Recurring concern

Insufficient psychiatric inpatient bed capacity

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First reported 13 Feb 2014•Latest report 12 Mar 2026

Definition

What this concern includes

Includes deficiencies in the availability, adequacy or geographic provision of psychiatric inpatient beds, including resulting admission delays and dedicated bed-allocation or patient-flow measures used to manage the shortage.

Not included

  • Excludes generic acute hospital or emergency-department bed shortages that are not specifically psychiatric.
  • Excludes general discharge-planning, discharge-documentation or medication failures unless they are explicitly identified as part of managing psychiatric inpatient bed capacity.
  • Excludes training, communication or staffing deficiencies that are not dedicated to psychiatric inpatient capacity management.
  • Excludes the safety of an individual discharge where the underlying recurring concern is not insufficient psychiatric inpatient bed capacity.
Reports
67

Distinct published reports

Individual concerns
79

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
185

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care41
NHS England33
NHS Birmingham and Solihull Integrated Care Board10
Birmingham and Solihull Mental Health NHS Foundation Trust7
NHS Devon Integrated Care Board3
NHS Greater Manchester Integrated Care Board3
NHS Leicester, Leicestershire and Rutland Integrated Care Board3
Surrey and Borders Partnership NHS Foundation Trust3
Birmingham City Council2
Care Quality Commission2
Central and North West London NHS Foundation Trust2
Department for Education2
Devon Partnership NHS Trust2
Greater Manchester Health and Social Care Partnership2
Greater Manchester Mental Health NHS Foundation Trust2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West Sussex, Brighton and Hove

    AI-generated summary

    Matthew Zak Sheldrick (Matty) · 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

    Matthew Zak Sheldrick (Matty), who identified as non-binary, attended A&E in crisis on 3 November 2022 following deteriorating mental health and intense suicidal thoughts. After being assessed under the Mental Health Act and not detained, Matty left the hospital and was found suspended by a ligature in the hospital grounds. The report identified concerns including the lack of suitable inpatient beds, the unsuitability of A&E for neurodivergent patients, gaps in service provision, and shortcomings in the mental health assessment and discharge care planning.

    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

    Lack of inpatient mental health beds causing unacceptable A&E waits

    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 beds. In Matty’s case a bed was not found for them within a 26-day period. ”

    Source location

    Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 commissioned inpatient capacity by 27 acute beds, representing a net increase of 17 beds, by the end of March 2025.

    Verbatim wording from the response

    “By the end of March 2025, this will increase, including 27 acute beds (net increase 17). A business case for further beds in 2025-26, to ensure timely access to inpatient care when required, is being developed.”

    Source location

    Response from Sussex ICB
    Page 1 · response
    Published 19 December 2024

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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 business case for further inpatient beds in 2025–26 to support timely access to inpatient care.

    Verbatim wording from the response

    “By the end of March 2025, this will increase, including 27 acute beds (net increase 17). A business case for further beds in 2025-26, to ensure timely access to inpatient care when required, is being developed.”

    Source location

    Response from Sussex ICB
    Page 1 · response
    Published 19 December 2024

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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

    Sussex has above-average acute mental-health bed provision nationally, challenging the premise that insufficient beds explain the concern.

    Verbatim wording from the response

    “To note, Sussex benchmarks above average for the number of beds in acute mental health wards for benchmarked areas nationally (as of 31st March 2023). There are 25 beds per 100,000 population in Sussex, compared to a national mean of 23, where the upper quartile is 27 and the lower quartile 17.4. This position does not change when looking at weighted population whereby in Sussex the beds per 100,000 weighted population is 23.3. compared to a national mean of 18.9.”

    Source location

    Response from Sussex ICB
    Page 2 · response
    Published 19 December 2024

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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

    Flexibility within mental-health services is the Trust’s responsibility, while NHS Sussex retains overarching commissioning responsibility.

    Verbatim wording from the response

    “NHS Sussex has oversight of all performance targets and waiting times and has assurance conversations monthly with SPFT. NHS Sussex has the overarching commissioning responsibility for the totality of the contract with the SPFT, however the flexibility within the services is the responsibility of the Trust. The Trust report to NHS Sussex on performance both internally and publicly and manage the risks within their services.”

    Source location

    Response from Sussex ICB
    Page 4 · response
    Published 19 December 2024

    Open published response
  2. West Sussex, Brighton and Hove

    AI-generated summary

    Matthew Zak Sheldrick (Matty) · 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

    Matthew Zak Sheldrick (Matty), who identified as non-binary, had a history of mental health difficulties and was admitted to A&E in crisis on 3 November 2022 after a previous 26-day wait for a psychiatric bed. After being assessed under the Mental Health Act and not detained, Matty left hospital and was found hanging in the hospital grounds. Concerns included shortages and long waits for mental health beds, the unsuitability of A&E for neurodivergent patients, gaps in services and discharge planning, and shortcomings in the mental health assessment.

    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

    Lack of inpatient mental health beds

    Wider context from the report

    “1. 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. In Matty’s case a bed was not found for them within a 26-day period. ”

    Source location

    Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Shortage of mental health beds suitable for Autistic patients and transgender patients requiring a mixed ward

    Wider context from the report

    “2. There being a national shortage of mental health beds in particular for Autistic patients and those who are transgender requiring a mixed ward. ”

    Source location

    Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Commit £26 million in capital investment to open new mental health crisis centres.

    Verbatim wording from the response

    “As announced in the Budget, we are committing £26 million in capital investment to open new mental health crisis centres, reducing pressure on busy A&E services and ensuring people have the support they need when they need it.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 19 December 2024

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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 statutory guidance requiring coordinated, safe discharge from mental health, learning disability and autism inpatient settings.

    Verbatim wording from the response

    “It is also important that, when people are discharged, this happens in a way that considers their needs on discharge and any risks to their safety. To help support safe and timely discharge decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support safe discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults.”

    Source location

    Response from DHSC
    Page 3 · response
    Published 19 December 2024

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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

    Direct systems to reduce adult acute mental health ward length of stay and improve access to local inpatient beds.

    Verbatim wording from the response

    “NHS England’s 2024/25 priorities and operational planning guidance continues 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. This is being supplemented by a further £42 million recurrent investment from 2024/25, for all Integrated Care Boards (ICBs) in the country to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 19 December 2024

    Open published response

    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 £42 million recurrent investment for ICBs to recommission inpatient care in line with locally appropriate therapeutic models.

    Verbatim wording from the response

    “NHS England’s 2024/25 priorities and operational planning guidance continues 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. This is being supplemented by a further £42 million recurrent investment from 2024/25, for all Integrated Care Boards (ICBs) in the country to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 19 December 2024

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    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 responsible for assessing and managing mental-health bed capacity and patient flow.

    Verbatim wording from the response

    “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 19 December 2024

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    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Local provider-level inpatient accommodation availability falls outside NHS England’s national policy and programme remit.

    Verbatim wording from the response

    “Your Report raises concerns about the service provision and availability of services for patients suffering with their mental health, and the appropriateness of the Emergency Department as an environment for people who are autistic and/or neurodiverse to be held as they await a mental health bed. My response to the Coroner addresses the issues raised that sit within NHS England’s national policy and programme remit.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 19 December 2024

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    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NHS Sussex ICB is the responsible commissioner for the relevant local services, with the Trust responsible for its action plan.

    Verbatim wording from the response

    “NHS England’s South East regional colleagues have also engaged with NHS Sussex ICB, the responsible commissioner for the services described, on the concerns raised. We are advised that they have identified actions which include the provision of leaflets to patients and carers explaining delays in access to mental health beds, with information and signposting to support lines and apps. There are also now arrangements in place to support escalation and clinical discussion of patient flow and referral reviews. The ICB have requested an update from the Trust on their action plan, following Matty’s death.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 19 December 2024

    Open published response
  3. Suffolk

    AI-generated summary

    Timothy Robert DE BOOS · 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

    Timothy Robert DE BOOS was declared deceased at his home in Ipswich on 6 February 2024 after a self-inflicted domestic fire, with the medical cause of death recorded as smoke inhalation and severe burns. The report raises concerns about the lack of available Mental Health Unit inpatient beds and about the admission process when the patient, family, and an experienced mental health professional considered voluntary admission necessary.

    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

    Lack of Mental Health Unit inpatient beds

    Wider context from the report

    “1. I am concerned of the continuing lack of Mental Health Unit inpatient beds in Suffolk, and more widely throughout England and Wales. At the time of Tim’s mental health crisis on the 2ⁿᵈ February 2024, had the decision to admit him been possible, he still would not have been admitted as there were five other individuals in the queue before him also waiting for admission. The lack of available beds is not a new problem, and I have previously issued two Regulation 28 Prevention of Future Death Reports in which a lack of inpatient Mental Health Unit beds have contributed to a death- Nicola Rayner (died 10ᵗʰ June 2023), reported 7ᵗʰ March 2024. Piotr Kierzkowski (died 17ᵗʰ December 2019), reported 12ᵗʰ October 2020. ”

    Source location

    Timothy Robert DE BOOS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 statutory guidance on safe discharge from mental health inpatient settings.

    Verbatim wording from the response

    “It is also important that when people are discharged, this happens in a way that considers their needs on discharge and any risks to their safety. To help support safe and timely discharge decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support safe discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 19 December 2024

    Open published response
  4. Inner North London

    AI-generated summary

    JAGJEET SINGH · 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

    Jagjeet Singh, who had a history of intravenous substance misuse and mental and physical health problems, injected heroin after leaving hospital and was found deceased the following day with a syringe nearby. The inquest concluded that the death was drug related, with acute respiratory depression and fatal morphine and methadone toxicity identified as causes. The report raised concerns about the lack of an available mental health bed after medical-ward admissions, resulting in temporary accommodation, eviction and at least one night sleeping rough.

    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

    Lack of sufficient mental health bed capacity

    Wider context from the report

    “Mr Singh was an inpatient on a mental health ward at the Homerton Hospital from 20 August 2023 until 6 March 2024, initially under s.2 of the Mental Health Act and then as an informal patient. On three occasions he spent time on medical wards for infected leg ulcers, arising from his IV drug use. During these periods his mental health bed was, understandably, allocated to other patients. However, on discharge from the medical ward, there was no mental health bed available for him and he either went home or, as his property was uninhabitable for a period of time, was accommodated in a Travel Lodge at the cost of the Trust, returning to the mental health ward for meals and medication. Mr Singh did not like the Travel Lodge and on one occasion was evicted. He therefore slept on a coach in the mental health ward and appears to have spent at least one night sleeping rough. I heard that a bed on the mental health ward should have been available for Mr Singh when he was discharged from the medical wards but that there is a chronic shortage of mental health beds and not just in London but nationally. It was described to me as a crisis. ”

    Source location

    JAGJEET SINGH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 statutory guidance supporting safe discharge from mental health and learning disability and autism inpatient settings.

    Verbatim wording from the response

    “It is also important that when people are discharged, this happens in a way that considers their needs on discharge and any risks to their safety. To help support safe and timely discharge decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support safe discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 6 November 2024

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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

    Expand delivery of mental health care in community settings through new models of care and support.

    Verbatim wording from the response

    “As part of our mission to build an NHS fit for the future, we will make sure more mental health 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.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 6 November 2024

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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

    Invest in new mental health inpatient units to address local bed shortages.

    Verbatim wording from the response

    “In some local areas there is a need for more beds, this is being addressed in part through investment in new units and additionally 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. NHS England’s 2024/25 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.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 6 November 2024

    Open published response

    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 recurrent funding to Integrated Care Boards to recommission inpatient care under locally appropriate therapeutic models.

    Verbatim wording from the response

    “This is being supplemented by a further £42 million recurrent investment from 2024/25 for all Integrated Care Boards (ICBs) in the country to recommission inpatient care, in line with local models that provide the best evidence of therapeutic support.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 November 2024

    Open published response

    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 addressing the reported concerns about mental health bed availability.

    Verbatim wording from the response

    “I understand your concerns about a bed on the mental health ward not being available for Mr Singh when he was discharged from the medical wards. I note that you have also addressed these matters of concern to the Chief Executive of NHS England. I look forward to seeing her response and working with NHS England where appropriate, to avoid a repetition of the tragic events of this case.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 6 November 2024

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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 mental health bed capacity, patient flow and specialist rehabilitation availability.

    Verbatim wording from the response

    “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the availability of specialist personality disorder rehabilitation units. I recognise that mental health services have been under significant strain in recent years due to the rise in demand.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 6 November 2024

    Open published response
  5. Northamptonshire

    AI-generated summary

    Mr Robin Andrew Ward · 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

    Mr Robin Andrew Ward, a 73-year-old man, died by drowning in a bath at the Warren Crisis House on 4 July 2021; the conclusion was that his death was suicide. He had required an acute inpatient mental health bed, but no local bed was available for four days and he was placed at the crisis house as an interim measure. Concerns included pressures on acute and out-of-area mental health bed availability, the lower clinical capacity and lack of ligature safety in crisis houses, and long waiting times for psychological assessment.

    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

    Insufficient provision of acute mental health beds

    Wider context from the report

    “a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”

    Source location

    Mr Robin Andrew Ward · Prevention of Future Deaths report
    Page 1 · concerns

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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 out-of-area acute beds for elderly patients

    Wider context from the report

    “a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”

    Source location

    Mr Robin Andrew Ward · Prevention of Future Deaths report
    Page 1 · concerns

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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 working with the NHS to maximise mental health service capacity.

    Verbatim wording from the response

    “I am sure you will appreciate that the number of mental health inpatient beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an inpatient admission being necessary. I also recognise that mental health services have been under significant strain in recent years due to the rise in demand and the Department will continue to work with the NHS to maximise capacity.”

    Source location

    Response from Department of Health and Social care
    Page 1 · response
    Published 28 July 2026

    Open published response
  6. Surrey

    AI-generated summary

    Locket Ure Williams · 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

    Locket Williams, aged 15, died from injuries after leaving home and jumping to the road below on the night of 27 September 2021; their death was recognised at 00:01 on 28 September 2021. The report identified concerns about insufficient child psychiatric inpatient capacity, the recording and communication of suicide risk, and CAMHS engagement with multi-agency safeguarding meetings. The inquest found that the death was more than minimally contributed to by delays in assessment, underestimation of suicide risk, and delayed therapeutic treatment.

    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

    Unavailability of fully operational in-county psychiatric in-patient beds for children

    Wider context from the report

    “Concern 1 The evidence at the inquest hearing revealed that, at the time of Locket’s death, there were no psychiatric in-patient beds available for children in Surrey. It was recognised in the evidence that sending children out of the County, and sometimes to hospitals at a great distance away from their home, may be detrimental to their overall welfare, including their suicide risk, and may militate against their admission at all. At the prevention of future deaths hearing, I was told that a new, 12-bedded, unit named Emerald Place has since been opened by the Trust in partnership with a private provider. However, a concern about the level of in-county psychiatric in-patient beds for children continues because (i) the unit is not fully open and there is no fixed date for such opening, (ii) even when fully opened, it seems that the unit’s 12 beds will be insufficient to meet the probable need at any one time, and (iii) even when fully opened, the unit will not be able to treat children with eating disorders or children needing psychiatric intensive care. ”

    Source location

    Locket Ure Williams · Prevention of Future Deaths report
    Page 3 · concerns

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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 in-county psychiatric in-patient bed capacity for children

    Wider context from the report

    “Concern 1 The evidence at the inquest hearing revealed that, at the time of Locket’s death, there were no psychiatric in-patient beds available for children in Surrey. It was recognised in the evidence that sending children out of the County, and sometimes to hospitals at a great distance away from their home, may be detrimental to their overall welfare, including their suicide risk, and may militate against their admission at all. At the prevention of future deaths hearing, I was told that a new, 12-bedded, unit named Emerald Place has since been opened by the Trust in partnership with a private provider. However, a concern about the level of in-county psychiatric in-patient beds for children continues because (i) the unit is not fully open and there is no fixed date for such opening, (ii) even when fully opened, it seems that the unit’s 12 beds will be insufficient to meet the probable need at any one time, and (iii) even when fully opened, the unit will not be able to treat children with eating disorders or children needing psychiatric intensive care. ”

    Source location

    Locket Ure Williams · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inability of in-county psychiatric in-patient provision to treat children with eating disorders or needing psychiatric intensive care

    Wider context from the report

    “Concern 1 The evidence at the inquest hearing revealed that, at the time of Locket’s death, there were no psychiatric in-patient beds available for children in Surrey. It was recognised in the evidence that sending children out of the County, and sometimes to hospitals at a great distance away from their home, may be detrimental to their overall welfare, including their suicide risk, and may militate against their admission at all. At the prevention of future deaths hearing, I was told that a new, 12-bedded, unit named Emerald Place has since been opened by the Trust in partnership with a private provider. However, a concern about the level of in-county psychiatric in-patient beds for children continues because (i) the unit is not fully open and there is no fixed date for such opening, (ii) even when fully opened, it seems that the unit’s 12 beds will be insufficient to meet the probable need at any one time, and (iii) even when fully opened, the unit will not be able to treat children with eating disorders or children needing psychiatric intensive care. ”

    Source location

    Locket Ure Williams · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Open Emerald Place to provide additional general adolescent unit inpatient bed capacity in Surrey.

    Verbatim wording from the response

    “Typically, 6-8 General Adolescent Unit inpatient beds are required at any given time within Surrey. Emerald Place was opened by the Trust in partnership with a private provider, Elysium Healthcare, in March 2024. Emerald Place has sufficient bed capacity to meet the demand for GAU inpatient beds within Surrey.”

    Source location

    Response from Surrey and Borders Partnership NHS
    Page 1 · response
    Published 14 October 2024

    Open published response
  7. Surrey

    AI-generated summary

    Charne Nikita Petit · 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

    Charne Nikita Petit suffered psychotic delusions and, after a psychotic breakdown on 26 March 2023, was assessed as meeting the requirements for detention under section 2 of the Mental Health Act. No mental health hospital bed was available, and she was discharged on 31 March without assessment followed by medical treatment in a mental health hospital. She died by suicide on 12 May 2023; the narrative conclusion stated that the lack of a mental health hospital bed more than minimally contributed to her death. Concerns also included the effective detention of patients in general hospitals while awaiting mental health beds.

    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

    Detention of patients in general hospitals without a section while awaiting a mental health bed

    Wider context from the report

    “(2) The Court heard that owing to a shortage of mental health beds patients who have been assessed by 2 s12 consultant psychiatrists to require detention after a mental health act assessment are being effectively detained in general hospitals without a section, awaiting a bed, because they cannot be placed under section unless a mental health bed is available. ”

    Source location

    Charne Nikita Petit · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 mental health hospital beds for assessment, medical review and treatment

    Wider context from the report

    “(1) Evidence given by the court appointed expert consultant psychiatrist was that Ms Petit was not adequately medicalised and that she needed assessment and medical review with optimisation of treatment in a mental health hospital. Her response to treatment needed to be observed. This is what a s2 admission is designed to effect. The lack of a bed in a mental health hospital denied Ms Petit this opportunity for optimal treatment. ”

    Source location

    Charne Nikita Petit · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 in new mental health units and community, crisis, and acute services to improve access and reduce avoidable admissions.

    Verbatim wording from the response

    “In some local areas there is a need for more beds. This is being addressed in part through investment in new units and additionally as part of a whole system approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn 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. NHS England’s 2024/25 priorities and operational planning guidance continues 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 and in order to deliver more timely access to local beds.”

    Source location

    Response from NHSE
    Page 1 · response
    Published 26 September 2024

    Open published response

    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

    Direct systems to reduce average adult acute mental health ward stays and improve timely access to local beds.

    Verbatim wording from the response

    “In some local areas there is a need for more beds. This is being addressed in part through investment in new units and additionally as part of a whole system approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn 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. NHS England’s 2024/25 priorities and operational planning guidance continues 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 and in order to deliver more timely access to local beds.”

    Source location

    Response from NHSE
    Page 1 · response
    Published 26 September 2024

    Open published response

    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 recurrent funding to integrated care boards to recommission inpatient care in line with evidence-based therapeutic local models.

    Verbatim wording from the response

    “This is being supplemented by a further £42m recurrent investment from 2024/25 for all ICBs in the country to recommission inpatient care in line with local models that provide the best evidence of therapeutic support”

    Source location

    Response from NHSE
    Page 2 · response
    Published 26 September 2024

    Open published response

    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

    Embed Operational Pressures Escalation Level procedures, including daily bed-capacity meetings to manage demand and support people awaiting admission.

    Verbatim wording from the response

    “At a national level, this lack of bed availability is a matter for the Secretary of State for Health to address. Nonetheless, the Trust and our staff work to provide appropriate treatment in the context of the impact of bed shortages to those who require inpatient treatment. In response to the national shortage of mental health acute beds, the Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice. This is an NHS England framework which provides a consistent approach to managing demand across the health and social care system and a procedure for managing surges in demand for inpatient mental health beds. OPEL bed meetings are convened every morning by locality”

    Source location

    Response from Surrey and Borders Partnership
    Page 1 · response
    Published 26 September 2024

    Open published response

    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

    Undertake collaborative Mind and Body Transformation improvement work with acute-care partners to integrate physical and mental healthcare for people awaiting or receiving acute hospital care.

    Verbatim wording from the response

    “Since Charne’s sad death in May 2023, the Trust has embarked on collaborative improvement work with our acute care partners through the Mind and Body Transformation as part of the Trust Provider Collaborative (which consists of SaBP, Ashford and St Peter’s, Royal Surrey County Hospital and also includes East Surrey Hospital, Epsom General and Frimley Park Hospital). This work is in recognition of the challenges the system faces to support people safely whilst they may be awaiting a mental health bed or be in the acute hospital with both physical and mental health needs. The programme has been designed to better integrate physical and mental healthcare, and support for people attending acute hospitals with a combination of needs, by improving outcomes, flow and experience of those with mental health needs, their carers and families.”

    Source location

    Response from Surrey and Borders Partnership
    Page 2 · response
    Published 26 September 2024

    Open published response

    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

    Detention under the Mental Health Act in an acute hospital can occur only with the acute Trust’s agreement.

    Verbatim wording from the response

    “Therefore, where a person is admitted to the acute hospital and does not consent to remain there on a voluntary basis, steps are taken to detain the person under the Mental Health Act to a bed at the acute hospital wherever possible. This action can only be taken with the agreement of the acute Trust. The section under the Mental Health Act is commenced at the acute hospital and transfer to an inpatient mental health setting will take place as soon as a bed is available. Anyone detained under the Mental Health Act in an acute hospital would have a Responsible Clinician, who is a Consultant Psychiatrist. This ensures that medication can be introduced, where appropriate, and their response to treatment monitored. They also continue to benefit from the multi-disciplinary assessment and treatment of the Psychiatric Liaison Services while an inpatient mental health bed is awaited.”

    Source location

    Response from Surrey and Borders Partnership
    Page 2 · response
    Published 26 September 2024

    Open published response

    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 Trust is responsible for responding to concerns about medicalisation, observation, and inpatient mental health provision.

    Verbatim wording from the response

    “It is appropriate that Surrey and Borders Partnership Trust respond to your first concern regarding Charne not being properly medicalised or observed, as well as their inpatient mental health provision. I note that your Report was also addressed to the Trust and NHS England has asked to be sighted on their response to the Coroner. We have also engaged with Surrey Heartlands Integrated Care System, who we are aware are working with and monitoring improvements with the provider.”

    Source location

    Response from NHSE
    Page 2 · response
    Published 26 September 2024

    Open published response

    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

    Responsibility for addressing the national shortage of mental health inpatient beds rests with the Secretary of State for Health.

    Verbatim wording from the response

    “At a national level, this lack of bed availability is a matter for the Secretary of State for Health to address. Nonetheless, the Trust and our staff work to provide appropriate treatment in the context of the impact of bed shortages to those who require inpatient treatment. In response to the national shortage of mental health acute beds, the Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice. This is an NHS England framework which provides a consistent approach to managing demand across the health and social care system and a procedure for managing surges in demand for inpatient mental health beds. OPEL bed meetings are convened every morning by locality”

    Source location

    Response from Surrey and Borders Partnership
    Page 1 · response
    Published 26 September 2024

    Open published response

    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 considered the body most appropriately placed to address the national mental health inpatient bed shortage.

    Verbatim wording from the response

    “While working within a legal framework acknowledged by the Government to be in need of reform, we and our partners within the health and care system must also react to increasing numbers of people presenting in crisis. I remain committed to continually improving the way in which we provide mental health care to those served by the Trust despite the bed availability difficulties faced and would very much welcome the resolution of this issue at a national level. I note that the PFD report has also been sent to NHS England who are most appropriately placed to address this issue nationally.”

    Source location

    Response from Surrey and Borders Partnership
    Page 3 · response
    Published 26 September 2024

    Open published response
  8. Manchester South

    AI-generated summary

    Amina Ahmed Ismail · 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

    Amina Ahmed Ismail, aged 19, died on 15 September 2023 at Pankhurst Ward, Priory Hospital Cheadle, after self-ligaturing; the medical cause of death was ligature strangulation. The report describes her prolonged stay in a PICU, deterioration in her mental health, shortages of appropriate specialist care beds, and delays in arranging and funding a suitable placement as concerns contributing to the circumstances of her 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

    National scarcity of specialist personality-disorder rehabilitation beds

    Wider context from the report

    “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months. These cases illustrate, a) Underfunding for local mental health beds. It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home. Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found. b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units. c) A national scarcity of specialist PD rehabilitation units The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing, ‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’. ‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’ ‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’. ‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’. Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral. Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients. Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina. In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm. d) A funding process for rehabilitation units that is not fit for purpose. The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally. The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient. This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome. The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding. It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed. ”

    Source location

    Amina Ahmed Ismail · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Funding allocation failing to secure available specialist rehabilitation beds for identified patients

    Wider context from the report

    “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months. These cases illustrate, a) Underfunding for local mental health beds. It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home. Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found. b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units. c) A national scarcity of specialist PD rehabilitation units The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing, ‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’. ‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’ ‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’. ‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’. Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral. Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients. Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina. In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm. d) A funding process for rehabilitation units that is not fit for purpose. The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally. The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient. This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome. The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding. It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed. ”

    Source location

    Amina Ahmed Ismail · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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 working with the NHS to maximise mental health service capacity.

    Verbatim wording from the response

    “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the availability of specialist personality disorder rehabilitation units. I understand that mental health services have been under significant strain in recent years due to the rise in demand and the Department will continue to work with the NHS to maximise capacity.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 25 June 2024

    Open published response

    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 bed capacity, patient flow and specialist rehabilitation-unit availability.

    Verbatim wording from the response

    “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the availability of specialist personality disorder rehabilitation units. I understand that mental health services have been under significant strain in recent years due to the rise in demand and the Department will continue to work with the NHS to maximise capacity.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 25 June 2024

    Open published response
  9. Inner West London

    AI-generated summary

    Juan David Martin · 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

    Juan David Martin, who had been detained under the Mental Health Act and was awaiting an appropriate mental health bed, was evacuated from a hospital assessment suite during a fire alarm and ran away. He was later witnessed allowing himself to fall from height and was confirmed deceased on 13 April 2022. The principal concern was that inadequate mental health bed capacity in London created a genuine risk of future deaths.

    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

    Inadequate mental health bed capacity in London

    Wider context from the report

    “(1) Juan Martin was held informally on 7 April 2022 and following a mental health assessment on 11 April subsequently became liable for detention. He therefore spent 6 days in the Lotus Assessment Suite. Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022, which then became unavailable. (2) The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved. The Matron provided one recent example where a patient waited for 7 days in the Accident and Emergency Department for a mental health bed. (3) The Matron added there was an exceptional process which required a considered decision at a high level to make a bed available through identifying someone currently occupying a bed space to be discharged and that the ‘flow’ of patients being discharged or moving to another setting amplified the bed capacity issue. Based on the evidence heard, my principal concern is that bed capacity in London remains inadequate. Whilst some action may have been taken by the Trust to better triage the need for beds it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of mental health bed spaces in London unless further action is taken. ”

    Source location

    Juan David Martin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 discharge-planning best practices, including the 100-day challenge, high-impact interventions and ward workflow improvements.

    Verbatim wording from the response

    “As part of our integrated transformation programme, we have implemented a range of projects aimed to improve acute mental health patient flow and bed access, including:”

    Source location

    Response from SW London ICB
    Page 3 · response
    Published 14 June 2024

    Open published response

    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

    Conduct collaborative discharge and patient-flow work with local-authority partners through the Strategic Operational Interface Programme.

    Verbatim wording from the response

    “As part of our integrated transformation programme, we have implemented a range of projects aimed to improve acute mental health patient flow and bed access, including:”

    Source location

    Response from SW London ICB
    Page 3 · response
    Published 14 June 2024

    Open published response

    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

    Strengthen the Bed Management Policy and implement real-time electronic bed-status and waiting-list management.

    Verbatim wording from the response

    “- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management. - Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024. - Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow. - Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.”

    Source location

    Response from SW London ICB
    Page 4 · response
    Published 14 June 2024

    Open published response

    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

    Embed a clinical prioritisation tool in acute-flow management to prioritise patient safety when allocating limited beds.

    Verbatim wording from the response

    “- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management. - Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024. - Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow. - Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.”

    Source location

    Response from SW London ICB
    Page 4 · response
    Published 14 June 2024

    Open published response

    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 additional private-sector acute mental-health beds from a local provider.

    Verbatim wording from the response

    “- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management. - Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024. - Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow. - Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.”

    Source location

    Response from SW London ICB
    Page 4 · response
    Published 14 June 2024

    Open published response

    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 stepdown hostel beds to support patient flow.

    Verbatim wording from the response

    “- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management. - Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024. - Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow. - Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.”

    Source location

    Response from SW London ICB
    Page 4 · response
    Published 14 June 2024

    Open published response

    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 in community and crisis-prevention services to help patients remain well and avoid acute admission.

    Verbatim wording from the response

    “- Revised and strengthened our Bed Management Policy, including additional actions at higher levels of escalation, and moved to real-time electronic bed status and waiting list management. - Embedded a clinical prioritisation tool into our acute flow management process to ensure that patient safety and risk is foremost in allocating limited bed capacity. This tool has subsequently formed the basis of a London-wide prioritisation scoring tool commissioned by NHSE London and to be adopted by all mental health trusts in 2024. - Commissioned additional, unfunded private sector acute mental health beds from a local provider, and stepdown hostel beds to support flow. - Invested significantly into community and crisis prevention services to support patients to remain well in the community and avoid the need for an acute admission, thus helping to also provide more available beds.”

    Source location

    Response from SW London ICB
    Page 4 · response
    Published 14 June 2024

    Open published response

    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 intensive support to acute ward teams to identify flow barriers and improve safe, timely discharge practices.

    Verbatim wording from the response

    “Despite this, we appreciate there is still a risk around patients awaiting admission due to the lack of beds and we are undertaking further work in the following areas:”

    Source location

    Response from SW London ICB
    Page 4 · response
    Published 14 June 2024

    Open published response

    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

    Transform the mental-health crisis offer by developing triage and rapid-access services for local emergency departments.

    Verbatim wording from the response

    “Despite this, we appreciate there is still a risk around patients awaiting admission due to the lack of beds and we are undertaking further work in the following areas:”

    Source location

    Response from SW London ICB
    Page 4 · response
    Published 14 June 2024

    Open published response

    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 rehabilitation and supported-living settings with partners to improve access to onward care.

    Verbatim wording from the response

    “Despite this, we appreciate there is still a risk around patients awaiting admission due to the lack of beds and we are undertaking further work in the following areas:”

    Source location

    Response from SW London ICB
    Page 4 · response
    Published 14 June 2024

    Open published response

    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 healthcare providers to reduce care-pathway delays, shorten stays and minimise out-of-area placements.

    Verbatim wording from the response

    “The ICB is working with SWLSTG and other healthcare providers in South West London to address situations where patients experience delay in all parts of the care pathway. This includes work focused on reducing length of stay and minimising the use of out of area placements. As part of the 2024/25 planning process, ongoing investment was made into commissioning additional beds in the private sector to mitigate the current bed pressures while longer term work on improved patient flow continues.”

    Source location

    Response from SW London ICB
    Page 4 · response
    Published 14 June 2024

    Open published response

    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 in commissioning additional private-sector mental-health beds to mitigate current bed pressures while longer-term patient-flow work continues.

    Verbatim wording from the response

    “The ICB is working with SWLSTG and other healthcare providers in South West London to address situations where patients experience delay in all parts of the care pathway. This includes work focused on reducing length of stay and minimising the use of out of area placements. As part of the 2024/25 planning process, ongoing investment was made into commissioning additional beds in the private sector to mitigate the current bed pressures while longer term work on improved patient flow continues.”

    Source location

    Response from SW London ICB
    Page 4 · response
    Published 14 June 2024

    Open published response

    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

    Deliver mental health care in the community through new models of care and support wherever possible.

    Verbatim wording from the response

    “At national level, as part of our mission to build an NHS fit for the future, we will make sure mental health care is delivered in the community wherever possible - through new models of care and support available for those who are struggling - so that more people are prevented from needing to go into hospital.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 14 June 2024

    Open published response

    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

    Full resolution of London’s acute mental health bed shortage is constrained by rising demand and limitations in funding and resources.

    Verbatim wording from the response

    “SWLStG recognises this as a key risk to patient safety, which is fully captured and articulated within our Board Assurance Framework, and we are working to mitigate the risk as far as possible. We note, as has the Coroner, that this is not fully within our control due to the increasing complexity and level of demand for acute mental health services and the constraints on funding and resources to provide acute mental health beds. Where appropriate and available, we seek acute mental health beds in the private sector, but with a recognition that this is not always in the best interest of the patient as these admissions can be remote from a patient’s local support networks and disconnected from their broader NHS care.”

    Source location

    Response from SW London ICB
    Page 3 · response
    Published 14 June 2024

    Open published response

    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 mental health bed capacity and patient flow concerns are assigned to the relevant NHS Trust and Integrated Care Board.

    Verbatim wording from the response

    “I understand that South West London and St George’s Mental Health NHS Trust and NHS South West London Integrated Care Board will respond to your concerns about local mental health bed capacity directly, reflecting their responsibility to assess bed capacity and the ‘flow’ of patients being discharged or moving to another setting.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 14 June 2024

    Open published response
  10. Cheshire

    AI-generated summary

    Emma Louise MORRIS · 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

    Emma Louise Morris died after deliberately walking in front of a bus on 20 September 2023, following a deterioration in her mental health. A mental health practitioner had assessed that inpatient admission was clinically indicated because of an immediate risk to her safety, but no inpatient bed was available. The concern was that pressure on hospital trusts and the lack of available inpatient mental health beds could put future patients at risk of death when admission is clinically needed.

    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

    Failure to provide access to inpatient mental health beds at the time of clinical need

    Wider context from the report

    “During the course of the inquest, I heard that there is national pressure on hospital trusts as there is a national increase in people waiting for inpatient beds. I am therefore concerned that there is a risk of future deaths as it is not possible to access inpatient mental health beds at the time of clinical need. ”

    Source location

    Emma Louise MORRIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    “In some local areas there is a need for more beds. This is being addressed in part through investment in new units but should also be considered as part of a whole system transformation approach. This is supported by the NHS Long Term Plan (LTP), which is seeing an additional £2.3 billion funding being invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 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.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 31 May 2024

    Open published response

    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 £1.6 billion available through the Better Care Fund to support mental health inpatient services and wider system capacity.

    Verbatim wording from the response

    “To address the wider system issues that impact on health services, a further £1.6 billion has been made available via the Better Care Fund (‘BCF’) from 2023-25. This funding can be used to support both mental health inpatient services as well as the wider system, which should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 31 May 2024

    Open published response

    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

    “In some local areas there is a need for more beds. This is being addressed in part through investment in new units but should also be considered as part of a whole system transformation approach. This is supported by the NHS Long Term Plan (LTP), which is seeing an additional £2.3 billion funding being invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 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.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 31 May 2024

    Open published response
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Data last updated 7 September 2026