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. Birmingham and Solihull

    AI-generated summary

    Leroy Patrick HAMILTON · 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

    Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.

    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. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU. Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments. ”

    Source location

    Leroy Patrick HAMILTON · Prevention of Future Deaths report
    Page 3 · 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

    Support faster hospital discharge to reduce bed occupancy and A&E waiting times.

    Verbatim wording from the response

    “Regarding the lack of inpatient mental health beds and psychiatric decisions unit (PDU) spaces and the availability of ‘safe space’, we are supporting the NHS to take action to reduce waiting times in A&E, including through adding 5,000 more permanent general and acute beds, speeding up hospital discharge and increasing transparency and the available information on waiting times and the NHS’s progress in reducing them.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 16 January 2023

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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 funding to support adult social care and NHS discharges, including from mental health inpatient settings.

    Verbatim wording from the response

    “To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, with the aim of reducing bed occupancy.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 16 January 2023

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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 and publish statutory guidance for discharge from mental health inpatient settings.

    Verbatim wording from the response

    “The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 16 January 2023

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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

    Expand adult community mental health services to support patients in the community and reduce reliance on inpatient treatment.

    Verbatim wording from the response

    “More widely, through the NHS Long Term Plan, we have invested almost £1 billion extra in community mental health care for adults by March 2024, expanding community mental health services, so that patients are supported to stay well in their communities. This major expansion in funding for community mental health services commenced in all areas in 2021/22 and one of its aims is to reduce reliance on inpatient treatment.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 16 January 2023

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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

    Commission additional mental health beds to improve flow through bedded capacity and support step-down and return from out-of-area placements.

    Verbatim wording from the response

    “Over this winter period the ICB have commissioned additional beds to aid flow through bedded capacity to enable step down ahead of discharge and to facilitate return into the system from out of area placement. There is also a considerable focus on flow through all MH bedded capacity, with a focus on overcoming delays in discharge of stable patients to maximise productivity of available capacity.”

    Source location

    Response from Birmingham and Solihull Integrated Care
    Page 2 · response
    Published 16 January 2023

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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

    Commissioning and operating psychiatric decisions units falls outside the police force’s functions and authority.

    Verbatim wording from the response

    “Whereas the third, fourth and fifth of the Coroner’s concerns are pertinent to West Midlands Police (WMP), the first and second concerns relating to the Psychiatric Decisions Unit (PDU) are, in my view, pertinent to other addressees of the report, namely: (i) the Birmingham and Solihull Mental health NHS Foundation Trust; (ii) the Birmingham and Solihull Integrated Care Board; (iii) University Hospital Birmingham NHS Foundation Trust; and (iv) the Secretary of State for Health. WMP has no involvement in the commissioning and operation of the PDU. For these reasons, this response focuses on the third, fourth and fifth concerns identified by the Coroner.”

    Source location

    Response from West Midlands Police
    Page 2 · response
    Published 16 January 2023

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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

    Responsibility for psychiatric decisions unit beds and spaces rests with the named health bodies and Secretary of State for Health.

    Verbatim wording from the response

    “Whereas the third, fourth and fifth of the Coroner’s concerns are pertinent to West Midlands Police (WMP), the first and second concerns relating to the Psychiatric Decisions Unit (PDU) are, in my view, pertinent to other addressees of the report, namely: (i) the Birmingham and Solihull Mental health NHS Foundation Trust; (ii) the Birmingham and Solihull Integrated Care Board; (iii) University Hospital Birmingham NHS Foundation Trust; and (iv) the Secretary of State for Health. WMP has no involvement in the commissioning and operation of the PDU. For these reasons, this response focuses on the third, fourth and fifth concerns identified by the Coroner.”

    Source location

    Response from West Midlands Police
    Page 2 · response
    Published 16 January 2023

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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

    The Mental Health Provider Collaborative is responsible for designing and delivering services and leading strategic cases for additional mental health bed capacity.

    Verbatim wording from the response

    “A Mental Health Provider Collaborative was formed April 2023 within Birmingham and Solihull ICS with responsibility for designing and delivering appropriate mental health services across the ICS. This collaborative is leading on the strategic cases to establish further bedded capacity, but we recognise that this will take time. The developing health infrastructure strategy for the local NHS will highlight additional inpatient mental health facilities as a priority for any bids for national capital.”

    Source location

    Response from Birmingham and Solihull Integrated Care
    Page 2 · response
    Published 16 January 2023

    Open published response
  2. Manchester North

    AI-generated summary

    James Alan Tice · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    James Alan Tice, who had recurrent depressive disorder with anxiety features, took his own life at home on 28 April 2022 while awaiting an informal admission to an older adult mental health ward. The report identifies concerns about the availability of beds for such admissions and psychotherapy services for older adults whose needs exceed community provision.

    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 beds for informal admissions to older adults mental health wards

    Wider context from the report

    “(1) Availability of beds for patients requiring an informal admission to an older adults mental health ward in the area covered by Pennine Care NHS Foundation Trust ”

    Source location

    James Alan Tice · 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

    Share the Regulation 28 report and response with Greater Manchester mental health commissioners.

    Verbatim wording from the response

    “3. Regulation 28 Report and response to be shared with mental health commissioners in Greater Manchester to ensure that a review of older adult inpatient provision is undertaken.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 4 October 2022

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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

    Undertake a review of older adult inpatient provision.

    Verbatim wording from the response

    “3. Regulation 28 Report and response to be shared with mental health commissioners in Greater Manchester to ensure that a review of older adult inpatient provision is undertaken.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 4 October 2022

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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

    Mental health commissioners are assigned responsibility for reviewing older adult inpatient provision.

    Verbatim wording from the response

    “3. Regulation 28 Report and response to be shared with mental health commissioners in Greater Manchester to ensure that a review of older adult inpatient provision is undertaken.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 4 October 2022

    Open published response
  3. Manchester South

    AI-generated summary

    Laura Jane Medcalf · 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

    Laura Jane Medcalf died on 17 February 2021 after being found unresponsive in her mental health ward bed, following a period of repeated self-harm incidents and signs of deteriorating mental health. The investigation concluded that her death was suicide, contributed to by failures to recognise her deteriorating mental health and increased risk, and to take effective steps to reduce that risk. Concerns also included shortages of mental health beds and staffing challenges affecting services.

    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 inpatient bed capacity causing delays in access to mental health beds

    Wider context from the report

    “1. The inquest heard that Laura Medcalf was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental health beds. The inquest heard that there is a national shortage of inpatient beds and that this delay is not unusual. ”

    Source location

    Laura Jane Medcalf · Prevention of Future Deaths report
    Page 3 · 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

    Invest in mental-health estate improvements, including non-medical admission alternatives, step-down beds and supported living services.

    Verbatim wording from the response

    “You may also wish to note that the Department is investing £150 million for significant improvements in the mental health estate over the course of the Spending Review (2021). This will be used to support our NHS Long Term Plan ambitions regarding system capacity and pressure reduction. It will cover a range of schemes, including non-medical alternatives to admission, step-down community beds and supported living services.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 29 April 2022

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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

    Replace mental-health dormitory beds with single, en-suite rooms across more than 50 sites by 2024/25.

    Verbatim wording from the response

    “We are also investing £300 million over this Spending Review to eradicate mental health dormitories by 2024/25. By 2024/25, over 1200 beds in mental health dormitories across more than 50 sites will be replaced with single, en suite rooms. Although this may impact bed availability temporarily, it will support patients by improving their care, safety and sense of dignity.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 29 April 2022

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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

    Fund safe and appropriate discharge from mental-health inpatient units.

    Verbatim wording from the response

    “An additional £116 million was invested in the NHS in 2021/22 to support people to be discharged safely and appropriately from mental health inpatient units. Improving flow will help ensure beds are available to those most in need. Major expansion in funding for community mental health services commenced in all areas in 2021/22, which has been key to managing pressures on beds. As set out in the NHS Long Term Plan, our aim is to improve community support for serious mental illnesses”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 29 April 2022

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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 community mental-health services to improve support for people with serious mental illnesses and manage bed pressures.

    Verbatim wording from the response

    “An additional £116 million was invested in the NHS in 2021/22 to support people to be discharged safely and appropriately from mental health inpatient units. Improving flow will help ensure beds are available to those most in need. Major expansion in funding for community mental health services commenced in all areas in 2021/22, which has been key to managing pressures on beds. As set out in the NHS Long Term Plan, our aim is to improve community support for serious mental illnesses”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 29 April 2022

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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

    Publish and fund the Mental Health Recovery Action Plan to expand services, reduce waiting times and strengthen the NHS workforce.

    Verbatim wording from the response

    “You also raise the matter of Covid-19 measures, including lockdown. The Covid-19 pandemic required the Government to put a number of unprecedented measures in place, including shielding, social distancing and local and national lockdowns. We know that the pandemic and these measures have had, and will continue to have, an impact on the mental health and wellbeing of many people. That is why we published our Mental Health Recovery Action Plan⁴ in March 2021, backed by an additional £500 million for 2021/22, to accelerate our expansion plans in order to address waiting times for mental health services, give more people the mental health support they need, and invest in the NHS workforce.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 29 April 2022

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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

    The root cause analysis did not find that a shortage of beds contributed to Ms Medcalf’s death.

    Verbatim wording from the response

    “I understand that several actions have been taken following Ms Medcalf’s death. A Root Cause Analysis was undertaken by Greater Manchester Mental Health NHS FT (GMMH) as a result of Ms Medcalf’s death in line with the patient safety and serious incident process. This did not reveal that a shortage of beds was a contributory factor in this case. However, patient flow continues to be a main priority for the mental health system at a local, regional and national level. You may wish to know that GMMH are addressing these issues through the purchase of independent sector beds, alongside increased investment in schemes and workforce initiatives to support patient flow. In addition, system partners continue to support All-Age Mental Health Liaison teams in A&E and the advisory capacity they offer across Greater Manchester.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 29 April 2022

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  4. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Sky Louise Rollings · 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

    Sky Louise Rollings was transferred from a child and adolescent mental health hospital to an adult mental health unit on 4 November 2019 and died at Royal Stoke University Hospital on 9 November 2019, following an incident at Harplands Hospital. The inquest heard concerns about differences between child and adult mental health care and the lack of inpatient provision for people aged 14 to 25, which was considered to create a risk of further 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

    Lack of mental health inpatient provision for people aged 14-25

    Wider context from the report

    “During the inquest evidence was heard about the differences in the way CAMHS Hospitals and Adult mental Health Hospitals approached the care of the patients on their wards. When hearing evidence during the inquest it was established that when a child turned 18, and was a patient on a Mental health ward, once transferred to an adult Mental Health Hospital they would immediately be treated in accordance with the adult provisions. It was accepted that there is no provision there is currently no one in-patient provision for people between the ages of 14-25. It was also accepted that simply because a child becomes 18 does not mean that they are an adult. The lack of this provision in a mental health in-patient setting leads me to conclude that there is a risk of further deaths resulting. ”

    Source location

    Sky Louise Rollings · Prevention of Future Deaths report
    Page 1 · concerns

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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 single 14–25 inpatient ward is not recommended because developmental differences and safeguarding risks could place vulnerable young people at risk.

    Verbatim wording from the response

    “There are safeguarding concerns and implications that need to be taken into consideration in having young people under 18 years and those over 18 years on the same ward, which will usually mean requiring increased observations (which places additional pressure on staffing and can feel restrictive for young people themselves).”

    Source location

    2021-0354-Response-from-NHS-England_Published
    Page 2 · response
    Published 21 October 2021

    Open published response
  5. Manchester South

    AI-generated summary

    Martin Gibbons · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Martin Gibbons attempted to take his own life on 19 March 2020 and was taken to hospital, where he was assessed as needing admission to a psychiatric ward. While waiting for a bed, he left the hospital unobserved and was found dead on 24 March 2020; the inquest concluded suicide. Concerns included differing assessments of risk between acute and mental health trusts, the absence of shared risk assessments and care plans, and delays in obtaining a mental health bed.

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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 availability of mental health beds

    Wider context from the report

    “3. It was during the prolonged wait in the Emergency Department for a mental health bed that Mr Gibbons left. The inquest heard that this wait was contributed to by a number of factors in particular • A national lack of mental health beds; • The fact that although he had presented to Tameside Hospital and had been assessed by Pennine Care staff because he was a resident of a neighbouring borough covered by a different NHS Mental Health Trust that other Trust had to be contacted ,given all of the information and find him a bed. The inquest was told that this was as a result of how services were commissioned and that the workers who had assessed him had no choice other than to follow this process notwithstanding the additional delay it created. ”

    Source location

    Martin Gibbons · Prevention of Future Deaths report
    Page 3 · concerns

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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 an additional £500 million in 2021/22 to support mental-health service recovery, including expanded community, crisis and discharge-support services.

    Verbatim wording from the response

    “You may also wish to note that, while we are emerging from the crisis period resulting from COVID-19, we continue to monitor the impact of the pandemic and adjust policy and investment priorities where necessary. The NHS will be investing significantly in mental health service capacity this year, with an additional £500million in 2021/22 to support recovery in mental health services on top of the funding already committed through the NHS Long Term Plan. This investment includes funding to bring forward existing plans to improve/expand community mental health services, crisis care services and support for people to be discharged from hospital in a timely manner. All of which should help to both reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.”

    Source location

    2021-0166-Response-from-Department-of-Health-Social-Care_Published.pdf
    Page 3 · response
    Published 24 May 2021

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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 significantly in community and crisis services to provide a holistic offer and manage demand for mental-health beds.

    Verbatim wording from the response

    “There has been an overarching reduction in the mental health bed base capacity across the country over a number of years. This is having an ongoing impact in terms of local systems having the necessary capacity to meet the ever-increasing demand on services. In Greater Manchester we are investing significantly into our community and crisis services so that we have a holistic service offer, which will ensure that the demand on mental health beds is manageable.”

    Source location

    2021-0166-Response-from-GMCA_Published.pdf
    Page 3 · response
    Published 24 May 2021

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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 NHS commissioners determine mental health bed provision based on local need and the effectiveness of community care.

    Verbatim wording from the response

    “I have noted your concerns about the time taken to identify and confirm a mental health bed for Mr Gibbons. The provision of mental health beds is determined by local NHS commissioners, taking into consideration local need as well as the effectiveness of the local mental health system in providing access to care and support to people in the community, thereby reducing the requirement for admission to hospital. While in some local areas there may be a genuine need for more inpatient capacity, this should always be considered as part of whole system transformation to reduce over reliance on hospital-based care.”

    Source location

    2021-0166-Response-from-Department-of-Health-Social-Care_Published.pdf
    Page 2 · response
    Published 24 May 2021

    Open published response
  6. Manchester South

    AI-generated summary

    Carole Mitchell · 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

    Carole Mitchell died at home on 22 November 2019 after taking a fatal amount of her prescribed medication; the inquest conclusion was suicide. The report identifies concerns about delays in accessing psychological assessment and support-worker services, limited mental health bed capacity, and difficulties gathering information from her family because of concerns about confidentiality.

    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 local mental health inpatient bed capacity

    Wider context from the report

    “2. Mrs Mitchell on two occasions could not be accommodated locally when an inpatient stay was required. The evidence heard at the inquest was that this was due to limited national mental health bed capacity against the demand within mental health services. The inquest heard evidence that suggested that this impacted on how she could be supported by her family and overall care. ”

    Source location

    Carole Mitchell · Prevention of Future Deaths report
    Page 3 · concerns

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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 local systems to eliminate inappropriate adult out-of-area mental health placements as soon as reasonably possible, with revised local targets where necessary.

    Verbatim wording from the response

    “Turning to your second matter of concern regarding the availability of inpatient beds, the Five Year Forward View for Mental Health², set out the commitment to eliminate inappropriate adult Out of Area Placements (OAPs) by the end of 2020/21, recognising their negative impact on the quality of care and of being disconnected from family, friends and support networks.”

    Source location

    2021-0037-Response-from-Dept-of-Health-and-Social-Care-Redacted
    Page 2 · response
    Published 15 February 2021

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use £87 million to support good-quality discharge from mental health facilities.

    Verbatim wording from the response

    “In addition to transforming and expanding community mental health services, we are ensuring discharge is well-planned and effective, so that people are not in hospital for any longer than they need to be. We have recently announced that £87million will be used to support good quality discharge from mental health facilities. This is part of the additional £500 million mental health recovery plan³ announced to address waiting times for mental health services, give more people the mental health support they need, and invest in the NHS workforce.”

    Source location

    2021-0037-Response-from-Dept-of-Health-and-Social-Care-Redacted
    Page 3 · response
    Published 15 February 2021

    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

    Mobilise the Delayed Transfer of Care programme, including 36 schemes funded to reduce bed blockage and out-of-area placements.

    Verbatim wording from the response

    “As a consequence, we have mobilised a number of initiatives to ensure that GM patients are, in the main, treated locally:”

    Source location

    2021-0037-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
    Page 2 · response
    Published 15 February 2021

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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

    COVID-19 capacity pressures prevent eliminating all out-of-area placements by April 2021; systems must set local targets and eliminate them as soon as reasonably possible.

    Verbatim wording from the response

    “Prior to the outbreak of COVID-19, good progress was being made towards this target nationally. However, COVID-19 has made the already stretching ambition even more challenging, due to consistently high capacity pressures resulting from the negative impact of the pandemic on mental health need; reduced bed capacity in some areas due to infection prevention and control requirements; interruptions to usual support structures and access to community services; and delayed progress in delivering planned pathway improvements while focussing on the COVID-19 response. Despite this, reliance on OAPs remains highly variable and has already been significantly reduced or eliminated in a number of areas.”

    Source location

    2021-0037-Response-from-Dept-of-Health-and-Social-Care-Redacted
    Page 2 · response
    Published 15 February 2021

    Open published response
  7. Suffolk

    AI-generated summary

    Piotr Kierzkowski · 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

    Piotr Kierzkowski was found deceased at home on 17 December 2019 after experiencing a mental health crisis and being assessed for admission to a psychiatric unit. No bed was available, so he was sent home with a friend and took his own life before he could return to hospital. The principal concerns were overall bed capacity for people seeking informal admission and arrangements for temporarily housing a patient when a bed is unavailable.

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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 provision to temporarily house patients awaiting informal admission

    Wider context from the report

    “In evidence it was heard that Piotr had not received his ‘depot’ medication for some time and was clearly suffering from a psychotic episode at the time of his assessment at the Accident and Emergency department of the West Suffolk Hospital on the 16th December 2019 Piotr told staff he was not actively suicidal at that point in time, and although the staff were concerned about his presentation, under mental health law least restrictive principles, they did not believe the powers of detention under the Mental Health Act were applicable. That said, it was also clear from the evidence that the mental health personnel who saw Piotr wanted to immediately admit him as an informal patient. It was also clear that when Piotr attended hospital on the 16th December 2019, he too wanted to be immediately admitted as an informal patient. As a result, staff tried to locate a bed for Piotr so he could be admitted as all involved wished. However, it was identified that there were no beds available in Suffolk, or anywhere else in the country at the time. Different options of keeping Piotr in the hospital were explored but none were viable. As such, Piotr was prescribed medication to reduce his immediate anxiety and sent home with a friend, with instructions to return if his symptoms deteriorated. Piotr took his own life the next morning before he could be returned to hospital. Had a bed been available and Piotr had been admitted as he and medical staff had wished on the evening of the 16th December 2019, his death would not have occurred. I am therefore concerned in relation to the overall bed capacity for those patients like Piotr seeking informal admission. In addition, I am concerned about the provisions to temporarily house a patient wishing informal admission in the circumstances that a bed is not immediately available. ”

    Source location

    Piotr Kierzkowski · 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

    Insufficient bed capacity for patients seeking informal admission

    Wider context from the report

    “In evidence it was heard that Piotr had not received his ‘depot’ medication for some time and was clearly suffering from a psychotic episode at the time of his assessment at the Accident and Emergency department of the West Suffolk Hospital on the 16th December 2019 Piotr told staff he was not actively suicidal at that point in time, and although the staff were concerned about his presentation, under mental health law least restrictive principles, they did not believe the powers of detention under the Mental Health Act were applicable. That said, it was also clear from the evidence that the mental health personnel who saw Piotr wanted to immediately admit him as an informal patient. It was also clear that when Piotr attended hospital on the 16th December 2019, he too wanted to be immediately admitted as an informal patient. As a result, staff tried to locate a bed for Piotr so he could be admitted as all involved wished. However, it was identified that there were no beds available in Suffolk, or anywhere else in the country at the time. Different options of keeping Piotr in the hospital were explored but none were viable. As such, Piotr was prescribed medication to reduce his immediate anxiety and sent home with a friend, with instructions to return if his symptoms deteriorated. Piotr took his own life the next morning before he could be returned to hospital. Had a bed been available and Piotr had been admitted as he and medical staff had wished on the evening of the 16th December 2019, his death would not have occurred. I am therefore concerned in relation to the overall bed capacity for those patients like Piotr seeking informal admission. In addition, I am concerned about the provisions to temporarily house a patient wishing informal admission in the circumstances that a bed is not immediately available. ”

    Source location

    Piotr Kierzkowski · 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

    End reliance on adult acute out-of-area placements by April 2021.

    Verbatim wording from the response

    “There are a number of key commitments that support this aim, most notably the national policy to end reliance on adult acute out of area placements by April 2021. This commitment aims to ensure that all local mental health systems are operating effectively, with sufficient local bed capacity so that everyone can be admitted close to home and at the right time.”

    Source location

    2020-0204-Response-from-Department-of-Health-and-Social-Care_Redacted.pdf
    Page 2 · response
    Published 1 December 2020

    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 national and regional improvement support to services reducing out-of-area placements.

    Verbatim wording from the response

    “National and regional support has been provided to mental health services working to reduce out of area placements, with a particular focus on those areas that have been the most challenged. This includes clinically-led, bespoke improvement support and ensuring that strategies are in place to invest in community services and alternatives to admission.”

    Source location

    2020-0204-Response-from-Department-of-Health-and-Social-Care_Redacted.pdf
    Page 2 · response
    Published 1 December 2020

    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 £50 million of strengthened post-discharge mental health support during the winter COVID-19 pressures.

    Verbatim wording from the response

    “In recognition of the additional service pressures this winter resulting from the COVID-19 pandemic, an additional £50million is being provided to deliver strengthened support for mental health patients following their discharge from inpatient care over the coming months. This will be used to ensure that patients who are ready to leave inpatient facilities”

    Source location

    2020-0204-Response-from-Department-of-Health-and-Social-Care_Redacted.pdf
    Page 2 · response
    Published 1 December 2020

    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

    Urgent mental-health admission does not require detention under the Mental Health Act to access a bed quickly.

    Verbatim wording from the response

    “However, patient safety is the first priority and NHSE/I, as system leader, is clear that if an urgent admission is required and a local bed is not available, mental health providers should seek and secure a placement out of area. You may wish to note that it is not the case that detention under the Mental Health Act is required to access a bed quickly.”

    Source location

    2020-0204-Response-from-Department-of-Health-and-Social-Care_Redacted.pdf
    Page 2 · response
    Published 1 December 2020

    Open published response
  8. Leicester City and South Leicestershire

    AI-generated summary

    Amanda Jaye Briley · 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

    Amanda Jaye Briley, who had Asperger’s and a history of serious self-harm attempts, was found unconscious with trousers around her neck in a psychiatric ward on 26 December 2016 and died in intensive care on 28 December 2016. Her observation level had been reduced for Christmas leave and was not reinstated at the previous level after her return. The report also raised concern about the lack of local inpatient provision and commissioning arrangements for people with autism requiring inpatient mental health 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 local inpatient mental health provision for people with autism

    Wider context from the report

    “The court was advised that CCG have only commissioned services in respect of the diagnosis of autism and not the management of this condition. There is no local in-patient provision and any patient with this diagnosis who requires in-patient mental health treatment would have to be placed out of area. It is a central tenet to the Winterbourne Report and the Mental Health Act Code of Practice that hospital provision should be as local as possible for individuals to maintain contact with families and communities. I ask that the CCG consider the local provision and given we are geographically so well placed, to consider (if not alone) a collaborative commissioning arrangement based on the Transforming care recommendations. ”

    Source location

    Amanda Jaye Briley · Prevention of Future Deaths report
    Page 1 · 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

    Give local service providers greater budgetary control for people receiving or at risk of inpatient care.

    Verbatim wording from the response

    “• Local service providers will be given more control of budgets for people who are in inpatient care, or who are at risk of it to help them spend the money on support in the community, make stays in inpatient services shorter and stop out of area placements.”

    Source location

    2019-0021-Response-by-NHS-England
    Page 3 · response
    Published 23 May 2019

    Open published response
  9. Birmingham and Solihull

    AI-generated summary

    Nigel Byron Abbott · 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

    On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.

    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 section 140 beds

    Wider context from the report

    “Summary of Concerns In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them. The five generic on-going matters of concern: (1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments. (2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds. (3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT. (4) Whilst section 4 is available to be used, it is not used. (5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed. ”

    Source location

    Nigel Byron Abbott · Prevention of Future Deaths report
    Page 10 · 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

    Chronic shortage of psychiatric beds

    Wider context from the report

    “Summary of Concerns In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them. The five generic on-going matters of concern: (1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments. (2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds. (3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT. (4) Whilst section 4 is available to be used, it is not used. (5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed. ”

    Source location

    Nigel Byron Abbott · Prevention of Future Deaths report
    Page 10 · 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 local arrangements delegating access management for Section 140 emergency beds.

    Verbatim wording from the response

    “13.1 The CCG recognises the responsibility to provide emergency beds pursuant to Section 140 of the Mental Health Act.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 6 · response
    Published 18 October 2019

    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

    Develop a crisis pathway to increase capacity in secondary mental health crisis services.

    Verbatim wording from the response

    “6.9 A further £1.7m is being spent on the development of a crisis pathway to increase the capacity in secondary mental health crisis services.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 4 · response
    Published 18 October 2019

    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

    Pool resources to provide a crisis house as an alternative to psychiatric inpatient admission.

    Verbatim wording from the response

    “8 Crisis House- expected completion spring 2020”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 4 · response
    Published 18 October 2019

    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 internal care pathways to maximise capacity in teams meeting patient demand.

    Verbatim wording from the response

    “10 Improving Flow Internally at BSMHFT”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 4 · response
    Published 18 October 2019

    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

    Pilot the Red to Green initiative to improve inpatient flow and reduce length of stay.

    Verbatim wording from the response

    “10.1 BSMHFT have appointed independent experts to help them review their current internal pathways of care, with the aim of ensuring that they have the maximum capacity possible in the right teams to meet patient demand. This work is ongoing. They are also piloting an evidence based national initiative called ‘Red to Green’ aimed at improving flow and reducing length of stay within adult acute inpatient units, by ensuring pre-discharge planning and touch point reviews for all patients. This approach has already demonstrated success in partnerships with other providers.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 4 · response
    Published 18 October 2019

    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

    Management of access to emergency Section 140 beds is delegated to BSMHFT and BWCT under local arrangements.

    Verbatim wording from the response

    “13.1 The CCG recognises the responsibility to provide emergency beds pursuant to Section 140 of the Mental Health Act.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 6 · response
    Published 18 October 2019

    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

    Delegated local arrangements provide flexible access to emergency beds and are considered to address Section 140 provision adequately.

    Verbatim wording from the response

    “13.4 The difficulties in implementing the Code of Practice was reviewed by Care Quality Commission in their report issued in June 2019, which recommended that “local leadership teams work together to discuss the way this [Section 140 provision] is working for patients and how to improve any problems with local implementation”.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 6 · response
    Published 18 October 2019

    Open published response
  10. Birmingham and Solihull

    AI-generated summary

    Anthony Joseph McCormack · 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

    Anthony Joseph McCormack was found dead at home on 7 May 2019 after concerns about his wellbeing. He had been identified as in crisis and assessed as fit for detention, but no inpatient bed was available; concerns included inadequate assessment and monitoring by overstretched community mental health services. The inquest concluded that the death was suicide due to the unavailability of an inpatient mental health bed.

    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 inpatient beds for people assessed and fit for detention

    Wider context from the report

    “1. Between the 16th March 2019 and the 25th April 2019, a bed could not be found for the Deceased even though he had been assessed and fit for detention. The absence of a bed meant that Mr. McCormack was not adequately assessed and appropriate treatment could not be given. With inpatient admission it is unlikely Mr. McCormack would have taken his life. The evidence from witnesses from BSMHT was that there continues to be a shortage of beds. ”

    Source location

    Anthony Joseph McCormack · Prevention of Future Deaths report
    Page 1 · 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

    Work with system partners to understand increased crisis-service demand and improve use of existing mental health resources.

    Verbatim wording from the response

    “3.4 In addition, the CCG has been, and continues to work with, system partners to understand the reason for the increased need, and to look at how the system can be improved to make best use of the existing resources.”

    Source location

    2019-0317-Response-by-Birmingham-and-Solihull-CCG
    Page 3 · response
    Published 6 November 2019

    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

    Continue monitoring pressures on mental health services and developing initiatives to manage patient flow and improve services.

    Verbatim wording from the response

    “4.3 The CCG will continue to keep under review the pressures on mental health services and the need to develop new initiatives to manage patient flow and improve services.”

    Source location

    2019-0317-Response-by-Birmingham-and-Solihull-CCG
    Page 4 · response
    Published 6 November 2019

    Open published response
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Data last updated 7 September 2026