Recurring concern

Insufficient and unsafe crisis-house provision for patients needing crisis care

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First reported 3 Feb 2014•Latest report 20 Feb 2025

Definition

What this concern includes

Includes failures in the dedicated crisis-house care arrangement, including insufficient beds or availability and inadequate clinical capacity, skills mix or capability for patients placed or awaiting placement in a crisis house.

Not included

Excludes shortages or inadequacy of acute mental-health hospital beds unless the assertion specifically concerns the crisis-house provision.
Excludes failures of crisis-team assessment, referral or response where crisis-house care is not the deficient arrangement.
Excludes inappropriate placement of a particular patient in an adult crisis house where the shared unsafe condition is age-inappropriate placement rather than the adequacy or availability of crisis-house provision.
Excludes generic mental-health service capacity, staffing or funding concerns without a direct crisis-house provision connection.

Reports: 3
Individual concerns: 4
Date range: 2014–2025
Stated actions: 4

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

NHS Cumbria Clinical Commissioning Group1

North London NHS Foundation Trust1

Concerns and responses across reports

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

20 Feb2025
Inner North London
Concerns raised1
1. Delays in reattempting crisis-house placement after a disputed refusal
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Require senior clinical review, an alternative plan, documented accountability and formal escalation before finalising any declined crisis house referral.
  Stated by North London NHS Foundation TrustStated completed
2. Action
  Provide clinicians with 24/7 Crisis Hub access to senior clinical advice for urgent escalation and referral guidance.
  Stated by North London NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  The referring team is responsible for reviewing declined referrals and agreeing an alternative plan.
  Stated by North London NHS Foundation TrustRedirects responsibility
AI-generated summary

Hayley Joanne BEAVINGTON · 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

Slightly before 1am on 21 September 2024, Hayley Joanne Beavington jumped from the fifth-floor balcony of her home and died by suicide after being discharged from hospital the previous day. The substantive concerns relate to the failure to secure a place for her at a local crisis house despite concerns about cuckooing and a view that she was definitely at risk of suicide, and the lack of instructions to challenge that decision.

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 reattempting crisis-house placement after a disputed refusal
Wider context from the report
“When planning for Ms Beavington’s discharge from hospital, it was agreed that the best place for her to go was a local crisis house. Upon application, the foundation year 1 doctor (FY1) was told by the crisis house team that this was not possible because: - Ms Beavington had secure accommodation; and - she was no longer actively suicidal. This was despite the fact that: - there was a strong suspicion that Ms Beavington was the victim of cuckooing in her own home; and - the team view was that she was definitely at risk of suicide. The consultant psychiatrist in charge of Ms Beavington’s care did not give the FY1 any instructions as to how to challenge the decision that the consultant believed was wrong. Instead, the consultant instructed the FY1 to leave it for three days and then just try again in the same way. By this time, Ms Beavington decided that she had waited too long and did not want another attempt to be made. Ms Beavington was discharged home and killed herself at 1am the next morning. ”
Source location
Hayley Joanne BEAVINGTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require senior clinical review, an alternative plan, documented accountability and formal escalation before finalising any declined crisis house referral.

Verbatim wording from the response
“• All declined referrals must now be escalated for senior clinical review before a final decision is made; this will ensure that no referral is left without further review and will seek to reduce the risk of missed opportunities for intervention.”

Source location
Response from North London NHS Foundation Trust
Page 2 · response
Published 25 February 2025
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 clinicians with 24/7 Crisis Hub access to senior clinical advice for urgent escalation and referral guidance.

Verbatim wording from the response
“• The Crisis Hub Health Professional Line now provides 24/7 access for clinicians needing urgent escalation or referral guidance. This guarantees that immediate support is available, reducing the risk of delays.”

Source location
Response from North London NHS Foundation Trust
Page 2 · response
Published 25 February 2025
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 referring team is responsible for reviewing declined referrals and agreeing an alternative plan.

Verbatim wording from the response
“• The pathway has been reviewed to make it clear that in the event of a referral being declined it is the responsibility of the referring team to review and agree an alternative plan.”

Source location
Response from North London NHS Foundation Trust
Page 3 · response
Published 25 February 2025
Open published response
18 Oct2024
Northamptonshire
Concerns raised2
1. Failure of crisis houses to provide ligature-safe environments
2. Insufficient clinical capacity and skills mix in crisis houses
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Request an NHS England report from the relevant integrated care board on local actions to prevent recurrence.
  Stated by Department of Health and Social CareStated planned
Respondent positions 1
1. Position
  Local ICBs and authorities are responsible for arranging crisis house provision and addressing concerns about specific facilities.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Mr Robin Andrew Ward · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of crisis houses to provide ligature-safe environments
Wider context from the report
“a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”
Source location
Mr Robin Andrew Ward · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient clinical capacity and skills mix in crisis houses
Wider context from the report
“a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”
Source location
Mr Robin Andrew Ward · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Request an NHS England report from the relevant integrated care board on local actions to prevent recurrence.

Verbatim wording from the response
“Where there are concerns about the provision provided in specific crisis houses, local ICBs and/or local authorities are best placed to address these as the organisations responsible for decisions about the provision of services in their area. I have asked NHS England to provide me with a report from the ICB detailing the local position so that I can understand what actions are being taken locally to prevent such a case from happening again.”

Source location
Response from Department of Health and Social care
Page 2 · response
Published 28 July 2026
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Local ICBs and authorities are responsible for arranging crisis house provision and addressing concerns about specific facilities.

Verbatim wording from the response
“Local integrated care boards (ICBs) and commissioning partners such as local authorities have flexibility to decide how to arrange the provision of crisis houses and similar facilities in their local area. However, in providing this flexibility, we expect crisis house services to be designed in a way which aligns with national requirements and guidance and local structures, to ensure appropriate safeguarding processes are in place.”

Source location
Response from Department of Health and Social care
Page 2 · response
Published 28 July 2026
Open published response
3 Feb2014
North and West Cumbria
Concerns raised1
1. Insufficient availability of crisis home beds
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop improved mental health pathways, including the configuration of community and bed-based crisis services across the county.
  Stated by NHS Cumbria Clinical Commissioning GroupStated planned
AI-generated summary

Amanda Jane Vickers · Prevention of Future Deaths report

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

Report summary

Amanda Jane Vickers had a long history of depression and suicidal ideation and was found hanging at her home on 22 August 2013. She was awaiting admission to 81 Lowther Street Crisis Home, but no place was immediately available; the report raised concern that this six-bedded unit was the only facility of its type in the county and suggested reviewing the availability of 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
Insufficient availability of crisis home beds
Wider context from the report
“This lady died whilst awaiting a place at 81 Lowther Street Crisis Home. She had been there before and found it therapeutic. No space was available, and no date when one might arise was known. She died whilst waiting for admission. The evidence was that this 6-bedded unit is the only one of its type in the whole county. It is understood that the CCG is responsible for commissioning such facilities. On the balance of probability an admission would have made a difference in this case. A review of the facilities available is suggested with a view to the provision of a greater number of beds for patients such as the deceased. ”
Source location
Amanda Jane Vickers · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop improved mental health pathways, including the configuration of community and bed-based crisis services across the county.

Verbatim wording from the response
“The independent review of mental health is due to report back at the end of May 2014. This will inform the future provision of mental health and wellbeing strategy from 2014. This is with a view to developing a new Mental Health Strategy for our County and will have a significant impact on public/patient consultation. Both of these elements will have a significant impact in informing the development of improved mental health pathways which will include configuration of community and bed-based crisis services across the county.”

Source location
2014-0052-Response-by-Cumbria-Clinical-Commissioning-Group
Page 1 · response
Published 3 February 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in reattempting crisis-house placement after a disputed refusal

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure of crisis houses to provide ligature-safe environments

Insufficient clinical capacity and skills mix in crisis houses

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Insufficient availability of crisis home beds

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 2

Respondent positions 1

Actions described in response 1

Respondent positions 1

Actions described in response 1