25 Mar 2024 Christopher Edward SIDLE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Shortage of inpatient mental health beds View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Department of Health and Social Care
Invest almost £1 billion in expanded adult community mental health services by March 2024.
View source
Department of Health and Social Care
Make funding available to support adult social care and NHS discharges, including from mental health inpatient settings.
View source
Department of Health and Social Care
Develop and publish statutory guidance for discharge from mental health inpatient settings.
View source
Department of Health and Social Care
Improve patient flow and work towards eliminating inappropriate out-of-area mental health placements.
View source See 1 more action
×
AI-generated summary
Christopher Edward SIDLE · 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
Christopher Sidle had schizophrenia and experienced a deterioration in his mental health during June 2023. After several assessments by mental health services, he was not admitted to hospital; on 1 July 2023 he jumped from a moving taxi, suffered life-threatening head injuries and died on 4 July 2023 after life-sustaining therapies ceased. The report identified inadequate assessments and missed opportunities to provide appropriate and timely care, alongside concerns about crisis-team training, communication, risk assessment, community support, and the shortage of inpatient mental health beds.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Shortage of inpatient mental health beds
Wider context from the report “7. Evidence was heard of a nationwide shortage of inpatient mental health beds . Action has been taken by NSFT in an effort to minimise impact, but this does remain an ongoing concern .
” Source location Christopher Edward SIDLE · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest almost £1 billion in expanded adult community mental health services by March 2024.
Verbatim wording from the response “Through the NHS Long Term Plan, we have invested almost £1 billion extra in community mental health care for adults by March 2024, compared to 2018/19, expanding and transforming community mental health services. The long-term aim set out within the NHS Long-Term Plan is to improve community support for those with serious mental illness to avoid the need for an inpatient admission where possible. As part of this, major expansion in funding for community mental health services commenced in all areas in 2021/22 which also aim to reduce pressure on beds. However, we recognise that there are occasions where a mental health bed is not available locally. The 2024/25 NHS priorities and operations planning guidance has a commitment to improving patient flow and working towards eliminating inappropriate out of area placements.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make funding available to support adult social care and NHS discharges, including from mental health inpatient settings.
Verbatim wording from the response “Timely discharge of patients who are ready to be discharged is important to free up beds for those who need them. 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, reducing bed occupancy. 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 published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. The guidance is available at: Hospital discharge and community support guidance - GOV.UK (www.gov.uk)” Source location Response from Department of Health and Social Care
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 and publish statutory guidance for discharge from mental health inpatient settings.
Verbatim wording from the response “Timely discharge of patients who are ready to be discharged is important to free up beds for those who need them. 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, reducing bed occupancy. 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 published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. The guidance is available at: Hospital discharge and community support guidance - GOV.UK (www.gov.uk)” Source location Response from Department of Health and Social Care
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 Improve patient flow and work towards eliminating inappropriate out-of-area mental health placements.
Verbatim wording from the response “Through the NHS Long Term Plan, we have invested almost £1 billion extra in community mental health care for adults by March 2024, compared to 2018/19, expanding and transforming community mental health services. The long-term aim set out within the NHS Long-Term Plan is to improve community support for those with serious mental illness to avoid the need for an inpatient admission where possible. As part of this, major expansion in funding for community mental health services commenced in all areas in 2021/22 which also aim to reduce pressure on beds. However, we recognise that there are occasions where a mental health bed is not available locally. The 2024/25 NHS priorities and operations planning guidance has a commitment to improving patient flow and working towards eliminating inappropriate out of area placements.” Source location Response from Department of Health and Social Care
Open published response
20 Mar 2024 Jonathan Harris · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Shortage of available inpatient psychiatric beds in Surrey View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Invest additional funding in mental health, community, crisis, acute and inpatient services to improve access and reduce pressure on beds.
View source
NHS England
Improve patient flow and reduce out-of-area placements through community service improvements, shorter inpatient stays and reduced discharge delays.
View source
×
AI-generated summary
Jonathan Harris · 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 Harris died in the early hours of 27 June 2022 after deliberately suspending himself while suffering a relapse of paranoid schizophrenia. The inquest concluded that his relapse followed reductions in antipsychotic medication and that an inpatient psychiatric bed was unavailable when an assessment was required. The court was concerned about the vacant consultant psychiatrist post and the shortage of inpatient psychiatric beds, which it considered presented a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Shortage of available inpatient psychiatric beds in Surrey
Wider context from the report “The court heard that a Consultant Psychiatrist post in the community mental health team that treated Mr Harris has been vacant with no suitable applicants since 1 May 2022. The court heard that this is in the context of a national shortage of suitably qualified psychiatrists.
The court also heard that there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds .
The court is concerned that both of these matters present a risk of future deaths.
” Source location Jonathan Harris · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest additional funding in mental health, community, crisis, acute and inpatient services to improve access and reduce pressure on beds.
Verbatim wording from the response “In some local areas where there is a need for more beds, this is being addressed in part through investment in new units, however, this should be considered as part of whole system transformation approach. This is supported by the NHS Long Term Plan (LTP), which is seeing an additional £2.3bn funding invested in mental health services from 2019/20 – 2023/24, around £1.3bn of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission. A further £1.6bn has been made available via the better care fund from 2023-25 which can be used to support mental health inpatient services as well as the wider system which should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.” Source location Response from NHS England
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 Improve patient flow and reduce out-of-area placements through community service improvements, shorter inpatient stays and reduced discharge delays.
Verbatim wording from the response “In 2024/25 NHS England and systems will have a renewed focus on improving patient flow and reducing the use of out of area placements. This will be delivered through ongoing improvements to community mental health services, as well as focussed work to reduce inpatient lengths of stay and delays around discharge linked to onward care, support and housing, all of which will improve access to mental health beds closer to home for patients.” Source location Response from NHS England
Open published response
7 Mar 2024 Nicola RAYNER · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Insufficient bed capacity for informal mental health inpatient admissions View source
×
AI-generated summary
Nicola RAYNER · 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
Nicola Raynor was found hanging on 6 June 2023 and later died at Addenbrookes Hospital from a hypoxic brain injury. The report raises concerns about the lack of available informal mental health inpatient beds locally and nationally, including continuing insufficient bed capacity for patients awaiting admission.
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 bed capacity for informal mental health inpatient admissions
Wider context from the report “Had an informal Mental Health bed been available on the 6th June 2023, and Nicola had been admitted as both she and her psychiatrist had wished, her death would not have occurred.
I am therefore concerned in relation to the overall bed capacity for those patients like Nicola seeking informal inpatient admission.
Nicola’s case is not an isolated one.
Evidence was heard from the Norfolk and Suffolk Foundation Trust, that on the day of the inquest itself (23rd February 2024), the availability of bed provision for informal Mental Health patients had failed to improve at all.
The court heard that on the 23rd February 2024, the Operational Pressure Escalation Level was at its highest level (Four Black) and that at time of Nicola’s inquest, in Suffolk alone, there were 20 patients on a list waiting for an informal inpatient Mental Health bed.
The court heard, that just as on the 6th June 2023, there were no other available informal Mental Health beds anywhere else in the country.
The facts of Nicola’s case mirror those of another tragic Suffolk case, for which I produced a Prevention of Future Death Report in October 2020.
I am therefore concerned, that any measures that may have been taken in the intervening period since October 2020, have neither adequately, or effectively, addressed this clear and continuing local and national risk of future deaths occurring.
” Source location Nicola RAYNER · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest more than £400 million to replace mental health dormitories with ensuite bedrooms, with more than 600 beds already replaced across 34 sites.
Verbatim wording from the response “The strategy is supported by a wide-range of activity the government is funding and that will support people’s mental health. Between 2018/19 and 2023/24, NHS spending on mental health has increased by £4.7bn (in cash terms). This is significantly above the £3.4bn cash terms growth ambition set out at the time of the Long Term Plan. As part of our plans to improve mental health facilities, we are investing over £400 million to eradicate dormitories and give patients the privacy of their own ensuite bedroom - over 600 beds have already been replaced across 34 sites (out of a total of around 1,400 beds across 50 sites).” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Insufficient mental health bed capacity View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
×
AI-generated summary
Nicolas Gerasimidis · 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
Nicolas Gerasimidis had a history of mental illness manifesting as OCD and anxiety, which deteriorated despite referrals and treatment arrangements. He was found hanged at his home address on 3 June 2023, and the inquest recorded a conclusion of suicide. Concerns included community mental health referrals being rejected, shortages of care coordinators and consultants, a one-year waiting list for psychological treatment, lack of hospital bed availability, and shortcomings in information provided to his family.
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 mental health bed capacity
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available.
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area . The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas . It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Source location Nicolas Gerasimidis · Prevention of Future Deaths report
Open source report
×
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 The ICB considers its commissioned mental health bed capacity appropriate because it matches the national median per 100,000 population.
Verbatim wording from the response “The response from NHS Cornwall and Isles of Scilly Integrated Care Board (the ICB) is focused on your concern around the availability of beds and the transformation work underway more locally. The ICB reports that their commissioning of mental health beds is in line with the national median number of beds per 100,000 population which is 9.45. has advised that its contract with Cornwall Foundation Partnership Trust (CFT) specifies 54 acute mental health beds, however, data shows that there were 47 operational at the date of Mr Gerasimidis' sad death. This remains the situation today. The CFT has 7 closed Acute beds and 6 closed Rehab beds. These beds cannot be reinstated due to environmental issues which are being challenged through CFT Private Finance Initiative contract at the highest level, with the CFT Chief Executive.” Source location Response from DHSC
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 The ICB relies on alternative solutions to mitigate the impact of closed mental health beds.
Verbatim wording from the response “The ICB are aware of these bed closures and have been assured by CFT that the impact had been mitigated with alternative solutions” Source location Response from DHSC
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 Closed acute and rehabilitation beds cannot be reinstated because of environmental issues being challenged through the provider’s contract.
Verbatim wording from the response “The response from NHS Cornwall and Isles of Scilly Integrated Care Board (the ICB) is focused on your concern around the availability of beds and the transformation work underway more locally. The ICB reports that their commissioning of mental health beds is in line with the national median number of beds per 100,000 population which is 9.45. has advised that its contract with Cornwall Foundation Partnership Trust (CFT) specifies 54 acute mental health beds, however, data shows that there were 47 operational at the date of Mr Gerasimidis' sad death. This remains the situation today. The CFT has 7 closed Acute beds and 6 closed Rehab beds. These beds cannot be reinstated due to environmental issues which are being challenged through CFT Private Finance Initiative contract at the highest level, with the CFT Chief Executive.” Source location Response from DHSC
Open published response
29 Jan 2024 Shahzadi Khan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Shortage of available mental health beds View source
This report raised 7 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.
×
AI-generated summary
Shahzadi Khan · 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
Shahzadi Khan was detained under the Mental Health Act after a manic episode with psychotic symptoms and was discharged from an out-of-area private hospital to her family home. Following inadequate discharge planning, communication problems and a failure to arrange the appropriate community care pathway, she deteriorated and took a fatal overdose of prescribed zopiclone at home. The concerns included the effects of out-of-area placements, poor coordination of local care pathways, and insufficient awareness of menopause as a possible factor in mental health deterioration.
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 Shortage of available mental health beds
Wider context from the report “1. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds . The inquest heard that this meant that there were a number of consequences as a result of all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular:
• A family could not easily stay in contact and visiting was almost impossible. This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians.
• Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used.
• Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication
” Source location Shahzadi Khan · Prevention of Future Deaths report
Open source report
23 Nov 2023 Philip Laurence Justin MALONE · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2
Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients View source Inadequate psychiatric bed capacity in Birmingham and Solihull View source
Linked responses
Birmingham and Solihull Integrated Care System Birmingham and Solihull Mental Health NHS Foundation Trust Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Birmingham and Solihull Mental Health NHS Foundation Trust
Work with local authorities to improve inpatient social-care support and enable faster, safer discharges.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Operate a clinical oversight group with acute wards to support appropriate discharges and escalate delays caused by non-clinical issues.
View source
Department of Health and Social Care
Expand funding for community mental health services nationwide to help manage pressure on inpatient beds.
View source
Birmingham and Solihull Integrated Care System
Commission 20 additional mental health inpatient beds in the independent sector.
View source
Birmingham and Solihull Integrated Care System
Continue working with the Mental Health Provider Collaborative to commission more local independent-sector mental health provision.
View source
Birmingham and Solihull Integrated Care System
Work with BSMHFT to address Investment Committee actions so the additional inpatient bed-capacity business case can progress to full support.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Commission and complete a 12-month consultancy project addressing local mental health bed shortages and out-of-area placements.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Develop and lead a locality model linking local hospital beds with home treatment teams, community teams and local communities to prioritise admissions by clinical risk and need.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Lead a business case to secure funding for new Highcroft acute capacity, with submissions scheduled for early spring 2024.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Participate with the ICB in a steering group examining additional contracted beds closer to Birmingham as an interim measure.
View source See 7 more actions
×
AI-generated summary
Philip Laurence Justin MALONE · 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
Philip Laurence Justin Malone, who had treatment-resistant schizophrenia and had deteriorated significantly in late June 2023, was found deceased in his supported accommodation on 3 July 2023. The inquest concluded that his death was the consequence of suicide. The principal concern was inadequate psychiatric bed capacity in Birmingham and Solihull, after clinicians sought to admit him but no inpatient bed was available, creating an ongoing risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients
Wider context from the report “1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action.
2. The Patient Safety Manager ████████ gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved, and there is a genuine risk of the same problem with another patient in the future.
3. ████████ added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged . In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged , and amplifies the chronic shortage of beds.
4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board.
The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding.
My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate. Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.
” Source location Philip Laurence Justin MALONE · Prevention of Future Deaths report
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 Inadequate psychiatric bed capacity in Birmingham and Solihull
Wider context from the report “1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action.
2. The Patient Safety Manager ████████ gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved , and there is a genuine risk of the same problem with another patient in the future.
3. ████████ added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged. In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged, and amplifies the chronic shortage of beds.
4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board.
The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding.
My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate . Whilst some action may have been taken it is insufficient to resolve the problem . It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.
” Source location Philip Laurence Justin MALONE · Prevention of Future Deaths report
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 local authorities to improve inpatient social-care support and enable faster, safer discharges.
Verbatim wording from the response “The Trust is working with our local authorities to improve the social care support to patients on our inpatient wards with an aim to provide speedier and safer discharges and thus create more capacity within our bed stock (See appendix 1)” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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 Operate a clinical oversight group with acute wards to support appropriate discharges and escalate delays caused by non-clinical issues.
Verbatim wording from the response “A clinical oversight group (COG) now meets regularly with all acute wards to support clinically appropriate discharges and enable escalation of discharge delays that occur as a result of non-clinical issues (appendix 2).” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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 Expand funding for community mental health services nationwide to help manage pressure on inpatient beds.
Verbatim wording from the response “At a national level, through the NHS Long Term Plan we have provided record levels of investment to expand and transform NHS mental health services and increase the workforce. The long-term aim set out within the Plan is to improve community support for those with serious mental illness to avoid the need for an inpatient admission where possible. We are set to reach nearly £1 billion additional funding invested by 2023/24 (compared to 2018/19) to transform community mental health services. However, we recognise that community-based care will not always be appropriate for those with more complex needs. Major expansion in funding for community mental health services commenced in all areas in 2021/22, which has been key to managing pressures on inpatient beds.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission 20 additional mental health inpatient beds in the independent sector.
Verbatim wording from the response “Alongside the improvements BSMHFT set out in their response to you, in relation to managing demand and admission and improving overall patient flow, we are working collaboratively with BSMHFT to increase the mental health inpatient bed capacity. In March 2023, to increase capacity, an additional 20 mental health beds were commissioned in the independent sector within the Birmingham and Solihull geographic area. As per the response by BSMHFT, we continue to work with the Birmingham and Solihull Mental Health Provider Collaborative, with BSMHFT as the lead provider, to commission more local independent sector provision.” Source location Response from Birmingham and Solihull Integrated Care Board
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 working with the Mental Health Provider Collaborative to commission more local independent-sector mental health provision.
Verbatim wording from the response “Alongside the improvements BSMHFT set out in their response to you, in relation to managing demand and admission and improving overall patient flow, we are working collaboratively with BSMHFT to increase the mental health inpatient bed capacity. In March 2023, to increase capacity, an additional 20 mental health beds were commissioned in the independent sector within the Birmingham and Solihull geographic area. As per the response by BSMHFT, we continue to work with the Birmingham and Solihull Mental Health Provider Collaborative, with BSMHFT as the lead provider, to commission more local independent sector provision.” Source location Response from Birmingham and Solihull Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with BSMHFT to address Investment Committee actions so the additional inpatient bed-capacity business case can progress to full support.
Verbatim wording from the response “Firstly, may I apologise for the delay in our response; we have now been able to review a business case prepared by BSMHFT to increase their bed capacity with a proposed new build at the Highcroft site at the Birmingham and Solihull ICS System Investment Committee.” Source location Response from Birmingham and Solihull Integrated Care Board
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete a 12-month consultancy project addressing local mental health bed shortages and out-of-area placements.
Verbatim wording from the response “Birmingham and Solihull NHS Foundation Trust commissioned the services of Grant Thornton Consultancy to work with us on a specific 12-month project to address the issue of local bed shortages” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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 and lead a locality model linking local hospital beds with home treatment teams, community teams and local communities to prioritise admissions by clinical risk and need.
Verbatim wording from the response “3. Increasing bed base capacity locally.
The programme concluded in the summer of 2023 with the recommendation that two core workstreams are developed and delivered to improve bed capacity, namely:” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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 Lead a business case to secure funding for new Highcroft acute capacity, with submissions scheduled for early spring 2024.
Verbatim wording from the response “Additional workstreams
Highcroft redevelopment project: The Trust is currently leading on a business case to secure funding to build new acute hospital capacity on the Highcroft hospital site in North Birmingham. The long term plan is to replace all of the ageing bed stock on the site. The medium term plan is to realise two new additional wards. Based on our acute bed case for need, these are currently proposed to be an 18-bedded acute ward and a 12-bedded acute intensive care ward (PICU). Business case submissions are scheduled to be submitted in early Spring 2024. However, even if the case is approved, this is only the first step and it would be at least a few years before it is likely to be completed.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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 Participate with the ICB in a steering group examining additional contracted beds closer to Birmingham as an interim measure.
Verbatim wording from the response “Strategic bed procurement steering group: This group is led by ICB with BSMHFT and FTB input. It is looking at how additional contracted beds can be contracted closer to Birmingham as an interim measure while the Highcroft programme is in development.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS capital constraints may prevent delivery of the proposed additional mental health inpatient bed capacity.
Verbatim wording from the response “The business case for additional mental health inpatient bed capacity has been supported in principle by the Investment Committee and we are working alongside BSMHFT to ensure that the case addresses actions raised by the Committee to allow it to progress to full support. We are, however, concerned as to whether the system will be able to raise the necessary capital to facilitate delivery because of the constraints placed upon NHS capital availability.” Source location Response from Birmingham and Solihull Integrated Care Board
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 Addressing mental health bed availability relies substantially on system partners, so the Trust cannot resolve the issue alone.
Verbatim wording from the response “I would like to take this opportunity to explain that whilst many steps are being taken to address the matter of bed availability, the solution is very much reliant on our system partners as well. We are continuing to work closely with them. As you state within your PFD Report; this is a national problem. The Trust is therefore taking all available steps, within its power, in order to minimise and reduce the risks associated with this issue. I understand that in making the decision around the PFD at and request you expressed that you took into account that multiple PFD reports have already been issued, but in your view the volume of reports and repetition of issuing further reports is tangible and the fact that another report is being issued may contribute.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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 The Trust can develop capacity and pathways only within the resources, scope and abilities available to it.
Verbatim wording from the response “I would like to express that the issuing of PFDs has not directly influenced the ongoing work the Trust has been undertaking for some time on this matter and we remain committed to do all we can to develop capacity and pathways that enable us to meet the needs of our population within the resources we have available to us.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
15 Nov 2023 Madeleine Eve SAVORY · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Insufficient national availability of Tier 4 paediatric mental health beds for timely allocation View source
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. 4
NHS England
Introduce NHS-led Provider Collaboratives to bring children’s and young people’s inpatient care closer to home.
View source
NHS England
Invest capital and revenue funding in localised Tier 4 inpatient and alternative-to-inpatient provision over three years.
View source
NHS England
Issue planning guidance requiring Lead Provider Collaboratives and Integrated Care Systems to provide adolescent and psychiatric intensive care units for local needs.
View source
NHS England
Commission a review of the children’s and young people’s inpatient model addressing pathway pressures, quality, safety and future care requirements.
View source See 1 more action
×
AI-generated summary
Madeleine Eve SAVORY · 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
Madeleine Savory, aged 15, died on 26 February 2022 after being found ligatured in a bathroom on Bergholt Ward at Ipswich Hospital, following a period during which their whereabouts were unknown. The substantive concerns included the availability of Tier 4 paediatric mental health beds, failures in risk assessment and communication, ward staff understanding of risk, and the implementation of a school safety plan.
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 national availability of Tier 4 paediatric mental health beds for timely allocation
Wider context from the report “I also received helpful evidence from the East of England Provider Collaborative concerning the measures which that organisation had undertaken in their area of responsibility to address my concern in relation to the availability and allocation of Tier 4 beds in a paediatric mental health facilities to children such as Madeleine .
The availability, nationally, of Tier 4 beds in paediatric mental health facilities to allow for the timely allocation to children in need of care in such facilities such as Madeleine Savory.
” Source location Madeleine Eve SAVORY · Prevention of Future Deaths report
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 Introduce NHS-led Provider Collaboratives to bring children’s and young people’s inpatient care closer to home.
Verbatim wording from the response “NHS England has sought to improve the availability of local inpatient (Tier 4) care for children and young people through several actions:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest capital and revenue funding in localised Tier 4 inpatient and alternative-to-inpatient provision over three years.
Verbatim wording from the response “• Investing capital and revenue funding into localised inpatient (Tier 4) and alternative to inpatient provision over a three-year period.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue planning guidance requiring Lead Provider Collaboratives and Integrated Care Systems to provide adolescent and psychiatric intensive care units for local needs.
Verbatim wording from the response “• The NHS Planning Guidance 2022/23 outlined the need for Lead Provider Collaboratives (LPCs) and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive care Units to meet the needs of their local population.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission a review of the children’s and young people’s inpatient model addressing pathway pressures, quality, safety and future care requirements.
Verbatim wording from the response “• In 2022, NHS England commissioned a review of the Children and Young People’s inpatient model recognising the continued pathway pressures and quality and safety challenges. The review included how our English model compares internationally, the views of children, young people and their families and requests from local teams to work together to improve the model of care. The findings of the review will present a future vision for CYPMH inpatient care and will be published in Quarter 2 of 2023/24. Support will then be provided to local systems and provider collaboratives to plan a timeline for implementing the changes, coupled with implementation support as requested.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for considering concerns about Tier 4 bed availability and setting out responsive actions.
Verbatim wording from the response “Your report raises concerns over the availability of Tier 4 beds in paediatric mental health facilities. I understand that NHS England has carefully considered the matters of concern in your report and has provided you with a comprehensive response setting out the actions being taken to improve care quality and patient safety and improve availability of Tier 4 beds where these are needed.” Source location Response from Department of Health and Social Care
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 Lead Provider Collaboratives and Integrated Care Systems are responsible for ensuring local provision of required adolescent psychiatric inpatient services.
Verbatim wording from the response “• The NHS Planning Guidance 2022/23 outlined the need for Lead Provider Collaboratives (LPCs) and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive care Units to meet the needs of their local population.” Source location Response from NHS England
Open published response
14 Jul 2023 PETER MARTIN AARON FLEMING · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Unavailability of mental health inpatient beds View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
PETER MARTIN AARON FLEMING · 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
Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.
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 mental health inpatient beds
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available , and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds , ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” Source location PETER MARTIN AARON FLEMING · Prevention of Future Deaths report
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 Establish and operate the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme.
Verbatim wording from the response “In 2022, NHS England also established a new Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme. The programme’s aim is to support cultural change and a reimagined model of care for the future across all NHS-funded mental health, learning disability and autism inpatient settings. It is underpinned by £36 million investment over three years and focuses on the following four themes:” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest at least £2.3 billion annually by March 2024 to expand and transform mental health services.
Verbatim wording from the response “In your report a concern was also raised regarding the lack of resources available at a national level which restricts patients from getting the mental health support that they require. We are investing at least £2.3 billion of additional funding a year by March 2024 to expand and transform mental health services in England so that two million more people can get the mental health support they need. We also provided a record investment of £15.9 billion in mental health across 2022/23, representing 27.7% more than in 2018/19.” Source location Response from Department of Health and Social Care
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 increased national mental health funding, including a record £15.9 billion investment in 2022/23.
Verbatim wording from the response “In your report a concern was also raised regarding the lack of resources available at a national level which restricts patients from getting the mental health support that they require. We are investing at least £2.3 billion of additional funding a year by March 2024 to expand and transform mental health services in England so that two million more people can get the mental health support they need. We also provided a record investment of £15.9 billion in mental health across 2022/23, representing 27.7% more than in 2018/19.” Source location Response from Department of Health and Social Care
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 Many concerns, particularly those relating to the mental health trust, fall outside the respondent’s remit.
Verbatim wording from the response “This letter responds to the concerns raised in your report relevant to NHS England. It is not within NHS England’s remit to respond to many of the concerns raised, particularly relating to Birmingham and Solihull Mental Health Trust (BSMHFT). NHS England has asked to be sighted on the responses from BSMHFT and Birmingham and Solihull Integrated Care Board (ICB) and will give due consideration to their responses.” Source location Response from NHS England
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 Relevant trusts are responsible for staffing and operating mental health services.
Verbatim wording from the response “The responsibility for the staffing and operations of mental health services lies with the relevant trust, however, we do recognise the wider need to increase capacity in NHS mental health services. Nationally, the mental health workforce increased by over 10,000 full-time equivalent staff in June 2023 compared to June 2022, and our aim is to grow the mental health workforce by an additional 27,000 staff by March 2024, compared to 2018/19.” Source location Response from Department of Health and Social Care
Open published response
22 Jun 2023 Stephen Norman RICHARDSON · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1
Lack of acute psychiatric beds for immediate inpatient assessment, treatment and care View source
Linked response
Department of Health and Social Care
×
AI-generated summary
Stephen Norman RICHARDSON · 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
Stephen Norman Richardson died on 28 September 2019 after a self-inflicted ligature incident at the Sid Watkins Unit on 24 September 2019, following extensive brain damage and withdrawal of life support by his family. The report identified concerns including failures to secure an acute mental health bed, missed opportunities relating to treatment and risk assessment, inadequate communication and safeguarding planning, and staff not following the correct emergency response procedure. It also noted an ongoing national shortage of acute psychiatric beds.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of acute psychiatric beds for immediate inpatient assessment, treatment and care
Wider context from the report “It was clear from the investigation that at the time of Stephen ligaturing in May 2019 there was anational shortage of acute psychiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient . The evidence heard has confirmed that that parlous situation has not improved .
” Source location Stephen Norman RICHARDSON · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England and the Integrated Care Board are responsible for addressing acute psychiatric bed availability and related care quality concerns.
Verbatim wording from the response “I understand that NHS England, in conjunction with Cheshire and Merseyside Integrated Care Board, has already carefully considered the matters of concern in your report and has provided you with a comprehensive response setting out the actions being taken to improve care quality and patient safety and on the specific concern around availability of beds.” Source location Response from Department of Health and Social Care
Open published response
27 Apr 2023 Ben Alan SHIPLEY · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 1
Delays in completing Mental Health Act detention when no bed is available overnight 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.
×
AI-generated summary
Ben Alan SHIPLEY · 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
Ben Alan Shipley, aged 22, died on 29 August 2019 after absconding from hospital and being struck by a train. The report raises concern about delays in securing a mental health bed, during which a section 2 detention could not be completed and Ben was reliant on the goodwill of A&E staff and his family for safety.
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 Delays in completing Mental Health Act detention when no bed is available overnight
Wider context from the report “Ben was assessed at 22.00 on 28th August 2019. It seems to me that there are about 12 hours of delay following a 22.00 assessment Health Act assessment built into the system if there is no bed . Presumably this would be longer if Ben had been assessed earlier in the night shift. I am told beds do not become available over night . This means Ben cannot be legally detained as the section 2 is not complete until there is a bed . He is therefore subject to the goodwill of the A&E (who are not trained in mental health) and the goodwill of the family (who are similarly not trained in mental health). ████████
████████
” Source location Ben Alan SHIPLEY · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.