Recurring concern

Unsafe management of required admissions when no bed is available

First to latest report 11 Oct 2014 — 12 Feb 2026

Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
3

What this concern includes

Includes failures of the dedicated admission, bed-management or transfer process for patients requiring admission when an appropriate bed is unavailable, including absent procedures and unsafe arrangements for acute psychiatric patient transfers.

What is not included
  • Excludes general shortages or unavailability of hospital or psychiatric beds where no failure to manage the admission or transfer pathway is identified.
  • Excludes ordinary delays in hospital admission where the specific no-bed contingency or transfer process is not deficient.
  • Excludes unrelated bed-management pathways, such as critical-care capacity, unless the assertion directly concerns managing a required admission when no bed is available.

Reports and published responses 6 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Buckinghamshire

    AI-generated summary

    Barry HARMER · 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

    Barry Harmer was found deceased at home on 11 April 2024 after sustaining a neck injury he had likely inflicted upon himself. He had been known to community mental health services, had agreed to voluntary psychiatric admission, and was awaiting a bed while remaining at home. Concerns included inadequate pursuit and communication regarding bed availability and home safety responsibilities, the absence of an earlier face-to-face psychiatric review, and shortcomings in the robustness and timely review of the investigation and learning process.

    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 immediate escalation of changing community psychiatric needs when voluntary admission is agreed but no bed is available

    Wider context from the report

    “(3) The fact that Barry had not had any face to face psychiatric review at any point during the time he was open to Oxford Health was not addressed in the PSII and it remains unclear how this can be escalated for immediate attention in the community, where circumstances are changing, where the need for a voluntary admission has been agreed, but no bed is available. ”

    Source location

    Barry HARMER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Birmingham and Solihull

    AI-generated summary

    Philip Laurence Justin MALONE · Prevention of Future Deaths report

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

    Report summary

    Philip Laurence Justin Malone, who had treatment-resistant schizophrenia and had deteriorated significantly in late June 2023, was found deceased in his supported accommodation on 3 July 2023. The inquest concluded that his death was the consequence of suicide. The principal concern was inadequate psychiatric bed capacity in Birmingham and Solihull, after clinicians sought to admit him but no inpatient bed was available, creating an ongoing risk of future deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients

    Wider context from the report

    “1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action. 2. The Patient Safety Manager ████████ gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved, and there is a genuine risk of the same problem with another patient in the future. 3. ████████ added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged. In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged, and amplifies the chronic shortage of beds. 4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board. The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding. My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate. Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken. ”

    Source location

    Philip Laurence Justin MALONE · Prevention of Future Deaths report
    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

    Work with local authorities to improve inpatient social-care support and enable faster, safer discharges.

    Verbatim wording from the response

    “The Trust is working with our local authorities to improve the social care support to patients on our inpatient wards with an aim to provide speedier and safer discharges and thus create more capacity within our bed stock (See appendix 1)”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 2 · response
    Published 29 November 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate a clinical oversight group with acute wards to support appropriate discharges and escalate delays caused by non-clinical issues.

    Verbatim wording from the response

    “A clinical oversight group (COG) now meets regularly with all acute wards to support clinically appropriate discharges and enable escalation of discharge delays that occur as a result of non-clinical issues (appendix 2).”

    Source location

    Response from Birmingham and Solihull Mental Health NHS Foundation Trust
    Page 2 · response
    Published 29 November 2023

    Open published response

  3. East London

    AI-generated summary

    Mr Matthew John Phipps · 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

    Matthew Phipps was admitted to hospital with severe acute kidney injury and symptoms associated with likely sepsis, and was recognised as critically unwell. There were delays in transferring him to intensive care, administering antibiotics, monitoring him, carrying out blood tests and commencing renal replacement therapy; the inquest found that these failings did not contribute to his death. A concern arose about the lack of a contingency plan for providing intensive care when the intensive care unit is full.

    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 contingency plan for providing intensive care when the intensive care unit is full

    Wider context from the report

    “A concern arose at the Inquest hearing in relation to the lack of a contingency plan in place to ensure that intensive care is provided to all patients who require it, but where the intensive care unit itself is full. The Inquest heard evidence from an independent consultant anaesthetist who stated: I do not understand why one or two of the 8 ICU patients who were deemed to be wardable, could not have been moved elsewhere (e.g. to a post anaesthetic care unit in an operating suite), to enable a sick patient such as Mr Phipps to be admitted to the ICU. It is my understanding that most ICUs have such contingency plans in place, in the form of agreed standard operating procedures. The Trust were aware of this concern, but did not provide any evidence to address this. ”

    Source location

    Mr Matthew John Phipps · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. North London

    AI-generated summary

    Ronald Gittens · 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

    Ronald Gittens was taken to hospital, assessed for an informal psychiatric admission and transferred while waiting for a bed, but left before admission. He was later found at home having hanged himself. The principal concerns were the transfer of acute psychiatric patients when no bed is available and the use of CRHTT as a filter for patients needing a bed.

    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

    Transfer of acute psychiatric patients when no bed is available

    Wider context from the report

    “The transfer of acute psychiatric patients when no bed is available and The use of CRHTT as a filter to prevent patients in need of a bed from having access to a bed. ”

    Source location

    Ronald Gittens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The local mental health trust is responsible for responding to concerns about patient transfers and crisis home treatment arrangements.

    Verbatim wording from the response

    “You have also sent your report to the Barnet, Enfield and Haringey Mental Health Trust. The concerns you raise are properly matters for the local Trust and I would expect them to respond appropriately to you. We give Trusts the freedom and discretion to arrange these matters in ways that best meet the needs of patients. However we insist that all patients receive timely, high-quality care. Where that does not happen, as in this case, Trusts must take action to put things right.”

    Source location

    2015-0117-Response-by-Department-of-Health
    Page 1 · response
    Published 12 March 2015

    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

    Decision-making on inter-trust transfers of at-risk psychiatric patients rests with the local NHS, not the Department of Health.

    Verbatim wording from the response

    “I appreciate that the issue of inter-trust transfers of at-risk psychiatric patients is indeed one relevant to all Mental Health NHS Trusts. However, the responsibility for decision making in this area resides with the local NHS rather than the Department of Health.”

    Source location

    2015-0117-Response-by-Department-of-Health
    Page 1 · response
    Published 12 March 2015

    Open published response

  5. Inner North London

    AI-generated summary

    Sandra Bodrožič’ · 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

    Sandra Bodrožič’ died after running to the attic, saying goodbye and jumping from a window, landing three storeys below. She had previously been detained under the Mental Health Act and treated in hospital and the community. The substantive concerns included delays in finding a hospital bed, arranging a Mental Health Act assessment, and the absence of clear urgency or timeframe protocols for such assessments.

    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 secure timely inpatient admission when no NHS bed is available

    Wider context from the report

    “1. Ms Bodrožič’ agreed on 23 May 2014 to the recommendation of those treating her that she be admitted to hospital on an informal basis. However, no bed was found for her until 30 May, by which time she had changed her mind. There was no exploration of the possibility of purchasing a bed from the private sector when no NHS bed was available. ”

    Source location

    Sandra Bodrožič’ · 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

    Clarify and disseminate the bed management policy, emphasising admission offers regardless of Mental Health Act status.

    Verbatim wording from the response

    “The Serious Incident Report in relation to Ms Bodrozic’s death noted that the Trust’s bed management policy was not followed correctly. Consequently, the Clinical Director for the Acute Division has clarified and disseminate the Trust’s bed management policy to its employees emphasising that, ‘any patient requiring a bed will be offered admission regardless of their Mental Health Act status’. This should ensure that private beds are available to informal patients promptly.”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 2 · response
    Published 24 November 2014

    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

    A private bed was not considered necessary because Trust bed availability was changing and a bed was expected within the required timeframe.

    Verbatim wording from the response

    “1. When ████████ took the decision to admit Ms Bodrozic to hospital on an informal basis on 23rd May 2014 she spoke to the duty nurse at the Highgate Mental Health Centre (the Centre) to make the referral. They discussed the urgency of the referral and although there was no bed available at the Centre it was anticipated that a bed would become available within the next few days. This was appropriate given the clinical urgency of the case at the time. Therefore, a private bed was not considered to be necessary. The family had been advised that they could take Ms Bodrozic to the Accident & Emergency department over the bank holiday weekend if there were any changes in her state of mind or behaviour.”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 2 · response
    Published 24 November 2014

    Open published response

  6. Manchester South

    AI-generated summary

    Mark Hancock · 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

    Mark Hancock had a history of severe clinical depression and was receiving treatment at the Priory Hospital. On 12 February 2014, he was found at his parents’ house with serious self-inflicted wounds after concerns about his deteriorating presentation had been escalated but hospital admission did not occur because no bed was available. The report identified concerns about poor or absent records, the lack of a documented risk assessment, insufficient reassessment after concerns were escalated, and the absence of a procedure for admission when no bed was available.

    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 procedure for managing required admissions when no bed is available

    Wider context from the report

    “- There was no procedure or policy in place for staff as to what they should do if a patient requires admission but a bed is not available. ”

    Source location

    Mark Hancock · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026