Concerns raised 1
Unavailability of psychiatric beds in the area View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
John Henry Robinson · 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
John Henry Robinson entered a nursing home for respite care, was subsequently recognised as requiring a psychiatric bed, and no suitable bed was available. His condition deteriorated after admission to hospital, where he died; the substantive concern was whether sufficient psychiatric resources were available in the area.
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 psychiatric beds in the area
Wider context from the report “The evidence at inquest suggested Mr Robinson required a psychiatric bed on Dovedale, but no such bed was available .
His condition deteriorated and he ultimately died.
The concern is whether sufficient resources are available in this area.
” Source location John Henry Robinson · Prevention of Future Deaths report
Open source report
7 Aug 2015 James Reuben Maxwell Adams · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 1
Lack of acute psychiatric beds in Cornwall View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
James Reuben Maxwell Adams · 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 Adams was found dead at home on 10 August 2012 with a plastic bag and helium cylinders, and suicide notes were found nearby. He had persistent depressive disorder, alcohol dependency and a mixed type personality disorder, and was being treated by mental health services. Concerns included the police response to a welfare concern, information sharing, shortages of acute psychiatric beds, and inadequate staffing at designated mental health places of 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 Lack of acute psychiatric beds in Cornwall
Wider context from the report “The inquest heard how lessons had been learnt from the inquest and that the working relationship with the Devon and Cornwall Police and the local Mental Health Services (provided by Cornwall Partnership NHS Foundation Trust) had been improved and formalised through appropriate protocols and Memorandum of Understanding. One continuing difficulty was the “lack of acute psychiatric beds” in Cornwall. In addition, the police had found that on a regular basis, the designated mental health places of safety were not staffed to the appropriate level and the patient could not be left there. The result of this was that patients were being inappropriately detained in police cells by way of a safety net or were regularly being transported out of County as far as Manchester and Bournemouth to access the appropriate acute mental health bed.
Cornwall Partnership NH Foundation Trust representative advised the Coroner that Cornwall has pro-rata less acute mental health beds than the national average. The preferred option for the mental health professionals was to treat local patients locally where they are known or are able to build up relationships with the local mental health team which is something that cannot happen if the patient is transported out of County. Further, the treating Psychiatrist is required to travel to the out of county unit to review the patient which results in valuable Consultant time not being available to local patients which may need access to them at a critical time. The result of this is that unnecessary stress is put on patients which can result in a deterioration of the patients mental health (and possibility death) at a time when the patient needs increased support and treatment.
” Source location James Reuben Maxwell Adams · Prevention of Future Deaths report
Open source report
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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 commissioning acute mental health inpatient services in Cornwall rests with NHS Kernow Clinical Commissioning Group.
Verbatim wording from the response “Your main concern in this case was the lack of acute psychiatric beds in Cornwall and how this could continue to have an adverse impact on the care of mental health patients in this area. Commissioning mental health inpatient services is the responsibility of the local Clinical Commissioning Group (CCG) - in this case the NHS Kernow CCG. It commissions services for Cornwall from the Cornwall Partnership NHS Foundation Trust.” Source location James-Adams-Response
Open published response
14 Jul 2015 Emma Carpenter · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Lack of inpatient beds for mentally ill children and adolescents View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
George Freeman MP 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
Invest in inpatient CAMHS capacity and increase eating-disorder bed availability in the East Midlands and nationally.
View source
NHS England
Commission specialist inpatient eating-disorder units nationally.
View source
NHS England
Plan a procurement process to commission inpatient beds according to assessed need rather than historical provision.
View source
George Freeman MP
Provide £7 million to expand children’s and adolescents’ mental health provision, including Tier 4 beds, case managers, access protocols and case management.
View source See 1 more action
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AI-generated summary
Emma Carpenter · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Emma Carpenter was treated as an outpatient by child and adolescent mental health services from February 2004 to November 2006 and died from multi-organ failure caused by severe anorexia nervosa. The report identified insufficient physical-health monitoring, lack of specialist paediatric or physician input, and delay in accessing effective inpatient treatment as concerns.
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 beds for mentally ill children and adolescents
Wider context from the report “2. There remains still a national lack of provision of inpatient beds for mentally ill children and adolescents including those who suffer from eating disorders .
” Source location Emma Carpenter · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in inpatient CAMHS capacity and increase eating-disorder bed availability in the East Midlands and nationally.
Verbatim wording from the response “Admission into hospital, in the majority of cases, ought to be the result of all community interventions being exhausted. Since NHS England became responsible for commissioning inpatient services in 2013, we have invested financial resources and increased the capacity of inpatient beds both in the East Midlands and across the country to enable greater access to beds at time of clinical need. Working with expert clinicians and service managers, NHS England has developed national service specifications that require acute inpatient mental health units (also known as CAMHS Tier 4 units) for children and young people to manage a range of mental illnesses including eating disorders. In addition, NHS England also commissions specialist inpatient eating disorder units across the country.” Source location 2015-0276-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission specialist inpatient eating-disorder units nationally.
Verbatim wording from the response “Admission into hospital, in the majority of cases, ought to be the result of all community interventions being exhausted. Since NHS England became responsible for commissioning inpatient services in 2013, we have invested financial resources and increased the capacity of inpatient beds both in the East Midlands and across the country to enable greater access to beds at time of clinical need. Working with expert clinicians and service managers, NHS England has developed national service specifications that require acute inpatient mental health units (also known as CAMHS Tier 4 units) for children and young people to manage a range of mental illnesses including eating disorders. In addition, NHS England also commissions specialist inpatient eating disorder units across the country.” Source location 2015-0276-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Plan a procurement process to commission inpatient beds according to assessed need rather than historical provision.
Verbatim wording from the response “Further to the additional beds already commissioned by NHS England, we are currently in the planning stage of a procurement process which will help to ensure that we commission inpatient beds according to need rather than based on history.” Source location 2015-0276-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £7 million to expand children’s and adolescents’ mental health provision, including Tier 4 beds, case managers, access protocols and case management.
Verbatim wording from the response “On the issue of in-patient bed provision, DH provided NHS England with £7million in 2014/15 in response to an NHS England Tier 4 Report, published in July 2014. This funding was to provide: around 50 extra Children and Adolescents Mental Health Service (CAMHS) Tier 4 beds for young patients in the areas with the least provision (South West and Yorkshire). Also additional case managers, new standardised access protocols throughout the country, and a new case management system to make the best use of existing resources.” Source location 2015-0276-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England understood that inpatient beds were available when the death occurred, disputing a premise of insufficient bed availability.
Verbatim wording from the response “Whilst it is our understanding that there were beds available at the time of this tragic death, NHS England also recognises the importance of appropriate community eating disorder services and gaps in this provision across the country. This is reflected in the recent report of the Children and Young People’s Mental Health Taskforce ‘Future in” Source location 2015-0276-Response-by-NHS-England
Open published response
6 Feb 2015 George Allan Taylor · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 1
Lack of acute psychiatric beds View source
Linked responses
Department of Health and Social Care NHS Cornwall and the Isles of Scilly Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Department of Health and Social Care
Set out in the Mandate that plans must ensure people in mental health crisis are not turned away.
View source
NHS Cornwall and the Isles of Scilly Integrated Care Board
Work with providers and service users to develop alternatives to hospital admission and enable earlier assessment and intervention.
View source
NHS Cornwall and the Isles of Scilly Integrated Care Board
Assign alternative funding to support least-restrictive community care and interventions specified in individual care plans.
View source
NHS Cornwall and the Isles of Scilly Integrated Care Board
Review out-of-county placements and current provision with providers to inform future commissioning and service delivery.
View source See 1 more action
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AI-generated summary
George Allan Taylor · 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
George Allan Taylor, who had a history of mental health issues and previous overdoses, was found hanged at home on 2 July 2013 after leaving a care home and returning home under daily supervision. The report identified concerns about inadequate provision of acute psychiatric beds in Cornwall, with 8 to 12 patients per month typically sent out of county, and noted that a future death could result from this lack of beds in changed circumstances.
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
Wider context from the report “It was established in evidence that Mr Taylor’s death was not caused by the lack of an acute psychiatric bed.
Furthermore, it was established that no patient had died out of county because an in county acute psychiatric bed was not available. It was further established that no patient had died in Cornwall while waiting for an acute psychiatric bed to become available.
That said, it appears far from desirable that 8 to 12 patients are being sent out of county per month due to a lack of acute psychiatric beds .
It is easy to see that, with only a small change in circumstances, a future death could result as a consequence of a lack of acute psychiatric beds .
” Source location George Allan Taylor · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set out in the Mandate that plans must ensure people in mental health crisis are not turned away.
Verbatim wording from the response “I was saddened to hear of Mr Taylor’s death. The Government has made it clear that beds must always be available for those who need them and have set out in the Mandate — our annual contract with NHS England — that plans must be put in place to ensure no one in mental health crisis will be turned away. I have made NHS England aware of your report.” Source location 2015-0044-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with providers and service users to develop alternatives to hospital admission and enable earlier assessment and intervention.
Verbatim wording from the response “As part of the health and social care community commitment to implementing the National Crisis Care concordat, NHS Kernow is working with Cornwall Partnership NHS Foundation Trust, Royal Cornwall Hospitals Trust, service users and other providers to develop alternatives to hospital admission and to ensure the individual receives assessment and intervention as early as possible. This includes a notional budget assigned to Cornwall Partnership NHS Foundation Trust to implement the least restrictive option by delivering care to the individual in the community and prevent admission to hospital. The ‘alternative funding’ will facilitate access to a range of interventions that meet the needs of the individual as evidenced in the individual’s written care plan. This work commenced in October 2014 and will be reviewed in 2015 to assess the impact for individuals and the whole system.” Source location 2015-0044-Response-by-Kernow-CCG
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign alternative funding to support least-restrictive community care and interventions specified in individual care plans.
Verbatim wording from the response “As part of the health and social care community commitment to implementing the National Crisis Care concordat, NHS Kernow is working with Cornwall Partnership NHS Foundation Trust, Royal Cornwall Hospitals Trust, service users and other providers to develop alternatives to hospital admission and to ensure the individual receives assessment and intervention as early as possible. This includes a notional budget assigned to Cornwall Partnership NHS Foundation Trust to implement the least restrictive option by delivering care to the individual in the community and prevent admission to hospital. The ‘alternative funding’ will facilitate access to a range of interventions that meet the needs of the individual as evidenced in the individual’s written care plan. This work commenced in October 2014 and will be reviewed in 2015 to assess the impact for individuals and the whole system.” Source location 2015-0044-Response-by-Kernow-CCG
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review out-of-county placements and current provision with providers to inform future commissioning and service delivery.
Verbatim wording from the response “NHS Kernow is actively working with Cornwall Partnership NHS Foundation Trust and providers to review current provision and the needs of individuals who due to complex need and demand issues, are placed out of county. This review will inform future commissioning and service delivery.” Source location 2015-0044-Response-by-Kernow-CCG
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Decisions about the appropriate number of mental health beds in Cornwall are for local clinicians to make.
Verbatim wording from the response “As you heard during the inquest, the local Clinical Commissioning Group (CCG) is reviewing bed provision in Cornwall with the Cornwall Partnership Foundation Trust. Decisions about the appropriate number of beds to be commissioned in Cornwall are for local clinicians to make. I note that you have also sent your report to the CCG.” Source location 2015-0044-Response-by-Department-of-Health
Open published response
19 Nov 2014 George Christian Werb · Prevention of Future Deaths report Exeter & Greater Devon
View report summary
Concerns raised 2
Failure to provide locally accessible child psychiatric inpatient care View source Insufficient availability of child psychiatric inpatient beds View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
NHS England
Commission additional general CAMHS and psychiatric intensive-care capacity from existing providers, targeting 50 additional beds nationally.
View source
NHS England
Reopen Wessex House in phases to provide twelve generic CAMHS beds in the South West.
View source
NHS England
Commission additional Huntercombe capacity in Torquay, comprising six generic and four psychiatric intensive-care beds, through phased opening.
View source
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AI-generated summary
George Christian Werb · 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
George Christian Werb was receiving inpatient treatment for serious mental health issues and died after walking onto a railway track near his home while on home leave. The report raises concerns about the distant placement, inadequate risk assessment, poor communication and engagement with the family, and insufficient local child 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 Failure to provide locally accessible child psychiatric inpatient care
Wider context from the report “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients.
(2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time.
(3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support.
(4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need.
(5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties.
(6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care.
(7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.
” Source location George Christian Werb · 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 Insufficient availability of child psychiatric inpatient beds
Wider context from the report “(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients.
(2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time.
(3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support.
(4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need.
(5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties.
(6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met , and is impacting on patient care.
(7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.
” Source location George Christian Werb · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission additional general CAMHS and psychiatric intensive-care capacity from existing providers, targeting 50 additional beds nationally.
Verbatim wording from the response “NHS England has conducted two separate processes during 2014 to identify and commission additional inpatient general CAMHS and psychiatric intensive care capacity from existing providers that should result in an additional 50 beds nationally by the end of the financial year. This includes additional capacity in the South West area.” Source location 2014-0510-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reopen Wessex House in phases to provide twelve generic CAMHS beds in the South West.
Verbatim wording from the response “The South West region can now also report that Wessex House, Bridgewater, Somerset is now in the process of a phased reopening. There are currently four generic beds open, with a further four opening during January 2015 and the full twelve bed commitment will be open by March 2015. In addition there has been a further six generic beds and four Psychiatric Intensive Care Unit (PICU) beds commissioned from the Huntercombe Group with a unit now based in Torquay, Devon. Again this unit has a phased opening plan, with four generic beds currently open, a further two will open during January 2015 and the PICU beds will be available by the end of January 2015. In total this will give the South West a total of fifty two generic beds and four PICU beds.” Source location 2014-0510-Response-by-NHS-England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission additional Huntercombe capacity in Torquay, comprising six generic and four psychiatric intensive-care beds, through phased opening.
Verbatim wording from the response “The South West region can now also report that Wessex House, Bridgewater, Somerset is now in the process of a phased reopening. There are currently four generic beds open, with a further four opening during January 2015 and the full twelve bed commitment will be open by March 2015. In addition there has been a further six generic beds and four Psychiatric Intensive Care Unit (PICU) beds commissioned from the Huntercombe Group with a unit now based in Torquay, Devon. Again this unit has a phased opening plan, with four generic beds currently open, a further two will open during January 2015 and the PICU beds will be available by the end of January 2015. In total this will give the South West a total of fifty two generic beds and four PICU beds.” Source location 2014-0510-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The review identified contributory issues but could not conclusively establish that suicide would have been prevented without them or that distance caused the death.
Verbatim wording from the response “In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death.” Source location 2014-0510-Response-by-NHS-England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finding an available psychiatric bed is the responsibility of the referring community CAMHS team.
Verbatim wording from the response “Finding a bed is the responsibility of the referring community CAMHS team and they would have contacted available units and taken the bed that was made available to them. Whilst every effort is made to keep patients/children and young people as close to home as possible, sometimes lack of available beds mean that this cannot always happen.” Source location 2014-0510-Response-by-NHS-England
Open published response
23 May 2014 Samarjit Natasha SINGH · Prevention of Future Deaths report The Wirral
View report summary
Concerns raised 1
Lack of a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Samarjit Natasha SINGH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Samarjit Natasha Singh developed postnatal depression after giving birth to her son and had acts of deliberate self-harm and a threat of self-harm. On 4 December 2012, she was found in cardiac arrest following hanging and sustained an irreversible hypoxic brain injury; she died the following day. The report identified concerns about the absence of a Specialist Community Perinatal Mental Health Service and a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region.
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 a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region
Wider context from the report “Mrs Singh suffered from severe postnatal depression following the birth of her son. Clearly she needed to be with her son whilst she was being treated for her perinatal mental health issues, given his needs.
1. There was no Specialist Community Perinatal Mental Health Service in the Wirral to meet both her son’s and her needs. The treatment that was available was sub-optimal.
2. There is not a Mother and Baby Perinatal Mental health—in-patient Unit in the Liverpool City Region serving the needs of Lancashire, Merseyside and East Cheshire . 50% of referrals from this area to the Manchester Unit decline because it is too far from family and support networks but more relevantly from older sibling children who remain in the family home
” Source location Samarjit Natasha SINGH · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and nationally consult on a specification for specialised perinatal mental health services.
Verbatim wording from the response “NHS England has had responsibility for commissioning the ‘Specialised’ element of this pathway (Mother and Baby in-patient Units) since April 2013. A specification for these specialised perinatal services was developed by the NHS England specialised perinatal Clinical Reference Group, which comprises representatives from across the country with both clinical members and patients/Carers. The specification was subject to national consultation and NHS England work with the Royal College to develop quality standards.” Source location 2014-0239-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact NHS England network representatives and discuss commissioning inpatient mother-and-baby units at the next available regional Perinatal Group.
Verbatim wording from the response “With regards to the second point that you raise, the commissioning of mother and baby units is within the commissioning responsibility of Specialised Commissioning, which sits with NHS England. NHS England has set up Strategic Clinical Networks and ████████ had been appointed as Clinical Network Lead (Maternity Services) for Cheshire & Merseyside Strategic Clinical Network for Maternity Children & Young People; we are in the process of contacting ████████ along with ████████ to ensure that your second concern, regarding the commissioning of inpatient units, is discussed at the next available regional Perinatal Group, and that the commissioning of these units is discussed in light of this incident and the risks highlighted. We will continue to work with NHS England to ensure a partnership approach to this issue, with the aim of achieving seamless patient care across the whole pathway.” Source location 2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regional commissioning and the Manchester Mother and Baby Unit are considered sufficient for North West demand, with neighbouring units available when necessary.
Verbatim wording from the response “Mother and Baby Units fall under this category of service and are therefore commissioned on a regional, rather than local, basis. This ensures that those very specialised qualifications, clinical skills and experience required to treat the patient group can be maintained and that the service can be commissioned cost-effectively, making best use of public funds. If there were to be a Mother and Baby unit in every major city, the use of the service by that city’s population would be minimal and clinicians would quickly lose their specialist knowledge and skills because of infrequent use. It would also be inefficient because of the low demand.” Source location 2014-0239-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioning mother and baby units is the responsibility of NHS England’s Specialised Commissioning, not the CCG.
Verbatim wording from the response “With regards to the second point that you raise, the commissioning of mother and baby units is within the commissioning responsibility of Specialised Commissioning, which sits with NHS England. NHS England has set up Strategic Clinical Networks and ████████ had been appointed as Clinical Network Lead (Maternity Services) for Cheshire & Merseyside Strategic Clinical Network for Maternity Children & Young People; we are in the process of contacting ████████ along with ████████ to ensure that your second concern, regarding the commissioning of inpatient units, is discussed at the next available regional Perinatal Group, and that the commissioning of these units is discussed in light of this incident and the risks highlighted. We will continue to work with NHS England to ensure a partnership approach to this issue, with the aim of achieving seamless patient care across the whole pathway.” Source location 2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
Open published response
13 Feb 2014 Lisa Marie Inkin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Shortage of local general adult psychiatric inpatient beds View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Lisa Marie Inkin · 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
Lisa Marie Inkin, who had severe anorexia nervosa and was on home leave from an eating disorders unit, took her own life by diving in front of a train at Victoria Station on 9 April 2013. The report raised concerns about the lack of local specialist inpatient eating disorder services, communication between local and out-of-area providers, inadequate escalation of information about suicidal intent, possible failures to record or answer calls, and the proposed lack of overnight supervision and transport difficulties in Kent.
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 local general adult psychiatric inpatient beds
Wider context from the report “1. The shortage of local General Adult Psychiatric in-patient beds .
” Source location Lisa Marie Inkin · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.