use of crisis alternatives where appropriate and able to meet patient needs. Such services include the 24/7 crisis lines, ‘111 press 2 for mental health service’, community-based crisis cafés, and Home Treatment Teams.” Source location Response from NHS South West London Integrated Care Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the assessment outputs to identify pathway gaps, support future commissioning and winter planning, and produce tailored improvement plans for mental healthcare delivery.
Verbatim wording from the response “The outputs of this work will identify gaps within current pathways and support future commissioning plans, including winter planning. It will also provide tailored improvement plans aimed at enhancing mental healthcare delivery within SWLSTG and reducing demand and delays in emergency departments across SW London.” Source location Response from NHS South West London Integrated Care Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.
Verbatim wording from the response “Epsom and St Helier University Hospitals NHS Trust is an acute trust, offering inpatient physical healthcare services at Epsom Hospital and St Helier Hospital. For patients within our locality, mental health services are provided by Surrey and Borders Partnership NHS Foundation Trust (‘SABP’). Whilst we are not commissioned to provide care for patients who do not have physical health needs, we acknowledge and are mindful of the situation that is faced across the country where the demand for mental health services far exceeds the availability. We work collaboratively with our partners in SABP to provide care for patients whilst they remain in the Trust. I welcome the opportunity to respond to your concerns on behalf of the Trust.” Source location Response from Epsom General Hospital
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.
Verbatim wording from the response “NHS Surrey Heartlands ICB (‘the ICB’) is the responsible ICB for the geographical area in which the Trust sits. It is responsible for commissioning the mental health care provision for the population within its geographical area.” Source location Response from Epsom General Hospital
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.
Verbatim wording from the response “We expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Surrey patients’ psychiatric beds are commissioned by Surrey Heartlands ICB from Surrey and Borders Partnership NHS Foundation Trust.
Verbatim wording from the response “Psychiatric beds for patients who require inpatient care and present at the emergency department at Epsom General Hospital (EGH) are commissioned separately depending on GP registration. SW London patients are admitted to South West London & St George’s NHS Mental Health Trust (SWLStG), commissioned by SW London ICB. Surrey patients are admitted to Surrey and Borders Partnership NHS Foundation Trust (SABP), commissioned by Surrey Heartlands ICB.” Source location Response from NHS South West London Integrated Care Board
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.
Verbatim wording from the response “We expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from Department for Health and Social Care
Open published response
8 May 2025 James Oliver Sheppard · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 1
Insufficient psychiatric unit bed capacity View source
Linked responses
Department of Health and Social Care Gloucestershire Health and Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Department of Health and Social Care
Shift mental health treatment toward community and crisis services through new care and support models to reduce hospital admissions.
View source
Gloucestershire Health and Care NHS Foundation Trust
Implement measures improving bed-management structure and efficiency and reducing out-of-area placements.
View source
Gloucestershire Health and Care NHS Foundation Trust
Continue reducing average inpatient length of stay to improve psychiatric bed availability and utilisation.
View source
Gloucestershire Health and Care NHS Foundation Trust
Engage with the local Integrated Care Board on improving local inpatient capacity and access.
View source See 1 more action
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AI-generated summary
James Oliver Sheppard · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Oliver Sheppard, who had a history of mental health difficulties, died after diving onto the track in front of a train on 27 June 2023. The principal concern was that there appeared to be insufficient beds available in psychiatric units to meet patient demand.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient psychiatric unit bed capacity
Wider context from the report “There appear to be insufficient beds available in psychiatric units to meet patient demand
” Source location James Oliver Sheppard · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Shift mental health treatment toward community and crisis services through new care and support models to reduce hospital admissions.
Verbatim wording from the response “As part of our mission to build an NHS fit for the future, we will focus treatment away from hospital and inpatient care and improve community and crisis services, making sure more mental health crisis care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. This will hopefully reduce delays, though increasing bed availability, for those who need inpatient care the most.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement measures improving bed-management structure and efficiency and reducing out-of-area placements.
Verbatim wording from the response “We are grateful for the acknowledgement during your concluding remarks at the inquest that the Trust is responsible for delivery of psychiatric beds locally and issues of commissioning and total levels of available resource are responsibilities held in the wider health system locally and nationally. As such, our response is focused on what we can influence. As examined during the hearing, particularly in consideration of the witness testimony provided by ████████, significant work has been undertaken over the past few years to manage mental health bed capacity and patient flow within the Trust.” Source location Response from Gloucestershire Health & Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reducing average inpatient length of stay to improve psychiatric bed availability and utilisation.
Verbatim wording from the response “Although bed availability and resourcing continue to present challenges across mental health wards nationally, the measures implemented by the Trust have improved the structure and efficiency of bed management systems and significantly reduced the use of Out of Area Placements over the past three years, clearly demonstrating the Trust commitment towards an ongoing improvement of processes to ensure that every possible effort is made to ensure that those patients who require in-patient mental health care have access to a bed as quickly as possible. Our further work is focused on reducing, wherever possible, the average length of stay of inpatients to ensure that the current number of beds are being used as efficiently and effectively as possible. The Trust will be monitored nationally on this measure as part of NHS England’s Performance Assessment Framework.” Source location Response from Gloucestershire Health & Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage with the local Integrated Care Board on improving local inpatient capacity and access.
Verbatim wording from the response “In its ongoing efforts to improve the position locally, the Trust has also engaged in discussions with the local Integrated Care Board (NHS Gloucestershire ICB) and the development of an inpatient strategy is one of the agreed priorities for the Integrated Care System this year. We will ensure that the importance of adequate access to inpatient care is formally acknowledged through our Contract Management Board meeting with the ICB.” Source location Response from Gloucestershire Health & Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local trusts, health systems and integrated care boards are responsible for assessing and managing capacity and reducing delays in mental health services.
Verbatim wording from the response “I expect individual trusts and local health systems to effectively assess and manage bed capacity through the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioning and determining total psychiatric bed resources are responsibilities of the wider local and national health system.
Verbatim wording from the response “We are grateful for the acknowledgement during your concluding remarks at the inquest that the Trust is responsible for delivery of psychiatric beds locally and issues of commissioning and total levels of available resource are responsibilities held in the wider health system locally and nationally. As such, our response is focused on what we can influence. As examined during the hearing, particularly in consideration of the witness testimony provided by ████████, significant work has been undertaken over the past few years to manage mental health bed capacity and patient flow within the Trust.” Source location Response from Gloucestershire Health & Care NHS Foundation Trust
Open published response
Concerns raised 1
Lack of inpatient psychiatric beds causing unacceptable A&E waits for people awaiting mental health beds View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England NHS Surrey and Sussex Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS Surrey and Sussex Integrated Care Board
Commission and extend 14 additional independent-sector acute adult mental health beds to support winter pressures and capacity.
View source
NHS Surrey and Sussex Integrated Care Board
Work with partners to improve timely discharge and support prompt admission for people awaiting mental health inpatient care.
View source
NHS England
Measure response times for people presenting to urgent and emergency mental-health services to support faster access to appropriate care.
View source
NHS England
Monitor patients waiting more than 72 hours in emergency departments for mental-health placements and escalate cases nationally for executive intervention.
View source
NHS England
Provide trusts and systems with action cards to reduce emergency-department waiting times, including actions for people with complex learning disabilities and autism.
View source See 2 more actions
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AI-generated summary
Sapphire Kathleen BERNARD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sapphire Kathleen BERNARD was detained under the Mental Health Act and waited 19 days in an A&E department for a psychiatric bed while continuing to self-ligature. After admission to Langley Green Hospital, she self-tied a ligature while on intermittent observations and died at East Surrey Hospital on 30 October 2023. The principal concerns were the lack of psychiatric beds, the unsuitability of A&E as a holding environment for people needing mental health care, and vulnerabilities in the risk assessment and observation requirements at Langley Green Hospital.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of inpatient psychiatric beds causing unacceptable A&E waits for people awaiting mental health beds
Wider context from the report “1. 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 .
” Source location Sapphire Kathleen BERNARD · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and extend 14 additional independent-sector acute adult mental health beds to support winter pressures and capacity.
Verbatim wording from the response “There are 302 commissioned acute adult care beds and 40 Independent sector beds. In addition to the 40 acute adult beds in the independent sector NHS Sussex and Sussex Partnership commissioned an additional 14 beds between January- March 2025 to support winter pressures. These have now been extended for Quarter one 2025/26 taking the total number of acute adult beds in the independent sector to 54. Further to this, SPFT have redesigned their acute dementia ward in Brighton & Hove to support population need which will reopen in May 2025 as an adult ward and increase the SPFT bed base by 15 adult beds.” Source location Response from NHS Sussex Integrated Care Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with partners to improve timely discharge and support prompt admission for people awaiting mental health inpatient care.
Verbatim wording from the response “NHS Sussex recognises that some people wait longer than we would like to access mental health inpatient care due to patient flow and acuity of patients, NHS Sussex are working closely with partners to improve timely discharge to support prompt admission.” Source location Response from NHS Sussex Integrated Care Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Measure response times for people presenting to urgent and emergency mental-health services to support faster access to appropriate care.
Verbatim wording from the response “NHS England’s ambition is not just to improve the access point and connection to the specialist mental health points of access, but to bring significant improvements and expansion in the mental health services that ‘sit behind’ the point of access, so that people can be facilitated to access support that meets their needs and preferences in a more timely way. To this effect, we are moving at pace and are beginning to measure response times to those presenting to urgent and emergency mental health services, either in the community and/or emergency departments, with the aim of supporting these people to access appropriate care more quickly.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor patients waiting more than 72 hours in emergency departments for mental-health placements and escalate cases nationally for executive intervention.
Verbatim wording from the response “NHS England recognises the unsuitability of emergency departments for people experiencing mental health crisis once their immediate physical health needs have been attended to. We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements. Due to this oversight, individual patient cases are escalated at a national level and executive input is then sought to expedite care.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide trusts and systems with action cards to reduce emergency-department waiting times, including actions for people with complex learning disabilities and autism.
Verbatim wording from the response “From Winter 2024/25 we have also introduced action cards for trusts and systems, articulating key actions to be taken by trusts and systems to reduce the time patients spend in emergency departments. These include specific actions for people with complex learning disabilities and autism.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SPFT manages Sussex’s inpatient mental health bed capacity and clinically prioritises patients according to need.
Verbatim wording from the response “SPFT as the lead Mental Health service provider manages the inpatient bed capacity to best support the needs of all mental health patients in Sussex and they will then clinically prioritise accordingly. Sussex Partnership Foundation Trust can flex their capacity on a gender basis within their overall number of beds.” Source location Response from NHS Sussex Integrated Care Board
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.