7 May 2026 Elsie Margaret Jones · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2
Delays in finding suitable specialist placements for patients with severe dementia View source Delays in securing funding for specialist placements for patients with severe dementia View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Elsie Margaret Jones · Prevention of Future Deaths report
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Report summary
Elsie Margaret Jones, who had advanced dementia and was at high risk of falling, spent several months in hospital while awaiting discharge to a specialist service. She experienced several falls, including a fall on 1 November 2025 that caused a hip fracture, and died on 16 November 2025 after receiving palliative care. The concern was that lengthy delays in securing funding and suitable specialist placements for patients with severe dementia can leave them inadequately supervised on acute hospital wards, creating a risk of future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in finding suitable specialist placements for patients with severe dementia
Wider context from the report “The inquest heard evidence that patients who suffer from severe dementia who need specialist placements often spend many months in hospital whilst funding and suitable placements are being found. Given the resources available on acute hospital wards this puts these patients at risk as they cannot always be adequately supervised. I am concerned that the lengthy delays in securing funding and finding suitable placements for these most vulnerable patients creates a risk of future deaths and I consider action should be taken.
” Source location Elsie Margaret Jones · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in securing funding for specialist placements for patients with severe dementia
Wider context from the report “The inquest heard evidence that patients who suffer from severe dementia who need specialist placements often spend many months in hospital whilst funding and suitable placements are being found. Given the resources available on acute hospital wards this puts these patients at risk as they cannot always be adequately supervised. I am concerned that the lengthy delays in securing funding and finding suitable placements for these most vulnerable patients creates a risk of future deaths and I consider action should be taken.
” Source location Elsie Margaret Jones · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with NHS England, CQC and local partners to improve discharge timeliness and ensure safe, appropriate care and supervision for people with severe dementia.
Verbatim wording from the response “We will continue to work closely with NHS England, CQC and local partners to address the risks identified in your report, including improving the timeliness of discharge and ensuring that people with severe dementia receive safe, appropriate care and supervision.” Source location Response from Department of Health and Social Care
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Concerns raised 2
Failure of the acute paediatric ward to provide a secure, suitable setting for children and young people with mental health concerns View source Unavailability of Tier 4 paediatric mental health beds for children and young people remaining on acute paediatric wards View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Ellame FORD-DUNN · Prevention of Future Deaths report
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Report summary
Ellame FORD-DUNN, aged 16, was detained on an acute paediatric ward because no Tier 4 Paediatric Mental Health bed was available. She absconded from the ward during a toilet visit and died following her absconding. The principal concerns included insufficient Tier 4 beds, inadequate security and risk management, inconsistent handovers and unclear procedures for responding to absconsion, and poor coordination between agencies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the acute paediatric ward to provide a secure, suitable setting for children and young people with mental health concerns
Wider context from the report “3. I heard that at Worthing Hospital the Acute Paediatric Ward has been altered since Ellame’s death but due to fire regulations cannot be locked in the same way as a Tier 4 Paediatric Mental Health Unit would be and is not designed for the admission and treatment of children and young people with mental health concerns . I heard that the staff are not able to provide the mental health care that these patients are considered to require in their setting.
” Source location Ellame FORD-DUNN · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of Tier 4 paediatric mental health beds for children and young people remaining on acute paediatric wards
Wider context from the report “2. I heard from clinicians at University Hospitals Sussex NHS Foundation Trust that they continued to have on acute paediatric wards a number of children and young people who have no physical medical needs for which they requirement treatment in an acute hospital but do not have packages of care in the community in place or a Tier 4 Paediatric Mental Health bed available to be admitted to .
” Source location Ellame FORD-DUNN · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an NHS Estates Technical Bulletin on therapeutic paediatric ward design, incorporating safety investigation findings and wider evidence.
Verbatim wording from the response “• Led by clinical advisors, policy teams are currently working with NHSE’s Estates team to produce an NHS Estates Technical Bulletin (NETB) on the design of the paediatric ward. This will incorporate recommendations from the Health Services Safety Investigations Body (HSSIB) and wider evidence on the importance of a therapeutic environment for children and young people with a mental health need.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish implementation guidance defining a comprehensive 24/7 urgent and emergency mental health offer for children and young people.
Verbatim wording from the response “In 2024, NHS England published updated implementation guidance on urgent and emergency mental health care for children and young people, which set out the components of a comprehensive 24/7 offer that must be available to all children and young people experiencing mental health crisis. As well as a single point of access through NHS 111, the offer should include brief interventions in the community and intensive home treatment, avoiding admissions to hospital where these are not necessary and helping to ensure that beds are available for those who do need them.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish intensive home treatment services across Sussex as an alternative to hospital admission where safe.
Verbatim wording from the response “From a regional perspective, there has been substantial investment in Intensive Home Treatment Services (COAST) in Sussex, either directly via NHS England funded schemes or directly via the Lead Provider Trust and/or Sussex ICB and Sussex Partnership NHS Foundation Trust. These services have been co-produced with young people with lived experience and their parents, families and carers. These services, now established across all counties in the Sussex Integrated Care System (ICS) geography, currently provide:” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide early discharge planning through intensive home treatment services to reduce prolonged hospital stays and dependence on inpatient admission.
Verbatim wording from the response “From a regional perspective, there has been substantial investment in Intensive Home Treatment Services (COAST) in Sussex, either directly via NHS England funded schemes or directly via the Lead Provider Trust and/or Sussex ICB and Sussex Partnership NHS Foundation Trust. These services have been co-produced with young people with lived experience and their parents, families and carers. These services, now established across all counties in the Sussex Integrated Care System (ICS) geography, currently provide:” Source location Response from NHS England
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5 Jun 2025 David Thomas BENDELL · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Lack of a step-down community rehabilitation facility for patients unsuitable for inpatient rehabilitation but unsafe at home View source
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AI-generated summary
David Thomas BENDELL · 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
David Bendell fell while trying to use a commode at home after being discharged from hospital following a stroke, and later died in hospital from a large brain bleed. The report raises concern that rehabilitation options limited to specialist inpatient care or treatment at home may place people who cannot safely manage alone at risk when discharged home.
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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 step-down community rehabilitation facility for patients unsuitable for inpatient rehabilitation but unsafe at home
Wider context from the report “4. In evidence it was heard that David’s condition was such that he was not a candidate for hospital-based rehabilitation on a specialist stroke rehabilitation ward. This meant that the only available treatment option for David was to treat him at home.
5. The court was told that there is no step-down community rehabilitation facility to act as a ‘half way house’ for patients like David, if like David they are not eligible for inpatient rehabilitation, but are in reality not physically capable of keeping themselves safe when alone at home .
6. I am therefore concerned that with the current rehabilitation options available being either in a specialist hospital ward or at home , other individuals in David’s situation who are not deemed suitable for in-patient hospital, will also be placed at risk by being sent home when it is not safe to do so .
” Source location David Thomas BENDELL · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrated Care Boards are responsible for commissioning stroke services, including rehabilitation.
Verbatim wording from the response “Commissioning of stroke services, including rehabilitation, is the responsibility of Integrated Care Boards (ICB).” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Shortage of mental health beds suitable for Autistic patients and transgender patients requiring a mixed ward View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report
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Report summary
Matthew Zak Sheldrick (Matty), who identified as non-binary, had a history of mental health difficulties and was admitted to A&E in crisis on 3 November 2022 after a previous 26-day wait for a psychiatric bed. After being assessed under the Mental Health Act and not detained, Matty left hospital and was found hanging in the hospital grounds. Concerns included shortages and long waits for mental health beds, the unsuitability of A&E for neurodivergent patients, gaps in services and discharge planning, and shortcomings in the mental health assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Shortage of mental health beds suitable for Autistic patients and transgender patients requiring a mixed ward
Wider context from the report “2. There being a national shortage of mental health beds in particular for Autistic patients and those who are transgender requiring a mixed ward.
” Source location Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local trusts and health systems are responsible for assessing and managing mental-health bed capacity and patient flow.
Verbatim wording from the response “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local provider-level inpatient accommodation availability falls outside NHS England’s national policy and programme remit.
Verbatim wording from the response “Your Report raises concerns about the service provision and availability of services for patients suffering with their mental health, and the appropriateness of the Emergency Department as an environment for people who are autistic and/or neurodiverse to be held as they await a mental health bed. My response to the Coroner addresses the issues raised that sit within NHS England’s national policy and programme remit.” Source location Response from NHS England
Open published response
Concerns raised 2
Unclear access and eligibility criteria for specialist rehabilitation provision View source Lack of specialist rehabilitation accommodation for women at low or medium risk of harm to others and high risk of self-harm View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Kirsten Hocking · 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
Kirsten Hocking, aged 31, died in hospital on 24 May 2023 as a result of a heroin overdose after being released from prison and found in a public toilet. The concerns identified included a lack of specialist rehabilitation accommodation for some women leaving prison, training needs for probation officers arranging accommodation and release plans, and unclear placement-offer and decision-making systems at a specialist accommodation charity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unclear access and eligibility criteria for specialist rehabilitation provision
Wider context from the report “Concern (1) is that there was and remains a real lack of specialist rehabilitation for women, and in particular, women who represent only a low or medium risk of harm to others, but a high risk of self-harm. This cohort are for the most part shut out from Approved Premises (“AP”) (it appears that it is possible for medium risk women to be admitted to an AP but that possibility is not well understood and the reality is that it is not available; that kind of accommodation being very over-subscribed in any event). This means there is little or no effective system of rehabilitative provision for that cohort. This is a cohort in which the state has invested a great deal of time and money (in imprisoning and rehabilitative work) only, the evidence suggests, for that investment to be at risk of being squandered on release. It also means that provision can become dependant on small charities and related acts of individual generosity, which is patchwork and may bring problems of unclear access and unclear criteria (as happened here). The evidence was that this was being looked at by the Probation Service, which does not generally provide specialist rehabilitation accommodation itself but which has an obvious interest in it being available and so is monitoring the situation. However the evidence was also that the situation is getting worse not better, particularly for women (who tend to have higher levels of self-harm), and this is despite things like the Corston review in 2007 and the case of Voll SVJ seen later, which found discrimination because of the gender disparity with respect to the availability of APs. There is now a similar lack, and apparent gender impact, with regard to specialist rehabilitation accommodation too. The circumstances creating the risk of other deaths therefore subsist, and might benefit from some renewed focus.
” Source location Kirsten Hocking · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of specialist rehabilitation accommodation for women at low or medium risk of harm to others and high risk of self-harm
Wider context from the report “Concern (1) is that there was and remains a real lack of specialist rehabilitation for women, and in particular, women who represent only a low or medium risk of harm to others, but a high risk of self-harm . This cohort are for the most part shut out from Approved Premises (“AP”) (it appears that it is possible for medium risk women to be admitted to an AP but that possibility is not well understood and the reality is that it is not available; that kind of accommodation being very over-subscribed in any event). This means there is little or no effective system of rehabilitative provision for that cohort . This is a cohort in which the state has invested a great deal of time and money (in imprisoning and rehabilitative work) only, the evidence suggests, for that investment to be at risk of being squandered on release. It also means that provision can become dependant on small charities and related acts of individual generosity, which is patchwork and may bring problems of unclear access and unclear criteria (as happened here). The evidence was that this was being looked at by the Probation Service, which does not generally provide specialist rehabilitation accommodation itself but which has an obvious interest in it being available and so is monitoring the situation. However the evidence was also that the situation is getting worse not better, particularly for women (who tend to have higher levels of self-harm), and this is despite things like the Corston review in 2007 and the case of Voll SVJ seen later, which found discrimination because of the gender disparity with respect to the availability of APs. There is now a similar lack, and apparent gender impact, with regard to specialist rehabilitation accommodation too . The circumstances creating the risk of other deaths therefore subsist, and might benefit from some renewed focus.
” Source location Kirsten Hocking · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a Central Referral Process with a dedicated Female Central Referral Unit Manager to assess women’s need for Approved Premises placements.
Verbatim wording from the response “With specific reference to the female Approved Premises estate, the need to accommodate women with a wide range of needs is recognised and the estate does aim to accommodate women with complex needs who may pose a medium risk of harm. There is a new Central Referral Process which is managed by a dedicated Female Central Referral Unit Manager who has experience of such cases and can best assess the need for an AP space. Such spaces are also available for women who are subject to a community-based disposal, not just for those on licence release.” Source location Response from HMPPS
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Concerns raised 1
Lack of available suitable placements for people with complex needs View source
This report raised 1 other concern. 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.
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AI-generated summary
DECLAN GORDON GERARD MORRISON · 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
Declan Morrison, who had complex care needs and required 24-hour residential care, was detained under the Mental Health Act after no suitable alternative placement could be found. He was found unresponsive after suffering catastrophic brain injuries and died in hospital on 2 April 2022. The principal concerns were the shortage of suitable community and NHS placements and the use of a Section 136 Suite considered inappropriate for his longer-term detention and complex needs.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of available suitable placements for people with complex needs
Wider context from the report “(1) The evidence revealed that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS .
(2) Once it was clear that Declan’s community placement had broken down in late 2021 no suitable alternative could be found . This resulted in a decline in Declan’s mental health and behaviour which ultimately necessitated his detention under the Mental Health Act. There was then nowhere suitable to detain him under Section 2 of the Mental Health Act .
(3) The Section 136 Suite was completely inappropriate. Declan’s mental health and behaviour declined further and ultimately this resulted in his death.
(4) Declan was in crisis for several months – the facilities were simply not available in the community and once detained , in order to prevent his death.
” Source location DECLAN GORDON GERARD MORRISON · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop solutions and contingency plans for crises where accommodation or staffing is unavailable.
Verbatim wording from the response “The Cambridgeshire and Peterborough Learning Disability and Autism Board reports into the ICB Quality Performance and Finance Committee and has a Quality Improvement Programme work underway. One of the five priority programmes of work across the system to find a solution and build contingency plans and processes for when there is no accommodation and or no staffing available to meet the needs of someone who has a learning disability and is in mental health crisis. Locally, a short pilot community crisis bed model was implemented from November 2023 to April 2024 with service development funds from NHS England and the understanding from this pilot is informing the improvement work which will report to the ICB Quality Performance and Finance Committee in early 2025.” Source location Response from Cambridgeshire and Peterborough Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a community crisis bed pilot to help avoid hospital admission.
Verbatim wording from the response “The Cambridgeshire and Peterborough Learning Disability and Autism Board reports into the ICB Quality Performance and Finance Committee and has a Quality Improvement Programme work underway. One of the five priority programmes of work across the system to find a solution and build contingency plans and processes for when there is no accommodation and or no staffing available to meet the needs of someone who has a learning disability and is in mental health crisis. Locally, a short pilot community crisis bed model was implemented from November 2023 to April 2024 with service development funds from NHS England and the understanding from this pilot is informing the improvement work which will report to the ICB Quality Performance and Finance Committee in early 2025.” Source location Response from Cambridgeshire and Peterborough Integrated Care Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Made £124 million available to local areas for community services preventing mental health hospital admission.
Verbatim wording from the response “In 2024/25, NHS England made available £124 million for local areas to invest in community services to help prevent the need for admission to mental health hospitals for people with a learning disability and autistic people. In line with the commitments set out in the NHS Long-Term Plan published in 2019, we would expect local areas to have community alternatives to hospital in place, including crisis and intensive support for people at greatest risk of admission.” Source location Response from NHS England
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PFD Monitor interpretation Developed and published guiding principles for integrated care systems to commission appropriate community services.
Verbatim wording from the response “NHS England has worked with the Local Government Association and the Association of Directors of Adult Social Service to develop a set of guiding principles, published in 2023 (NHS England » Joint guiding principles for integrated care systems – learning disability and autism) for integrated care systems, setting out how partners in local” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commissioned six Neighbourhood Mental Health Centres providing 24/7 community support, crisis intervention, and open-access beds.
Verbatim wording from the response “NHS England has also commissioned six new Neighbourhood Mental Health Centres, offering 24/7 community support for individuals with serious mental illness. These centres integrate crisis intervention, community support, and open access beds to facilitate extra support, tailored to local needs. This includes support for people who have a learning disability and who are autistic. These Mental Health Centres in local neighbourhoods enable individuals to visit without a referral, to receive help from a range of professionals including psychiatrists, social workers, and peer support workers, and support such as psychological therapies, medication support, and assistance with related issues such as housing or employment. Each centre, led by an NHS provider, will work in partnership with people with lived experience, as well as voluntary, charity, faith and social enterprise organisations.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue the two-year pilot programme supporting six neighbourhood mental health centres through 2025/26.
Verbatim wording from the response “NHS England has also commissioned six new Neighbourhood Mental Health Centres, offering 24/7 community support for individuals with serious mental illness. These centres integrate crisis intervention, community support, and open access beds to facilitate extra support, tailored to local needs. This includes support for people who have a learning disability and who are autistic. These Mental Health Centres in local neighbourhoods enable individuals to visit without a referral, to receive help from a range of professionals including psychiatrists, social workers, and peer support workers, and support such as psychological therapies, medication support, and assistance with related issues such as housing or employment. Each centre, led by an NHS provider, will work in partnership with people with lived experience, as well as voluntary, charity, faith and social enterprise organisations.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Mental Health Bill proposing Dynamic Support Register duties for people with learning disabilities and autistic people at risk of detention.
Verbatim wording from the response “As highlighted in your report, when no suitable placement could be found Declan was then detained under Section 2 of the Mental Health Act. Through our proposed reforms to the Mental Health Act 1983 (MHA), as set out in the Mental Health Bill introduced to parliament on 6th November 2024, integrated care boards (ICBs) will have a legal duty to ensure hold Dynamic Support Registers of people with a learning disability and autistic people who have risk factors for detention under Part II of the MHA. The Dynamic Support Register is intended to improve monitoring of the needs of, and support for, people who may be at risk of going into crisis and being detained under Part II of the MHA.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ICB generally does not commission welfare placements alone because they are not medical-treatment beds.
Verbatim wording from the response “We agree that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS. Generally, we do not commission these beds on our own as an ICB as they tend to be for welfare and not for medical treatment. We do tend to commission these beds jointly with our Local Authority colleagues. As availability of these types of beds is a nation-wide issue, we have raised our concerns on the difficulty in finding them with NHS England.” Source location Response from Cambridgeshire and Peterborough Integrated Care Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Community and NHS placements are generally commissioned jointly with Local Authority colleagues rather than by the ICB alone.
Verbatim wording from the response “We agree that there is currently a widespread shortage of available placements for someone with Declan’s complex needs both in the community and within the NHS. Generally, we do not commission these beds on our own as an ICB as they tend to be for welfare and not for medical treatment. We do tend to commission these beds jointly with our Local Authority colleagues. As availability of these types of beds is a nation-wide issue, we have raised our concerns on the difficulty in finding them with NHS England.” Source location Response from Cambridgeshire and Peterborough Integrated Care Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local areas are responsible for establishing community alternatives and support for people at risk of mental health hospital admission.
Verbatim wording from the response “In 2024/25, NHS England made available £124 million for local areas to invest in community services to help prevent the need for admission to mental health hospitals for people with a learning disability and autistic people. In line with the commitments set out in the NHS Long-Term Plan published in 2019, we would expect local areas to have community alternatives to hospital in place, including crisis and intensive support for people at greatest risk of admission.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Cambridgeshire and Peterborough Integrated Care Board is the responsible commissioner for the individual’s care and service development.
Verbatim wording from the response “We note that your Report is also addressed to Cambridgeshire and Peterborough Integrated Care Board (ICB), the responsible commissioner for Declan’s care, and we are aware they have responded to the Coroner separately to outline the learning they have undertaken in response to this case and the next steps they will be taking to enhance service development for complex patients. We are aware that this includes work to better support patients under a Mental Health Act and an outline of the ICB’s work to transform services for people with mental health, learning disabilities and autism, including ensuring that there is no inappropriate detention of individuals with learning disabilities and/or who are autistic.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual trusts and local health systems are responsible for assessing and managing bed capacity, patient flow, and specialist unit availability.
Verbatim wording from the response “Individual trusts and local health systems are expected to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting and the availability of specialist units. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with local health systems directed to reduce the average length of stay in adult acute mental health wards to deliver more timely access to local beds. And in areas where there is a clear need for more beds, this has been addressed in part through investment in new units, as part of a whole system transformation approach.” Source location Response from DHSC
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7 Aug 2024 Martyn Harvey Stringer · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1
Insufficient availability of suitable placements for people requiring compulsory treatment View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Martyn Harvey Stringer · 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
Martyn Harvey Stringer was detained by police after being found at a location where he had ostensibly gone to take his own life, and was assessed as liable for detention under Section 2 of the Mental Health Act. No suitable mental health placement was found, and he later left home and stepped in front of a lorry; he died on 29 March 2023 from multi-organ failure and polytrauma resulting from a road traffic collision. The principal concern was the lack of suitable beds and placements for people requiring compulsory mental health treatment, including the decision not to offer an available Health Based Place of Safety bed to Martyn.
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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 suitable placements for people requiring compulsory treatment
Wider context from the report “As you will note from the Conclusion, an application for compulsory detention for Martyn could not be completed due to the unavailability of beds despite extensive searches nationally .
My findings were that: ‘It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to Martyn.’
And also that: ‘in my view highly likely that Martyn would have benefited from a further admission to hospital – as he had previously – and he would have been prevented from further relapse and ultimately taking the actions he did on the morning of the 27 March.’
I heard evidence from experience mental health professionals that the lack of beds for those requiring detention under the Mental Health Act was a frequent occurrence .
In my view, you should consider a review of sufficiency of provision for suitable placements for those requiring compulsory treatment .
” Source location Martyn Harvey Stringer · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest in new mental health inpatient units to increase local bed capacity.
Verbatim wording from the response “In some local areas 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 a transformational approach. This is supported by the NHS Long Term Plan (LTP), which has seen an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards, in order to deliver more timely access to local beds.” 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 £2.3 billion in mental health services, including adult community, crisis and acute services, through the NHS Long Term Plan.
Verbatim wording from the response “In some local areas 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 a transformational approach. This is supported by the NHS Long Term Plan (LTP), which has seen an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards, in order to deliver more timely access to local beds.” 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 Make £1.6 billion available through the Better Care Fund to support mental health inpatient services and wider system capacity.
Verbatim wording from the response “To address the wider system issues that impact on health services, a further £1.6 billion has been made available via the Better Care Fund from 2023-2025. This funding can be used to support mental health inpatient services as well as the wider system,” 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 Provide £42 million recurrent investment to enable Integrated Care Boards to recommission inpatient care in line with local therapeutic models.
Verbatim wording from the response “This is being supplemented by a further £42 million recurrent investment from 2024/25 for all Integrated Care Boards (ICBs) in the country, to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.” 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 Establish a South East Quality Transformation Programme for urgent and emergency care flow, improving mental health crisis and acute pathway access, quality and capacity.
Verbatim wording from the response “NHS England’s South East region have also established a Quality Transformation Programme relating to Urgent and Emergency Care and Flow. The aim of this programme is to improve access and quality of the mental health crisis and acute adult pathway, including improving patient flow and capacity. The region is engaged with the national Quality Transformation Programme designed to help systems transform their current service offer. The national programme is built upon the cornerstones of good mental healthcare, continuity of care, therapeutic relationships and a relentless commitment to mental health care, meeting the needs of all people.” Source location Response from NHS England
Open published response
23 Jul 2024 Nathan Tesla George Scantlebury · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1
Lack of suitable placements for high-risk children with complex mental health needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 11
Action
Redesign inpatient mental health care toward timely, effective, person-centred community-based provision for children and young people.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024. View source
Action
Invest capital and revenue funding in localised inpatient and alternative-to-inpatient provision over three years.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024. View source
Action
Issue operational planning guidance requiring systems to provide general adolescent and psychiatric intensive care capacity for local populations.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 8 August 2024. View source
Action
Establish Youth Intensive Psychological Practitioner roles in inpatient multidisciplinary teams through a pilot with Exeter University.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 8 August 2024. View source
Action
Commission and complete a review of the children’s inpatient care model, including international comparisons, family views and pathway pressures.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 8 August 2024. View source
Action
Review the service specification and develop a new clinical model covering the whole children’s mental health care pathway.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 8 August 2024. View source
Action
Work with health and education departments to meet children’s mental health needs fairly across community, placement and inpatient settings.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024. View source
Action
Jointly lead cross-government work to improve integrated care and health services for children in complex situations at risk of deprivation of liberty.
Stated by Department for EducationStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024. View source
Action
Engage local authorities and integrated care boards to identify barriers, enabling factors and transferable learning for suitable integrated provision.
Stated by Department for EducationStated completedThe respondent said that this action was complete when they made their response on 8 August 2024. View source
Action
Improve joint working between local systems on funding and support for children with complex needs, including co-designing or commissioning suitable provision.
Stated by Department for EducationStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024. View source
Action
Maintain the cross-government commitment to designing, commissioning and delivering integrated models of care for children in the most complex situations.
Stated by Department for EducationStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024. View source See 8 more actions
×
AI-generated summary
Nathan Tesla George Scantlebury · 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
Nathan Scantlebury, aged 16, died in hospital shortly after being found unresponsive with a ████████ tight around his neck on 25 September 2019. The principal concerns were the lack of suitable placements for children with complex mental health needs and failures relating to the suitability and management of his placement and care arrangements.
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 suitable placements for high-risk children with complex mental health needs
Wider context from the report “The lack of availability of suitable placements for high risk children with complex mental health needs which is both a local and a national issue which has been ongoing for a number of years.
” Source location Nathan Tesla George Scantlebury · 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 Redesign inpatient mental health care toward timely, effective, person-centred community-based provision for children and young people.
Verbatim wording from the response “The model of inpatient mental health care is being re-designed to enable the move to a more community-based provision of care, where children and young people can access appropriate mental health support in a timely, effective, and person-centred way, at home or close to home and in the least restrictive environment.” Source location Response from DHSC
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 inpatient and alternative-to-inpatient provision over three years.
Verbatim wording from the response “NHS England has sought to improve the availability of local inpatient care for CYP through a number of 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 Issue operational planning guidance requiring systems to provide general adolescent and psychiatric intensive care capacity for local populations.
Verbatim wording from the response “• The NHS Operational Planning Guidance 2022/23 outlined the need for Mental Health Provider Collaboratives 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 Establish Youth Intensive Psychological Practitioner roles in inpatient multidisciplinary teams through a pilot with Exeter University.
Verbatim wording from the response “The CYPMH Clinical Reference Group has developed an inpatient strategy which provides an evidence base to support services when considering their workforce challenges and team composition. A new Youth Intensive Psychological Practitioner pilot (YIPP) is now entering its third year and in partnership with Exeter University has established roles in inpatient Multi-Disciplinary Teams (MDTs) to complement the team. There has been a refresh of the Care (Education) and Treatment Review (CETR) policy, and an escalation policy has been agreed with all NHS-Led Provider Collaboratives and regional teams.” 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 and complete a review of the children’s inpatient care model, including international comparisons, family views and pathway pressures.
Verbatim wording from the response “In 2022, NHS England (NHSE) commissioned a new Quality Improvement Programme and one of its priorities was to undertake a review of the CYP’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 evidence review presented and consolidated a future vision for CYPMH inpatient care, and now forms the cornerstone of the CYPMH Transformation Programme, which has resulted in a review of the service specification and the development of a new clinical model, which considers the needs of a young person across the whole pathway of care.” 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 Review the service specification and develop a new clinical model covering the whole children’s mental health care pathway.
Verbatim wording from the response “In 2022, NHS England (NHSE) commissioned a new Quality Improvement Programme and one of its priorities was to undertake a review of the CYP’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 evidence review presented and consolidated a future vision for CYPMH inpatient care, and now forms the cornerstone of the CYPMH Transformation Programme, which has resulted in a review of the service specification and the development of a new clinical model, which considers the needs of a young person across the whole pathway of care.” 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 Work with health and education departments to meet children’s mental health needs fairly across community, placement and inpatient settings.
Verbatim wording from the response “Children and young people’s mental health interventions can take place in many contexts and will depend on the clinical needs of the child as to whether interventions are delivered in the community, whilst the child is in a placement, or in an inpatient setting. NHSE are working with the Department for Health and Social Care (DHSC) and Department for Education (DfE) to ensure that the needs of children in different settings are met fairly and equitably.” 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 Jointly lead cross-government work to improve integrated care and health services for children in complex situations at risk of deprivation of liberty.
Verbatim wording from the response “We know that capital investment alone will not be sufficient. Since July 2023 officials from DfE and from NHS England (“NHSE”) have been jointly leading cross-government work to improve the provision of integrated care and health services for children who are in complex situations and are currently, or are at risk of, being deprived of their liberty, by ensuring that there is an aligned cross-government approach to commissioning and delivering the best possible models of care. The terms of reference for the Task and Finish Group (TFG) established to drive this forward can be found on our Gov.uk page, Improving cross-sector support for children in complex situations with multiple needs task and finish group.” Source location Response from Department for Education
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 Engage local authorities and integrated care boards to identify barriers, enabling factors and transferable learning for suitable integrated provision.
Verbatim wording from the response “We have undertaken engagement with Local Authorities (LAs) and Integrated Care Boards (ICBs) to build our understanding of (a) barriers and enabling factors to providing suitable provision with integrated care that meets the needs of children and (b) what can be learned, in terms of national and local policy making, from LAs which have been successful in setting up and registering such provision. NHSE are currently planning a webinar (postponed from June due to the election), co-chaired with DfE, for/with sector leads, clinicians, children and young people and their parents/carers,” Source location Response from Department for Education
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 joint working between local systems on funding and support for children with complex needs, including co-designing or commissioning suitable provision.
Verbatim wording from the response “In addition to suitable places and suitable models of care, we want to see improvements to the way health and social care partners work together for complex and vulnerable children. DfE is undertaking work on how to improve joint working between local systems when considering how to fund and support children with complex needs, to support ways of working required to co-design or commission provision for children like Nathan. NHSE is leading on a new set of Peer Collaboratives, which will bring together LAs/ICBs with senior commitment to co-design, test and learn the practicalities of implementing integrated pathways. The purpose is to surface and explore common obstacles to system change in order to identify national changes required and begin to test potential solutions to inform the development of future pilots to improve support for this cohort.” Source location Response from Department for Education
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 Maintain the cross-government commitment to designing, commissioning and delivering integrated models of care for children in the most complex situations.
Verbatim wording from the response “We remain committed to the vision of the TFG: to improve how system partners work together to support and improve outcomes for children and young people who are currently (or are at risk of) being deprived of their liberty and who are in the most complex situations, by ensuring that there is an aligned cross government approach to design, commission and deliver the best possible models of care, integrated across children’s social care, health, education and youth justice.” Source location Response from Department for Education
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 will address the concerns about suitable placements for high-risk children with complex mental health needs.
Verbatim wording from the response “In preparing this response, my Departmental officials have made enquiries with NHS England and Cheshire and Merseyside Integrated Care Board and I understand that NHS England will address your concerns in more detail in its response. We will work with colleagues at NHS England to ensure the appropriate steps are taken to avoid a repetition of this tragedy.” Source location Response from DHSC
Open published response
14 Jun 2024 Amina Ahmed Ismail · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4
Variation in admission criteria and exclusions across specialist personality-disorder rehabilitation units View source Funding allocation failing to secure available specialist rehabilitation beds for identified patients View source Home teams’ inability to commission or make funding decisions for specialist personality-disorder placements View source
Delays in funding approval for specialist rehabilitation beds View source See 1 more concern
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.
×
AI-generated summary
Amina Ahmed Ismail · 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
Amina Ahmed Ismail, aged 19, died on 15 September 2023 at Pankhurst Ward, Priory Hospital Cheadle, after self-ligaturing; the medical cause of death was ligature strangulation. The report describes her prolonged stay in a PICU, deterioration in her mental health, shortages of appropriate specialist care beds, and delays in arranging and funding a suitable placement as concerns contributing to the circumstances of her death.
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 Variation in admission criteria and exclusions across specialist personality-disorder rehabilitation units
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding ’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Source location Amina Ahmed Ismail · 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 Funding allocation failing to secure available specialist rehabilitation beds for identified patients
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it . The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding .
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Source location Amina Ahmed Ismail · 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 Home teams’ inability to commission or make funding decisions for specialist personality-disorder placements
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units . These are commissioned/funded directly by the ICB upon application by the FTB ; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months. In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Source location Amina Ahmed Ismail · 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 Delays in funding approval for specialist rehabilitation beds
Wider context from the report “This is now the third inquest (two within the past 8 months) I have heard where the delayed transfer of an out-of-area patient from an independent provider’s hospital has been a contributory factor in that patient’s death. Two of those cases involving prolonged stays on PICU units; in this case some 13 months and in the other, some 11 months.
These cases illustrate,
a) Underfunding for local mental health beds.
It took some 6 weeks in 2022 to transfer Amina from the PD specialist placement at Nield House (where the treating team felt that they could not keep Amina safe) to a PICU some 90 miles from home.
Further, there were no local PICU beds available for transfer out of The Priory, Cheadle in May/June/July 2023 when a PD placement could not be found.
b) An over-reliance by the NHS on independent providers for mental health beds whether general acute beds, PICU beds or specialist units.
c) A national scarcity of specialist PD rehabilitation units
The inquest heard evidence from two treating psychiatrists in Amina’s history (Nield House and The Priory), FTB PACT assessor, and the court appointed independent expert that there was, and is, a national shortage of specialist PD rehabilitation units/beds, paraphrasing,
‘rehabilitation beds for female patients with PD are limited – demand exceeding what is available nationally’.
‘shortage of rehabilitation placements nationally – impeding on young persons’ mental health treatments’
‘simply not enough beds (NHS or Independent) to cater for such complex patients as Amina – transfers not being accepted by such units even if not full because the acuity of their existing patients’.
‘PD rehabilitation beds are scarce – spread nationally often in isolated units far from home, family and the local/home team. Each having its own admission criteria/exclusions, such as the possible need for NGT feeding’.
Following the PACT assessment FTB, in early 2023, were only able to find two PD units that had a bed available. One of them, Eleanor House, was re-opening its doors having voluntarily closed at the end of 2022. It had 14 beds available. However, its extant CQC rating was overall inadequate and it was in the process of appealing a Notice of Decision. The other, Cygnet Alders, declined the referral.
Three other units were identified as possibilities but each declined a referral, without any assessment, based on the acuity of their own patients.
Just 5 beds available over a period 6-7months, before Fern Unit accepted Amina.
In the meantime Amina remained in a PICU, some 90 miles from home which was wholly unsuited to her presentation and unable (through no fault of its own) to deliver the care and therapy that she needed resulting in a deterioration in her mental state with increasing risks/incidents of self-harm.
d) A funding process for rehabilitation units that is not fit for purpose.
The inquest heard evidence about the funding set-up for secondary mental health care in the Birmingham area, which is replicated nationally.
The ICB commissioned FTB to provide secondary mental health services, both community and in-patient. FTB are able to commission NHS and independent sector acute beds and PICU’s, both in and out of area. However, FTB are not able to commission specialist placement, including PD units. These are commissioned/funded directly by the ICB upon application by the FTB; having found a unit that would accept a patient.
This system, for funding specialist/rehabilitation beds, is inadequate ; particularly in light of the shortage of such specialist/rehabilitation beds. The inquest heard evidence that the process from application to funding approval takes weeks, sometimes months . In this case it took from 13.03.23 to 04.05.23 for a negative outcome.
The shortage of beds/units means that when a bed becomes available there are a number of patients in competition for it. The beds are not kept open for any particular patient and, in essence, allocation becomes a race on funding.
It is surprising that a ‘home team’ (in this case FTB) commissioned by an ICB to provide secondary mental health services is not permitted to make its own funding decisions for specialist units, as it can for acute wards and PICU’s. As can be seen from the evidence Amina was able to be transferred within 24hrs once a PICU accepted her on 01.08.23, albeit it took a wholly unsatisfactory 6 weeks to find a PICU bed.
” Source location Amina Ahmed Ismail · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrated care boards are responsible for developing three-year plans to localise and realign inpatient mental health care, including independent-sector provision.
Verbatim wording from the response “In 2022 NHS England launched the mental health, learning disability and autism inpatient quality transformation programme. A core aim of the programme is to localise and realign care, harnessing the potential of people and communities. The programme is built upon the cornerstones of good mental healthcare; continuity of care, therapeutic relationships and a commitment to mental health care meeting the needs of the population. All integrated care boards have been tasked by NHS England with developing 3-year plans to localise and realign inpatient mental health care, including NHS-funded care provided by the independent sector, as part of this programme.” Source location Response from DHSC
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21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Insufficient consideration of alternative specialist placement View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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Alan Richard Miles Davies · Prevention of Future Deaths report
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Report summary
Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient consideration of alternative specialist placement
Wider context from the report “(5) Mr Davies was transferred to HMP Cardiff with the intention that he be transferred again within a short time to HMP Parc. Insufficient consideration was given as to whether Mr Davies’ needs were better met at an alternative specialist institution .
” Source location Alan Richard Miles Davies · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and establish a standard operating procedure for communicating health information and determining appropriate placement before transfers to HMP Cardiff.
Verbatim wording from the response “Regarding communication pathways, collaborative efforts with relevant parties have led to the development of a Standard Operating Procedure (SOP) for transferring individuals with mental/physical health needs into our care. This SOP delineates the necessary information required by HMP Cardiff to assess the individual's health needs and outlines a reliable route for sharing information across organisations to mitigate information-related risks. The protocol also identifies” Source location Response from Cardiff and Vale University Health Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HMPPS cannot override healthcare colleagues’ clinical decisions about whether an individual is medically suitable to return to custody.
Verbatim wording from the response “The Secretary of State can order the return of an individual to a prison if the responsible psychiatrist decides that the individual is no longer in need of medical treatment or that no effective treatment for the disorder can be given at the hospital to which he has been transferred to, as directed in PSI 50/2007 Transfer of Prisoners To and From Hospital Under Sections 47 and 48 of the Mental Health Act 1983. It is HMPPS’ duty to serve the public by keeping in custody those committed by the court. Therefore, if it is determined by healthcare colleagues that an individual is medically suitable to return to custody and that their needs would not be met at an alternative specialist institution, then HMPPS must accept that individual. HMPPS cannot override any clinical decisions made by healthcare colleagues.” Source location Response from HM Prison and Probation Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Healthcare colleagues determine whether an individual is medically suitable to return to custody and whether alternative specialist institutions can meet their needs.
Verbatim wording from the response “The Secretary of State can order the return of an individual to a prison if the responsible psychiatrist decides that the individual is no longer in need of medical treatment or that no effective treatment for the disorder can be given at the hospital to which he has been transferred to, as directed in PSI 50/2007 Transfer of Prisoners To and From Hospital Under Sections 47 and 48 of the Mental Health Act 1983. It is HMPPS’ duty to serve the public by keeping in custody those committed by the court. Therefore, if it is determined by healthcare colleagues that an individual is medically suitable to return to custody and that their needs would not be met at an alternative specialist institution, then HMPPS must accept that individual. HMPPS cannot override any clinical decisions made by healthcare colleagues.” Source location Response from HM Prison and Probation Service
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Includes deficiencies in identifying, assessing, accessing or securing suitable specialist placements when the placement is intended to meet materially specialised care or risk-management needs.
