24 Aug 2017 Jonathan Anthony MEANEY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to provide timely and appropriately urgent access to a mental health bed View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jonathan Anthony MEANEY · 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
Jonathan Anthony Meaney took an overdose on 13 March 2017 and was assessed at hospital, where inpatient treatment was recommended but no bed was found. He was discharged on 15 March after expressing a wish to leave and took his own life the following day; his medical cause of death was morphine and alcohol toxicity. Concerns included the prolonged wait for a bed, aspects of the pre-discharge mental health assessment, lack of consultation with another team member, and uncertainty about whether a proposed GP referral was made.
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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 Failure to provide timely and appropriately urgent access to a mental health bed
Wider context from the report “1. Mr Meaney waited in the emergency unit for 40 hours and so it was unsurprising that he was then keen to go home.
A mental health nurse from the C&I psychiatry liaison team called the bed manager on the morning of Tuesday, 14 March, and then saw Mr Meaney briefly to explain that no bed was available . The same nurse called the bed manager again the following morning, Wednesday, 15 March, and then saw Mr Meaney once again with no news about admission. It was at that point that Mr Meaney expressed a wish to leave.
There seemed no urgency about the need for a bed for such a seriously ill man.
” Source location Jonathan Anthony MEANEY · 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 Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.
Verbatim wording from the response “It follows that the Matters of Concern will need to be addressed substantively by CANDI, which we note has received your Prevention of Future Deaths Report. We understand that CANDI are undertaking a Serious Incident investigation and we are committed to working closely with CANDI, as necessary, to assist them in completing this investigation, developing and implementing an action plan to prevent similar incidents in future and to otherwise assist them in preparing their response to your Prevention of Future Deaths Report. Additionally, we have asked to be provided with copies of CANDI’s final Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately.” Source location 2017-0244-Response
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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 Complete a serious incident review examining the sequence of events and contributory factors in the case.
Verbatim wording from the response “We are undertaking a serious incident review of this case. Part of its scope is to undertake an in-depth analysis to ascertain in further detail exactly what steps were taken as Trust to secure Mr Meaney a bed. We will forward you our serious incident review on its completion. We are aiming to complete our review in November.” Source location 2017-0244-Response2
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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 CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.
Verbatim wording from the response “We have carefully considered the Matters of Concern, all of which relate to care that was delivered by the Camden & Islington NHS Foundation Trust’s Mental Health Liaison service, based within the Royal Free Hospital Emergency Department. The staff working within the Mental Health Liaison service are employed by the Camden & Islington NHS Foundation Trust (“CANDI”), not this Trust (the Royal Free London NHS Foundation Trust), and CANDI manage the Mental Health Liaison service. If a patient attending the Trust’s Emergency Department is considered to have a mental health problem (pertinent to the attendance) or requires a mental health assessment, they are referred to the Mental Health Liaison service, which will then assess the patient and take responsibility for referring onwards to either CANDI’s inpatient facilities or another mental health trust, as appropriate.” Source location 2017-0244-Response
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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 Bed allocation urgency was assessed against clinical risk and safety, with priority given to patients not in places of safety.
Verbatim wording from the response “The allocation of a bed is a centralised task, undertaken by the bed management team, managed by Camden and Islington NHS Foundation Trust. The bed management team received the referral from psychiatric liaison psychiatry, requesting a psychiatric bed for Mr Meaney at 04.46am on 14 March. Patients are prioritised according to both their clinical need, and the assessment of risk, for example, whether the patient is in a safe place. Patients who are not in places of safety i.e. at home or in police custody would take priority for acute beds. The referrals list is something that can change rapidly depending on the priority of the new referrals and whether the risk of an existing referral has changed. Senior staff meet daily to review all pending referrals and to estimate when a bed will become available.” Source location 2017-0244-Response2
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14 Feb 2017 Wendy Louise Telfer · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1
Lack of available psychiatric inpatient beds View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Devon Partnership NHS Trust NHS Devon 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. 7
Devon Partnership NHS Trust
Raise inpatient bed-capacity and patient-safety risks with commissioners through contract monitoring and formal Board-level correspondence.
View source
Devon Partnership NHS Trust
Extend Crisis Resolution and Home Treatment team operating hours to midnight, seven days a week.
View source
Devon Partnership NHS Trust
Provide temporary step-down care using spare recovery and rehabilitation ward capacity.
View source
Devon Partnership NHS Trust
Develop further alternatives to acute admission, including improved community support and additional step-down provision.
View source
Devon Partnership NHS Trust
Establish a central Trust-wide bed-management team to proactively manage and secure beds.
View source
Devon Partnership NHS Trust
Secure temporary additional contracted out-of-area bed capacity.
View source
NHS Devon Integrated Care Board
Work with DPT to identify solutions for additional step-down bed capacity in Exeter.
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Wendy Louise Telfer · 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
Wendy Louise Telfer died on 20 March 2016 in hospital from an overdose of purchased non-prescribed medication taken five days earlier; the medical cause of death was recorded as liver failure due to paracetamol overdose, with asthma also recorded. The report identified concerns about missed opportunities to keep Wendy safe, confusion about applying the Mental Health Act in a physical care setting, and the lack of an available psychiatric inpatient bed.
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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 psychiatric inpatient beds
Wider context from the report “(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds . The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one , but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients, and it is acknowledged that this is a wider issue of social and community care and resources. This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
” Source location Wendy Louise Telfer · 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 Raise inpatient bed-capacity and patient-safety risks with commissioners through contract monitoring and formal Board-level correspondence.
Verbatim wording from the response “The Trust is acutely aware of the pressure upon our available bed stock and has raised the issue with our commissioners through both our contract monitoring meetings and via a formal letter from our Board level clinicians highlighting the very real risk to patient safety.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Extend Crisis Resolution and Home Treatment team operating hours to midnight, seven days a week.
Verbatim wording from the response “We have agreed a plan of work internally to improve the capacity of our Crisis Resolution and Home Treatment teams and they have now extended their operational times to midnight 7 days per week with a view to supporting more people at home and facilitating early discharge from our inpatient wards. We have also agreed with both Devon County Council and both of our CCGs to take responsibility for and to streamline the current application and review process for both social and continuing health care funding which significantly adds to the length of time a person stays in hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 temporary step-down care using spare recovery and rehabilitation ward capacity.
Verbatim wording from the response “We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Develop further alternatives to acute admission, including improved community support and additional step-down provision.
Verbatim wording from the response “We have also used spare capacity in one of our recovery/rehabilitation wards to provide step down care for those people no longer requiring acute inpatient care on a temporary basis while we work on providing further alternatives to admission including possible crisis houses, a purpose commissioned step down facility and looking at how we may better support people with certain conditions in the community rather than admitting to hospital.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-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 Establish a central Trust-wide bed-management team to proactively manage and secure beds.
Verbatim wording from the response “We now have in place a central trust wide bed management team to proactively manage and secure beds for those in need as quickly as we possibly can. We have temporarily secured additional contracted bed capacity out of area to help meet demand as of Monday 20 March 2017 rather than rely on ad hoc arrangements as we are in competition with other NHS providers for private beds.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-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 Secure temporary additional contracted out-of-area bed capacity.
Verbatim wording from the response “We now have in place a central trust wide bed management team to proactively manage and secure beds for those in need as quickly as we possibly can. We have temporarily secured additional contracted bed capacity out of area to help meet demand as of Monday 20 March 2017 rather than rely on ad hoc arrangements as we are in competition with other NHS providers for private beds.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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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 Work with DPT to identify solutions for additional step-down bed capacity in Exeter.
Verbatim wording from the response “7. DPT have indicated a need for additional step down beds to be made available in the Exeter area and NEW Devon CCG is working with DPT to identify solutions for this need;” Source location 2017-0046-Response-by-Northern-Eastern-and-Western-Devon-NHS-Trust
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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 Financial pressures and reduced staff availability constrain the Trust's ability to secure additional inpatient capacity.
Verbatim wording from the response “I think it is important to note that securing additional capacity is compounded by both the ever tightening financial position of our commissioners, ourselves and the reducing availability of staff across the country. I would very much like to assure you that we as a Trust are doing everything we can to use our available resources in the most efficient way we can to meet the increasing demand we are facing. I would also like to assure you that we will always put the safety of our patients first and will continue to do our level best to ensure someone needing a bed is provided with one as soon as we are able to source either internally or externally via the private sector.” Source location 2017-0046-Response-by-Devon-Partnership-NHS-Trust
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7 Dec 2016 Dominic Adam Travis · Prevention of Future Deaths report Manchester (North)
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Concerns raised 1
Lack of specialist inpatient provision for young adults with mental health problems View source
This report raised 3 other concerns. 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
Dominic Adam Travis · 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
Dominic Adam Travis, an 18-year-old man with mental health problems and regular use of cannabis and other substances, died in hospital on 18 May 2015 after suffering catastrophic injuries when he fell or jumped from a derelict mill following an acute psychotic deterioration and absconding from supported accommodation. The concerns raised included whether specialist inpatient provision adequately met the needs of young adults with mental health problems and whether the NHS Trust’s investigation into his care was sufficiently independent, transparent and timely.
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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 specialist inpatient provision for young adults with mental health problems
Wider context from the report “1. Department of Health:
Dominic was aged just 18 when admitted to an acute psychiatric ward that cared for adults aged 18-65.
Given:
i) the very stark differences between the mental health needs of younger adults and older adults,
ii) an overall increase in the levels of vulnerability in such young people (by virtue of their age, condition, varying levels of maturity etc.),
iii) that acute psychiatric ward environments often care for older adult patients with profound and enduring mental health problems (that are extremely frightening to the younger adult inpatient)
&
iv) the very different mental health requirements of young people,
I am concerned that the needs of the latter are not being appropriately or adequately met, in the absence of specialist/specialist inpatient provision.
The vulnerability of young adults is clearly recognised and acknowledged in other areas such as young offenders under the age of 21 who are sentenced to YOI establishments rather than being sent to an adult prison, however no such recognition appears to exist in relation to young adults with mental health problems.
” Source location Dominic Adam Travis · Prevention of Future Deaths report
Open source report
Concerns raised 1
Shortage of acute mental health beds requiring out-of-county placements View source
This report raised 5 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 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. 5
Department of Health and Social Care
Eliminate clinically unnecessary out-of-area placements for adult acute mental health care by 2020/21.
View source
Department of Health and Social Care
Implement comprehensive community-based mental health pathways so people receive care at the right time and place.
View source
NHS England
Develop an evidence-based adult acute mental health treatment pathway and accompanying commissioning support tools with the NCCMH and stakeholder group.
View source
NHS England
Ensure all areas have high-quality, 24/7 Crisis Resolution Home Treatment Teams by 2020/21, supported by national investment.
View source
NHS England
Monitor progress toward eliminating inappropriate non-specialist adult acute out-of-area placements and provide targeted support to local areas.
View source See 2 more actions
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David Knight · 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
David Knight, who was detained under the Mental Health Act for chronic mental health issues, died on 23 May 2015 after walking onto a railway track in front of an oncoming train while on Section 17 leave. Concerns included a limited risk assessment before leave, no notification to local community and home treatment teams, and the difficulties associated with his out-of-county placement, including reduced family involvement and communication challenges.
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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 Shortage of acute mental health beds requiring out-of-county placements
Wider context from the report “At the inquest, evidence was given by the Cornwall Partnership Trust and Kernow Clinical Commissioning Group and the expert Psychiatrist that there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment . In Cornwall in 2015, the average out of placement was 6/7 patients per day but on occasions up to 20 patients . In the summer of 2015, there were between 30-40 patients per day placed out of County (due in part to renovation works on a local mental health hospital).
” Source location David Knight · 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 Eliminate clinically unnecessary out-of-area placements for adult acute mental health care by 2020/21.
Verbatim wording from the response “We will eliminate clinically unnecessary out of area placements for adult acute mental health care by 2020/21 and will reduce significantly delayed transfers of care.” Source location 2016-0414-Response-by-Department-of-Health
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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 Implement comprehensive community-based mental health pathways so people receive care at the right time and place.
Verbatim wording from the response “This will help people move easily between hospital and care in the community, ensuring that beds are available for those most in need. I appreciate that this will not happen overnight but we are committed to delivering change. Through the Five Year Forward View we will implement a comprehensive set of community-based mental health pathways of care so that people have access to care at the right time in the right place.” Source location 2016-0414-Response-by-Department-of-Health
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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 Develop an evidence-based adult acute mental health treatment pathway and accompanying commissioning support tools with the NCCMH and stakeholder group.
Verbatim wording from the response “To deliver on these commitments, NHS England is working with the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists (RCPsych) to develop an evidence-based treatment pathway and accompanying commissioning support tools for adult acute mental health care from referral through to discharge. This work is led by a multi-stakeholder Expert Reference Group (ERG) convened by the NCCMH involving patient experts, carers, and professionals from different NHS services, social care, public health, policing and the voluntary sector.” Source location 2016-0414-Response-by-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 Ensure all areas have high-quality, 24/7 Crisis Resolution Home Treatment Teams by 2020/21, supported by national investment.
Verbatim wording from the response “We aim to publish the acute evidence-based treatment pathway and accompanying commissioning support tools by April 2017. To support the implementation of the pathway locally, NHS England is committed to ensuring that all areas have Crisis Resolution Home Treatment Teams (CRHTTs) providing a high-quality, 24/7, community-based crisis response and intensive” Source location 2016-0414-Response-by-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 Monitor progress toward eliminating inappropriate non-specialist adult acute out-of-area placements and provide targeted support to local areas.
Verbatim wording from the response “The first report was published in December 2016, but we expect to have a reliable national baseline position for OAPs by the end of Q4 16/17, when data quality has improved after the adjustment period following the introduction of the new collection is over. Going forwards, this will allow us to monitor progress against the national ambition to eliminate inappropriate OAPs for non-specialist adult acute mental health care by 2020/21, enabling targeted support to be provided to local areas as required.” Source location 2016-0414-Response-by-NHS-England
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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 clinical commissioning groups are responsible for commissioning acute mental health beds because they assess and meet local community needs.
Verbatim wording from the response “You have raised concerns about the availability of acute mental health beds nationally. As you will know, acute mental health beds are commissioned locally by clinical commissioning groups (CCGs) as they are best placed to assess and meet the needs of their local communities. You may be aware that the Commission to review the provision of acute inpatient psychiatric care for adults, led by Lord Crisp, published its review in 2015. The review found that access to acute mental health beds was not so much an issue of bed capacity but rather a problem of discharge policies and providing alternatives to hospital admission in the community. We are committed to providing a full response to the review by the end of 2016/17.” Source location 2016-0414-Response-by-Department-of-Health
Open published response
Concerns raised 1
Lack of local psychiatric intensive care unit beds for female patients 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
Victoria Georgia Halliday · 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
Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality disorder.
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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 local psychiatric intensive care unit beds for female patients
Wider context from the report “1) There are currently no local psychiatric intensive care unit beds for female patients and this means all female patients can only be placed out of area, potentially many miles away from home and local support.
” Source location Victoria Georgia Halliday · 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 Engage potential provider organisations to resolve local female PICU capacity and placement options.
Verbatim wording from the response “East Leicestershire and Rutland CCG, as the lead commissioners for mental health in LLR would prefer, if possible, for this service to be provided within the LLR border. However, we need to take account of demand, patient quality, cost and provider availability. With this in mind, we are unable, at present, to commission a local service that meets all of these requirements.” Source location Response from East Leicestershire and Rutland Clinical Commissioning Group
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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 Work with regional commissioning colleagues to provide a wider range of female PICU placement options.
Verbatim wording from the response “In line with the national picture, there is recognition that the availability of general acute mental health and PICU beds is under pressure. This continues to be the case despite extensive efforts to minimise out of area placements. Since April 2016, there have been 10 female out of area placements made with an average length of stay of 45 days.” Source location Response from East Leicestershire and Rutland Clinical Commissioning Group
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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 A local PICU service cannot currently be commissioned because demand, quality, cost and provider availability cannot all be met.
Verbatim wording from the response “East Leicestershire and Rutland CCG, as the lead commissioners for mental health in LLR would prefer, if possible, for this service to be provided within the LLR border. However, we need to take account of demand, patient quality, cost and provider availability. With this in mind, we are unable, at present, to commission a local service that meets all of these requirements.” Source location Response from East Leicestershire and Rutland Clinical Commissioning Group
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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 Direct provision of local female psychiatric intensive care beds is outside the Trust’s commissioning remit.
Verbatim wording from the response “Service Response
LPT is not currently commissioned to directly provide Female Psychiatric Intensive care beds (PICU). Our commissioners are in the process of procuring a local, medium to long term solution, for female Psychiatric Intensive Care Unit (PICU) placements in Leicester, Leicestershire and Rutland. The procurement process is unlikely to be resolved until 2017/18. For patients who are placed out of area, through our Adult Mental Health (AMH) Bed Management Team, we keep in touch on a weekly basis with the placement providers to ensure that length of stay out of area is for an agreed period of time, and that repatriation back to local services is facilitated at the earliest opportunity. In Victoria’s case, referrals to PICU were made from the Bradgate inpatient area due to her challenging presentation and its impact on staff.” Source location Response from Leicestershire Partnership NHS Trust
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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 Commissioners are responsible for procuring a local medium- to long-term solution for female psychiatric intensive care placements.
Verbatim wording from the response “Service Response
LPT is not currently commissioned to directly provide Female Psychiatric Intensive care beds (PICU). Our commissioners are in the process of procuring a local, medium to long term solution, for female Psychiatric Intensive Care Unit (PICU) placements in Leicester, Leicestershire and Rutland. The procurement process is unlikely to be resolved until 2017/18. For patients who are placed out of area, through our Adult Mental Health (AMH) Bed Management Team, we keep in touch on a weekly basis with the placement providers to ensure that length of stay out of area is for an agreed period of time, and that repatriation back to local services is facilitated at the earliest opportunity. In Victoria’s case, referrals to PICU were made from the Bradgate inpatient area due to her challenging presentation and its impact on staff.” Source location Response from Leicestershire Partnership NHS 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 Local clinical commissioning groups are responsible for commissioning psychiatric intensive care beds because they assess and meet local community needs.
Verbatim wording from the response “You have raised concerns about the availability of psychiatric intensive care beds locally for women. Psychiatric intensive care beds are commissioned locally by clinical commissioning groups (CCGs) as they are best placed to assess and meet the needs of their local communities.” Source location 2016-0370-Response-by-Department-of-Health
Open published response
3 Oct 2016 Amy El-Keria · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Shortage of acute mental health beds near young people's homes View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Amy El-Keria · 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
Amy El-Keria, aged 14, died on 13 November 2012 after tying a ligature around her neck and suspending herself from a radiator while receiving inpatient mental health care. The inquest identified concerns about staffing levels being insufficient to provide the one-to-one support in her care plan and the shortage of acute mental health beds for young people close to home, limiting family support.
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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 Shortage of acute mental health beds near young people's homes
Wider context from the report “(2) There continues to be a shortage of acute mental health beds for young people close to where they live . This means that families have to travel long distances to visit their child and they are unable to provide the necessary day to day support to their child. Family support can play a very significant role in managing risk of suicide by avoiding and mitigating distress.
” Source location Amy El-Keria · 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 Develop comprehensive community-based mental health service pathways and standards to support treatment closer to home.
Verbatim wording from the response “However, we should also be seeking to avoid unnecessary admissions to hospital wherever possible. That is why the Government is developing a comprehensive set of community-based mental health service pathways and standards so that more people can be treated in the community closer to home. We have also invested £400 million to improve crisis care services in the community so that people receive the right care” Source location 2016-0347-Response-by-Department-of-Health
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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 £400 million to improve community crisis-care services.
Verbatim wording from the response “However, we should also be seeking to avoid unnecessary admissions to hospital wherever possible. That is why the Government is developing a comprehensive set of community-based mental health service pathways and standards so that more people can be treated in the community closer to home. We have also invested £400 million to improve crisis care services in the community so that people receive the right care” Source location 2016-0347-Response-by-Department-of-Health
Open published response
7 Sep 2016 Louise Turner · Prevention of Future Deaths report Exeter and Greater Devon
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Concerns raised 1
Unavailability of female psychiatric intensive care beds in Devon View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Louise Turner · 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
Louise Turner died on 27 June 2014 from inhalation of helium after recently being discharged from a lengthy inpatient stay while receiving treatment for a serious mental health illness. The report raised concerns about inadequate post-discharge care and contact, ineffective duty and buddying arrangements, expectations that patients initiate contact, and the absence of female intensive psychiatric care beds in Devon.
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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 female psychiatric intensive care beds in Devon
Wider context from the report “(4) There are no female intensive care beds for psychiatric patients in Devon . This does not match the desired parity of mental health care with physical health care. Devon Partnership Trust needs to consider future planning and provision to ensure the needs of patients can be met.
” Source location Louise Turner · 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 Lead an option appraisal with Peninsula commissioners and providers to identify the need for a Devon psychiatric intensive care unit.
Verbatim wording from the response “Following the publication of the Mental Health Crisis Care Concordat and the Care Quality Commission (CQC) inspection report into Devon Partnership NHS Trust in February 2014, it was identified that the lack of a Psychiatric Intensive Care Unit (PICU) in Devon was a significant deficit to the mental health acute care system. This was further magnified by the publication of the Crisp Report (Crisp, N., Smith, G. and Nicholson, K. (Eds.) Old Problems, New Solutions – Improving Acute Psychiatric Care) which identified serious issues with the use of out of area placements for people experiencing acute mental ill health.” Source location 2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
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 Review and agree a proposal for a 10-bed psychiatric intensive care unit on the Wonford Hospital site.
Verbatim wording from the response “The CCG led an option appraisal including all the Peninsula commissioners and providers, where it was identified that a PICU was required in Devon. This proposal was considered by the CCG and it was concluded that the revenue funding to support the operation of a PICU was available within the Devon Partnership NHS Trust contract and that they should develop a plan for the design, construction and operation of a PICU within Devon to ensure provision across Devon, Plymouth and Torbay. A proposal to build a local PICU facility was reviewed and agreed by the CCG Executive Committee on 20 July 2016 with the Governing Body confirming their support for implementation for a local, 10 bedded PICU on the Wonford Hospital site, adjacent to the Cedars Mental Health Acute Unit by April 2018.” Source location 2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
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 Devon Partnership NHS Trust should develop the plan for designing, constructing and operating the local psychiatric intensive care unit.
Verbatim wording from the response “The CCG led an option appraisal including all the Peninsula commissioners and providers, where it was identified that a PICU was required in Devon. This proposal was considered by the CCG and it was concluded that the revenue funding to support the operation of a PICU was available within the Devon Partnership NHS Trust contract and that they should develop a plan for the design, construction and operation of a PICU within Devon to ensure provision across Devon, Plymouth and Torbay. A proposal to build a local PICU facility was reviewed and agreed by the CCG Executive Committee on 20 July 2016 with the Governing Body confirming their support for implementation for a local, 10 bedded PICU on the Wonford Hospital site, adjacent to the Cedars Mental Health Acute Unit by April 2018.” Source location 2016-0322-Response-by-Northern-Eastern-and-Western-Devon-Clinical-Commissioning-Group
Open published response
7 Aug 2016 Mr. Rohan Fitzsimons · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1
Insufficient availability of in-patient mental health beds when detention is required following a Mental Health Act Assessment 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
Mr. Rohan Fitzsimons · 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. Rohan Fitzsimons, who had been detained under the Mental Health Act and was receiving inpatient psychiatric care, died after jumping from Clifton Suspension Bridge while on unescorted leave on 25 November 2015. The principal concern was that a necessary Mental Health Act Assessment was delayed for four days because no inpatient bed was available, with evidence that this commonly occurred and that assessments were not carried out until a bed became available.
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 availability of in-patient mental health beds when detention is required following a Mental Health Act Assessment
Wider context from the report “(1) The Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) told the Inquest that the provision of in-patient beds is subject to the funding provided by the Bristol Clinical Commissioning Group (CCG) .
(2) The Inquest heard evidence that no Mental Health Act Assessment was carried out on the Deceased when it was determined to be necessary because no bed was available and that this was a situation which commonly occurred .
(3) In the case of the Deceased the assessment was not performed until four days after it was deemed necessary and was only carried out once a bed was available. Whilst the Inquest did not hear evidence to indicate that the delay in carrying out the Mental Health Act Assessment contributed to the Deceased taking his own life it must follow that in some circumstances such a delay could lead to an individual taking their own life before the assessment was performed and a bed was made available.
(4) The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment .
The CCG should work with AWP in carrying out this review and determine what action can and should be taken when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment but no bed is available. If a person meets the criteria for a Mental Health Act Assessment such an assessment should be carried out promptly and not be delayed for an indeterminate period owing to a lack of beds.
” Source location Mr. Rohan Fitzsimons · Prevention of Future Deaths report
Open source report
25 Jul 2016 Patricia Ann Cleghorn · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Unavailability of acute mental health inpatient beds View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham and Solihull Mental Health NHS Foundation Trust Care Quality Commission Department of Health and Social Care 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. 5
Department of Health and Social Care
Set the expectation that beds must always be available for people who need them.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Review bed-management and community processes to enhance care for patients awaiting inpatient admission.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Implement a standard enhanced-care pathway for patients awaiting beds, including updated assessments, care plans, daily reviews and crisis plans.
View source
NHS England
Ensure all areas have evidence-based, high-quality 24/7 Crisis Resolution Home Treatment Teams providing intensive home treatment and acute-bed gatekeeping by 2020/21.
View source
NHS England
Develop evidence-based mental health treatment pathways and commissioning tools, including acute-care quality standards for inpatient and community services.
View source See 2 more actions
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AI-generated summary
Patricia Ann Cleghorn · 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 Ann Cleghorn, who had suicidal ideation and was awaiting an inpatient mental health bed, was found collapsed at home after receiving diazepam and was declared dead by paramedics on 14 December 2015. The concerns were the lack of an available inpatient bed, allowing her to self-medicate with potentially dangerous drugs despite repeated statements that she intended to overdose, and the absence of a formal risk assessment.
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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 acute mental health inpatient beds
Wider context from the report “(1) The deceased could not be admitted to hospital as there were no inpatient beds available . I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care.
” Source location Patricia Ann Cleghorn · 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 Set the expectation that beds must always be available for people who need them.
Verbatim wording from the response “The Government has made it clear that beds must always be available for those who need them.” Source location 2016-0270-Response-by-Department-of-Health
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 Review bed-management and community processes to enhance care for patients awaiting inpatient admission.
Verbatim wording from the response “As a result of the unfortunate death of Mrs Cleghorn we have taken immediate action to review our bed management processes and community processes, so that we can ensure that any patient awaiting access to an inpatient bed receives enhanced care from our community staff.” Source location 2016-0270-Response-by-Birmingham-and-Solihull-NHS-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 Implement a standard enhanced-care pathway for patients awaiting beds, including updated assessments, care plans, daily reviews and crisis plans.
Verbatim wording from the response “All of these patients have received:” Source location 2016-0270-Response-by-Birmingham-and-Solihull-NHS-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 Ensure all areas have evidence-based, high-quality 24/7 Crisis Resolution Home Treatment Teams providing intensive home treatment and acute-bed gatekeeping by 2020/21.
Verbatim wording from the response “As noted in ████████ recent letter, we are aware that Crisis Resolution Home Treatment Teams are not always resourced to fully meet their core functions in” Source location 2016-0270-Response-by-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 evidence-based mental health treatment pathways and commissioning tools, including acute-care quality standards for inpatient and community services.
Verbatim wording from the response “Further, we are working with the National Collaborating Centre for Mental Health at the Royal College of Psychiatrists to develop a series of evidence-based treatment pathways for mental health care with accompanying commissioning support tools. This includes the development of an acute care pathway comprising a comprehensive set of quality standards, which is planned for completion within 2016/17. The work involves a range of multi-agency experts, including clinicians, social workers, service managers, service users and carers, and will focus on access to care, patient safety, patient experience and clinical outcomes. The scope of the pathway comprises both inpatient and community settings, reflecting the need to ensure services are commissioned and delivered in the context of a whole system approach based on clinical need and the safe management of patients.” Source location 2016-0270-Response-by-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 Provision of acute mental health beds rests with the Trust and clinical commissioning groups.
Verbatim wording from the response “There remains a shortage of acute beds in this Trust and in other Mental Health Trusts in the region. This shortage will continue to impact on vulnerable people in the community. The provision of acute mental health beds rests with the Trust and with the clinical commissioning groups (CCGs). The role of the CCGs is to get the best possible health outcomes for the local population, by assessing local needs, deciding priorities and strategies, and then buying services (including mental health services) on behalf of the population from providers such as this Trust. The CCGs also check on the quality and safety of such services.” Source location 2016-0270-Response-by-Care-Quality-Commission
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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 Availability of acute mental health beds is a matter for local commissioners.
Verbatim wording from the response “The Crisis Care Concordat makes it clear that local commissioners should commission a range of mental health services that allow beds to be available for a person in urgent need. Each local area in England has produced its own ‘Mental Health Crisis Declaration’.” Source location 2016-0270-Response-by-Department-of-Health
Open published response
Concerns raised 1
Failure to ensure availability of psychiatric beds in Cornwall View source
This report raised 4 other concerns. 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
Simon Jonathon Klemberg · 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
Simon Jonathon Klemberg died in the early hours of 7 June 2015 following a reckless and impulsive overdose of prescription medication taken to address acute head pain, possibly related to his psychological condition. He had serious mental health problems, and individual psychological therapy recommended in February 2015 was delayed and never commenced. The report raised concerns about psychiatric bed availability, resources and thresholds for the home treatment team, and the prioritisation of high-risk patients awaiting psychological therapy.
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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 Failure to ensure availability of psychiatric beds in Cornwall
Wider context from the report “(1) To review the availability of beds for psychiatric patients in Cornwall . Kernow Clinical Commissioning group (KCCG) to respond
” Source location Simon Jonathon Klemberg · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.