Recurring concern

Failure to provide safe accommodation for inpatient mental health patients

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First reported 1 Nov 2018•Latest report 1 Feb 2023

Definition

What this concern includes

Includes deficiencies in accommodation design, room configuration, privacy, suitability, environmental safety or dedicated arrangements for delivering required care within inpatient mental health facilities, including inappropriate dormitory accommodation and inadequate accommodation-specific plans for enhanced care.

Not included

  • Excludes general inpatient mental-health care, staffing, observation or treatment failures that are not specifically tied to the safety or suitability of the accommodation.
  • Excludes generic building, maintenance or environmental deficiencies without a direct inpatient mental-health accommodation safety connection.
  • Excludes failures in discharge, placement or bed-capacity arrangements where the unsafe condition is not the suitability or safe operation of the accommodation provided.
  • Excludes generic care-planning or communication deficiencies unless they directly concern adapting or safely operating inpatient mental health accommodation.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2018–2023

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1
Langley Trust1
NHS Central East Integrated Care Board1
NHS England1

Concerns and responses across reports

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

  1. Gwent

    AI-generated summary

    Mary Doreen White · 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

    Mary Doreen White was admitted to hospital in April 2021 and suffered three falls while an inpatient, including fractures requiring surgery. Her condition deteriorated while recovering from surgery, and she died from a chest infection, with frailty of old age also recorded. Concerns included staffing shortages, difficulties providing required enhanced observation on the ward, and the absence of a documented and communicated plan for managing patients requiring Level 4 enhanced care in that setting.

    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 made and communicated plan for managing Level 4 patients in a single-room environment

    Wider context from the report

    “A Falls Review Panel had noted that Providing Level 4 Enhanced Care on this ward was extremely challenging and that quality care at Level 4 was unachievable in a single room environment. It was noted that the Corporate Nursing Team had reviewed the Enhanced Care Policy in light of the fact it did not fit single room environment, however at the time of the inquest it did not appear from evidence received that a plan to manage Level 4 patients on this ward had been made and/or communicated to staff. ”

    Source location

    Mary Doreen White · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Joy Burgess · 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

    Joy Burgess died by suicide on 9 June 2021 as a consequence of multiple injuries. She had complex mental health difficulties, was experiencing deteriorating mental health and thoughts of self-harm, and had left hospital because she found the ward environment busy and extremely noisy. The concerns identified were that mental health wards could be unsuitable for recovery and that patients experienced lengthy waits for psychological therapies.

    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

    Inability to provide mental health patients with an environment conducive to recovery

    Wider context from the report

    “1. The Court heard evidence that the mental health ward environment could be ‘chaotic’ (in the words of one Consultant Psychiatrist) and that resources and demands on inpatient beds were such that staff were not always able to care for patients in a suitable environment. It is a matter of concern that mental health patients are, on occasion, cared for in an environment which is very obviously not conducive to recovery. ”

    Source location

    Joy Burgess · 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

    Modernise inpatient mental health environments and eradicate dormitory accommodation to improve patient safety, privacy and dignity.

    Verbatim wording from the response

    “We recognise the importance of providing an environment that feels safe and comfortable for people receiving treatment in mental health inpatient care. I understand that in their Concise Investigation Report, the Trust acknowledged that Ms Burgess’s experience on the Taylor ward fell short of the expected standard. You may wish to note that the Government is committed to upgrading the physical environment for inpatient mental health care, and we are already taking steps to modernise inpatient environments and improve patient experience. We are investing more than £400 million over the 4 years up to 2024/25 to eradicate dormitory accommodation from mental health facilities to improve”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 7 February 2022

    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 £150 million in mental health estate improvements, including safer facilities, accident and emergency-linked services, and new mental health ambulances.

    Verbatim wording from the response

    “In addition, we are investing £150 million for significant improvements to the mental health estate, including investing in NHS mental health facilities linked to accident and emergency departments, enhancing patient safety in mental health units, and new mental health ambulances.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 7 February 2022

    Open published response

  3. Cheshire

    AI-generated summary

    Katharine Mary DOWLING · 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

    Katharine Mary Dowling, who had autism spectrum disorder and co-existing mental health issues, self-ligatured while receiving care on an acute psychiatric ward and died in hospital. The concerns included inadequate integration of autism into care planning, insufficient autism training and specialist input, an inappropriate ward environment, inconsistent observations, and wider variation in national guidance and support.

    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

    Limited availability of ASD-appropriate inpatient environments

    Wider context from the report

    “Environment ASD-appropriate environments for in-patients diagnosed with ASD and who have a co-existing mental health diagnosis / diagnoses appear to be limited, nationally. If, as a consequence of that, such patients are placed on acute psychiatric wards, potentially for several months (as in this case), they may be at greater risk of suicide. ”

    Source location

    Katharine Mary DOWLING · 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

    Consider capital funding requirements for improving therapeutic mental-health inpatient environments.

    Verbatim wording from the response

    “The Independent Review of the Mental Health Act called on the government and the NHS to commit in the 2019 Spending Review to a major multi-year capital investment programme to modernise the NHS mental health estate and improve inpatient environments. It was identified that steps were needed to make inpatient environments more therapeutic, including co-designing wards with people with lived-in experience in line with the reasonable adjustment duty, to ensure people with learning disabilities (‘LD’), autism, or both are not unnecessarily distressed by their environment.”

    Source location

    2019-0089-Response-by-NHS-Engalnd2
    Page 4 · response
    Published 11 June 2019

    Open published response

  4. Milton Keynes

    AI-generated summary

    Billie Jonathan LORD · 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

    Billie Jonathan LORD died from suicide on 11 July 2017 after suffering from psychosis, autism and a psychotic illness associated with non-prescription drug use. He had been admitted voluntarily to the Campbell Centre and was being monitored by intermittent 15-minute observations before absconding and entering the path of a high-speed train. The concern raised was that three-bed dormitory accommodation at the Campbell Centre was inappropriate and may have added to the stress experienced by the patient; a review of the accommodation was suggested.

    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 single-room accommodation for in-patient mental health patients

    Wider context from the report

    “During the course of the evidence I was informed by an independent expert that it is recognised that patients admitted to an in-patient mental health facility, such as the Campbell Centre, should be cared for in single rooms and that three bedded dormitory accommodation is inappropriate since in this particular case it added to the level of stress suffered by the patient. Consideration should be given to a review of the accommodation provided at the Campbell Centre, and whether alterations can be carried out to bring the accommodation up to modern standards as recommended by the Royal College of Psychiatrists. ”

    Source location

    Billie Jonathan LORD · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026