Recurring concern

Insufficient suitable supported accommodation for vulnerable people

First to latest report 2 Sep 2014 — 28 May 2021

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
4

What this concern includes

Includes continuing shortages or inadequate availability of suitable supported accommodation for vulnerable people, including young people and people with complex neurodevelopmental or mental-health needs, where the accommodation is intended to provide the support required for safe living.

What is not included
  • Excludes general housing shortages, homelessness or ordinary accommodation unavailability where supported accommodation is not the required safety condition.
  • Excludes failures of staffing, provider competence, regulation, placement matching or care quality after suitable supported accommodation is available.
  • Excludes psychiatric beds, Approved Premises, secure accommodation and other separately named placement systems unless the assertion explicitly concerns the same supported-accommodation capacity condition.
  • Excludes failures to arrange or fund an individual placement where the shared unsafe condition is not insufficient availability of suitable supported accommodation.

Reports and published responses 4 reports

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

  1. Cambridgeshire and Peterborough

    AI-generated summary

    SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · 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

    Sam died by suicide from an overdose of prescribed medication on 2 September 2018, aged 16. Chris died by suicide after deliberately stepping in front of a passing train on 26 January 2019, aged 17. The principal concerns included insufficient overnight support for adolescents cared for at home, shortcomings in local authority support and coordination, reluctance to use a Borderline Personality Disorder diagnosis, and unclear and inadequately implemented procedures for patients absent without leave.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unavailability of in-area supported accommodation for adolescent mental health patients

    Wider context from the report

    “(1) Overnight assistance for adolescent mental health patients being cared for at home but with high levels of need (For CPFT and CCC). I heard evidence of increased funding for CPFT being used to extend home treatment options, but that this would be unlikely to extend to a 24/7 service. I also heard evidence from CCC that available support would now be considered under s17 Children Act or s117 Mental Health Act or both but that this would need to be jointly funded between social care and health. I remain concerned that a clear pathway to securing overnight assistance (even if only on a respite basis) for similar cases of exceptional need has not yet been clearly agreed between CPFT and CCC. I am concerned that if alternative supported accommodation in the community were the best solution, there does not appear to be provision for it in-area, so that admission to a mental health unit becomes more likely. ”

    Source location

    SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · Prevention of Future Deaths report
    Page 3 · 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

    Continue discussing with the CCG and Local Authority how to meet needs for 24/7 in-home care, including bespoke arrangements or a fully funded service.

    Verbatim wording from the response

    “The discussion about the need for 24/7 in home care will continue with the CCG and the Local Authority and whether any needs are best met though bespoke arrangements, or the demand is such as to require a fully funded service.”

    Source location

    2021-0184-Response-from-Cambridgeshire-and-Peterborough-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 2 June 2021

    Open published response

  2. Inner West London

    AI-generated summary

    Georgia Sylvia Nelson · 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

    Georgia Sylvia Nelson, who had treatment-resistant schizophrenia and severe persistent symptoms, stepped in front of a train at Gloucester Road Underground Station on 11 May 2018 and was killed instantly. The report raised concerns about the lack of suitable long-term and rehabilitation housing for young people with severe mental illness, inadequate discharge planning, and missed opportunities to improve treatment and consider rehabilitation before discharge.

    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 long-term supported housing placements for patients with severe and enduring mental illness

    Wider context from the report

    “2. There are no long term placements, potentially life long, for any patients requiring supported housing in RBKC with such mental illness. ”

    Source location

    Georgia Sylvia Nelson · 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 commissioners and the local authority to secure a wider choice of rehabilitation services for patients.

    Verbatim wording from the response

    “NICE are due to produce guidelines on Rehabilitation in adults with complex psychosis and related severe mental health conditions that we know are likely to propose a wider range of options to provide patients with rehabilitation not just in an inpatient setting. This is the national direction of travel, with patients being brought back from out of area placements to their local community and rehabilitation being provided in high supported accommodation or even in patients’ independent accommodation. We are working with our commissioner and local authority to ensure that services are commissioned for our patients that give the widest choice of rehabilitation options and keep up to date with modern ways of working. This will mean that as discharge planning starts at admission, we will follow the new NICE guidance on considering rehabilitation as appropriate.”

    Source location

    2019-0140-Response-by-CNWL-NHS-Trust
    Page 3 · response
    Published 14 June 2019

    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

    Refer clients needing long-term or lifelong supported housing to the funding and placement panel for evidence-based multidisciplinary decisions on commissioned support and accommodation.

    Verbatim wording from the response

    “We would like to take the following action when addressing the prevention of future deaths. If the client may need long term or life long supported housing, the case will be brought to the funding and placement panel to decide what kind of long term or life-long support and accommodation will be commissioned through an evidence-based assessment by the”

    Source location

    2019-0140-Response-by-RBKC_Redacted
    Page 6 · response
    Published 14 June 2019

    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

    Organise and use regular placement, provider and partnership meetings to assess demand, identify service gaps and inform housing support commissioning.

    Verbatim wording from the response

    “We would like to offer you this joint response, to outline where the Housing Department, Adult Social Care and West London Commissioning Group colleagues, in partnership with Central North West London Trust, can work together to influence some of the changes you seek from your concerns. As part of the broader commissioning of services, we would like to strengthen the following regular partnerships meetings to look at need and demand, to support what services are jointly or singularly commissioned within the borough along with development of specifications to ensure key outcomes such as tenancy sustainment and the performance of the providers in enabling resident to be independent where possible is managed and monitored in each of the services. This is done through formal contract monitoring arrangements and placement review processes which are set out below: -”

    Source location

    2019-0140-Response-by-RBKC_Redacted
    Page 5 · response
    Published 14 June 2019

    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

    Housing provision for young people and rehabilitation placements is outside the Trust’s commissioning functions.

    Verbatim wording from the response

    “Concerns 1, 2 and 3 are within the domain of the Royal Borough of Kensington & Chelsea, who develop and commission housing provision, including a range of supported accommodation. Whilst the Trust does not commission these services, as the major provider of NHS mental health care within the Borough, we do work closely with the local authority to inform and assist them in developing new services. We think however, they will want to respond to these 3 points separately as the responsible organisation, and we are aware they are currently in the process of responding to you in this respect.”

    Source location

    2019-0140-Response-by-CNWL-NHS-Trust
    Page 2 · response
    Published 14 June 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Royal Borough of Kensington and Chelsea is responsible for developing and commissioning the relevant housing provision and should respond to these concerns.

    Verbatim wording from the response

    “Concerns 1, 2 and 3 are within the domain of the Royal Borough of Kensington & Chelsea, who develop and commission housing provision, including a range of supported accommodation. Whilst the Trust does not commission these services, as the major provider of NHS mental health care within the Borough, we do work closely with the local authority to inform and assist them in developing new services. We think however, they will want to respond to these 3 points separately as the responsible organisation, and we are aware they are currently in the process of responding to you in this respect.”

    Source location

    2019-0140-Response-by-CNWL-NHS-Trust
    Page 2 · response
    Published 14 June 2019

    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

    Where suitable local services are unavailable, specialist housing and rehabilitation placements will be purchased outside the borough.

    Verbatim wording from the response

    “Out of this number of young people with severe mental health issues, there may be a few who can be referred to supported housing services through the Single Homeless Team. The Housing Department agrees with and will continue to work with Adult Social Care, WL CCG and colleagues in the Central North West London NHS Foundation (CNWL) in any decision-making process in regard to the type of support and accommodation needed, ensuring decisions are made through an assessed process and agreed through a multi-disciplinary approach and monthly panel meeting. The Mental Health Placement Panel consists of Adult Social Care representatives and the Clinical Commissioning Group commissioners and care co-ordinator. Where services are not available within the borough, specialist placements outside of the borough can be purchased to best meet the individual’s needs.”

    Source location

    2019-0140-Response-by-RBKC_Redacted
    Page 3 · response
    Published 14 June 2019

    Open published response

  3. Somerset

    AI-generated summary

    Robin Damien Richards · 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

    Robin Damien Richards, who had a history of mental health problems and diagnoses including Asperger's Syndrome, ADHD and a learning disability, was found suspended by his belt at supported accommodation on 29 June 2015 and died in hospital on 3 July 2015. Concerns included a shortage of suitable supported accommodation, the suitability and inspection of his placement, and shortcomings in communication, handover, discharge planning, care planning and risk assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Shortage of suitable supported accommodation for people diagnosed with Asperger's Syndrome

    Wider context from the report

    “(1) That there exists a shortage of suitable supported accommodation for those diagnosed with Asperger's Syndrome, both in Somerset and nationally. In the case of Mr Richards this shortage resulted in him being obliged to remain on a psychiatric ward after his discharge under the Mental Health Act. This was not in Mr Richards best interests. (2) The suitability of Highbridge Court as a placement for Mr Richards which whilst CQC registered had not been CQC inspected. (3) A number of shortcomings on the part of Somerset Partnership NHS Foundation Trust ("the Trust") in Mr Richards mental health care were identified; a) Poor communication with family and between Trust staff. b) A lack of clarity in Mr Richards discharge plan and as to what Mr Richards could expect from his placement. c) An inadequate handover. d) Poor communication between Trust staff and Placement Staff and a failure to communicate with Mr Richards personally at a time of crisis for him. e) An inadequacy in the Trust's Risk Assessment process and subsequent management of risk to include only having telephone contact with staff and not speaking directly with Mr Richards ”

    Source location

    Robin Damien Richards · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. South Yorkshire (Western)

    AI-generated summary

    Peter Stanley · 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

    Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient capacity of supported accommodation

    Wider context from the report

    “(7) This case shows the need for a greater number of places in supported accommodation. ”

    Source location

    Peter Stanley · Prevention of Future Deaths report
    Page 4 · 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