19 Sep 2023 Lauren Elizabeth Bridges · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Out-of-Area patients remaining away from home because of delayed discharge or repatriation View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Dorset Healthcare University NHS Foundation Trust NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Department of Health and Social Care
Develop and publish statutory guidance for discharge from mental health inpatient settings.
View source
Department of Health and Social Care
Provide additional funding to support adult social care and NHS discharges, including from mental health inpatient settings.
View source
Department of Health and Social Care
Work with NHS England to ensure systems prioritise eliminating inappropriate out-of-area placements, focusing on discharge and patient flow.
View source
NHS England
Work towards eliminating adult acute out-of-area placements across the NHS.
View source
NHS England
Publish guidance supporting timely, local, high-quality therapeutic inpatient care and timely discharge.
View source
NHS England
Support health and care systems to operationalise inpatient mental health care localisation plans through regional and national assistance.
View source
Dorset Healthcare University NHS Foundation Trust
Add a dedicated Hospital Overview section identifying out-of-area patients requiring repatriation to support daily bed-allocation decisions.
View source
Dorset Healthcare University NHS Foundation Trust
Appoint a dedicated clinical Out of Area Coordinator.
View source
Dorset Healthcare University NHS Foundation Trust
Implement an out-of-area inpatient-care procedure requiring regular contact and documentation with patients, families, carers and treating clinicians.
View source
Dorset Healthcare University NHS Foundation Trust
Conduct monthly audits of out-of-area patient records against procedure standards, including coordinator input, care coordination, contacts, reviews and repatriation planning.
View source See 7 more actions
×
AI-generated summary
Lauren Elizabeth Bridges · 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
Lauren Elizabeth Bridges, who was detained under the Mental Health Act and treated in out-of-area mental health placements, died on 26 February 2022 after a ligaturing incident two days earlier. The report identified concerns about delayed discharge and repatriation, the distance from home, missed opportunities to move her closer to home, and inadequate communication between relevant organisations. It also identified wider concerns about shortages of local mental health beds and reliance on independent providers.
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 Out-of-Area patients remaining away from home because of delayed discharge or repatriation
Wider context from the report “With regard to delayed discharge/repatriation of an Out-of-Area patient I heard evidence that The Priory have devised a protocol/standing operating procedure in respect of delayed discharge, which should reduce the risks of a patient being left miles from home at all and in any event reduce the time taken to repatriate . However, it relies on the ‘home team’s’ engagement in the process.
” Source location Lauren Elizabeth Bridges · 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 Develop and publish statutory guidance for discharge from mental health inpatient settings.
Verbatim wording from the response “The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. The guidance is available at: Hospital discharge and community support guidance - GOV.UK (www.gov.uk)” Source location Response from Department of Health and Social Care
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 additional funding to support adult social care and NHS discharges, including from mental health inpatient settings.
Verbatim wording from the response “To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, reducing bed occupancy.” Source location Response from Department of Health and Social Care
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 NHS England to ensure systems prioritise eliminating inappropriate out-of-area placements, focusing on discharge and patient flow.
Verbatim wording from the response “All systems that still have inappropriate out of area placements have been required to refresh their local plans to ensure these placements are eliminated everywhere as soon as reasonably possible. NHS England continues to work with the worst performing areas and support them to improve and we are working with NHS England to ensure that systems prioritise this, including a focus on discharge and flow.” Source location Response from Department of Health and Social Care
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 towards eliminating adult acute out-of-area placements across the NHS.
Verbatim wording from the response “The NHS remains committed to eliminating the practice of adult acute Out of Area Placements. All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England’s 2023/24 Priorities and Operational Planning Guidance. An ICB is a statutory NHS organisation which is responsible for developing a plan for meeting the health needs of the population, managing the NHS budget, and arranging for the provision of health services within a given geographical area. They replace clinical commissioning groups (CCGs), taking on the NHS planning functions previously held by CCGs, as well as absorbing some planning roles from NHS England.” 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 Publish guidance supporting timely, local, high-quality therapeutic inpatient care and timely discharge.
Verbatim wording from the response “In July 2023 NHS England published renewed guidance to support the commissioning and delivery of timely access to high quality therapeutic inpatient care, close to home and in the least restrictive setting possible. Key to this are the principles of: timely and purposeful admissions that are local, timely discharge, joined-up care and continuous improvement.” 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 Support health and care systems to operationalise inpatient mental health care localisation plans through regional and national assistance.
Verbatim wording from the response “To implement this, all ICBs have been tasked with developing 3-year plans to localise and realign inpatient mental health care, including care provided by the Independent Sector, as part of the mental health, learning disability and autism inpatient quality transformation programme launched in 2022. Health and Care systems across England are currently being supported to operationalise the guidance via 3-year plans with direct support from regional and national teams. The transformation programme is underpinned by a £36 million investment.” 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 Add a dedicated Hospital Overview section identifying out-of-area patients requiring repatriation to support daily bed-allocation decisions.
Verbatim wording from the response “3. In addition, the Trust has also added a specific section to the daily Hospital Overview template showing patients who are in out of area beds who require repatriation to a local bed. This ensures that Clinical Site Managers are taking these patients into account when making daily decisions on bed allocations.” Source location Response from Dorset Healthcare University NHS Foundation Trust
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 Appoint a dedicated clinical Out of Area Coordinator.
Verbatim wording from the response “3. As referred to during the inquest, we have appointed a dedicated Out of Area Coordinator post, which is a clinical post. We have also written and implemented a SOP for the ‘Use of Out of Area Acute and Psychiatric Intensive Care (PICU) Mental Health Inpatient beds: Therapeutic inpatient care and proactive discharge planning’. The SOP includes standards to be met in respect of regular contact and recording of that contact with patients who are out of area, and their families / carers, as well as with clinicians working in out of area providers overseeing that care.” Source location Response from Dorset Healthcare University NHS Foundation Trust
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 Implement an out-of-area inpatient-care procedure requiring regular contact and documentation with patients, families, carers and treating clinicians.
Verbatim wording from the response “3. As referred to during the inquest, we have appointed a dedicated Out of Area Coordinator post, which is a clinical post. We have also written and implemented a SOP for the ‘Use of Out of Area Acute and Psychiatric Intensive Care (PICU) Mental Health Inpatient beds: Therapeutic inpatient care and proactive discharge planning’. The SOP includes standards to be met in respect of regular contact and recording of that contact with patients who are out of area, and their families / carers, as well as with clinicians working in out of area providers overseeing that care.” Source location Response from Dorset Healthcare University NHS Foundation Trust
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 Conduct monthly audits of out-of-area patient records against procedure standards, including coordinator input, care coordination, contacts, reviews and repatriation planning.
Verbatim wording from the response “5. A regular audit takes place every month involving reviewing the records of all patients receiving their care out of area against the standards set out within the SOP. This audit is undertaken by our Nursing and Quality Directorate and will remain ongoing. Audit standards include evidence of OOA coordinator input, date of last input, that the patient has an allocated Care Coordinator, date of last input from them, date of last contact with patient and family, date of Care Programme Approach meeting, date of last clinician attendance at a multidisciplinary team review, and whether there is a discharge / repatriation plan.” Source location Response from Dorset Healthcare University NHS Foundation Trust
Open published response
19 Sep 2023 Lauren Elizabeth Bridges · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3
Failure to record out-of-area patients’ identity and relevant circumstances timeously and correctly View source Failure to assess out-of-area patients for available beds when vacancies arise View source Failure to record discussions about allocating available beds to out-of-area patients View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Lauren Elizabeth Bridges · 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
Lauren Elizabeth Bridges was detained under the Mental Health Act and remained in an out-of-area psychiatric intensive care placement for about five months after she was ready for step-down. She died on 26 February 2022 following a ligaturing incident. Concerns included inadequate record keeping and communication, missed opportunities to move her closer to home despite beds being available, and the effects of the prolonged out-of-area placement on her deterioration and 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 Failure to record out-of-area patients’ identity and relevant circumstances timeously and correctly
Wider context from the report “During the course of the inquest it was apparent that Dorset Healthcare NHS Trust’s standard of record keeping was inadequate . Among other things,
1. Lauren’s name dd not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed in as being in an acute bed not a PICU.
2. There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the 5 months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim.
During the course of the inquest Dorset Health made the following admission,
Dorset Healthcare NHS Trust have admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients , and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed.
Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of these omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest.
a) the omission to update the Hospital Overview timeously and correctly.
b) it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took place.
” Source location Lauren Elizabeth Bridges · 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 Failure to assess out-of-area patients for available beds when vacancies arise
Wider context from the report “During the course of the inquest it was apparent that Dorset Healthcare NHS Trust’s standard of record keeping was inadequate. Among other things,
1. Lauren’s name dd not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed in as being in an acute bed not a PICU.
2. There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the 5 months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim.
During the course of the inquest Dorset Health made the following admission,
Dorset Healthcare NHS Trust have admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients, and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed.
Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of these omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest.
a) the omission to update the Hospital Overview timeously and correctly.
b) it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took place.
” Source location Lauren Elizabeth Bridges · 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 Failure to record discussions about allocating available beds to out-of-area patients
Wider context from the report “During the course of the inquest it was apparent that Dorset Healthcare NHS Trust’s standard of record keeping was inadequate. Among other things,
1. Lauren’s name dd not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed in as being in an acute bed not a PICU.
2. There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the 5 months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim.
During the course of the inquest Dorset Health made the following admission,
Dorset Healthcare NHS Trust have admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients, and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed.
Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of these omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest.
a) the omission to update the Hospital Overview timeously and correctly.
b) it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took place.
” Source location Lauren Elizabeth Bridges · Prevention of Future Deaths report
Open source report
21 May 2021 Martin Gibbons · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in cross-trust mental health bed allocation for patients outside the assessing trust’s commissioned area View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Martin Gibbons · 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
Martin Gibbons attempted to take his own life on 19 March 2020 and was taken to hospital, where he was assessed as needing admission to a psychiatric ward. While waiting for a bed, he left the hospital unobserved and was found dead on 24 March 2020; the inquest concluded suicide. Concerns included differing assessments of risk between acute and mental health trusts, the absence of shared risk assessments and care plans, and delays in obtaining a mental health 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 Delays in cross-trust mental health bed allocation for patients outside the assessing trust’s commissioned area
Wider context from the report “3. It was during the prolonged wait in the Emergency Department for a mental health bed that Mr Gibbons left. The inquest heard that this wait was contributed to by a number of factors in particular
• A national lack of mental health beds;
• The fact that although he had presented to Tameside Hospital and had been assessed by Pennine Care staff because he was a resident of a neighbouring borough covered by a different NHS Mental Health Trust that other Trust had to be contacted ,given all of the information and find him a bed . The inquest was told that this was as a result of how services were commissioned and that the workers who had assessed him had no choice other than to follow this process notwithstanding the additional delay it created .
” Source location Martin Gibbons · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.