Emma Louise MORRIS · Prevention of Future Deaths report

On 29 September 2023 I commenced an investigation into the death of Emma Louise MORRIS aged 39. The investigation concluded at the end of the inquest on 15 May 2024. The conclusion of the inquest was that:

Suicide

Emma Morris had a medical history of anxiety and depression. She had suffered a deterioration in her mental health and on the 20th September 2023, deliberately walked in front of a bus on the slip road of junction 39, Chester, heading towards the A55. A gatekeeping assessment had been completed by a mental health practitioner of the Crisis Resolution and Home Treatment Team on the 19th September where the practitioner found that an informal inpatient admission to a mental health ward was clinically indicated, but this could not be facilitated immediately as there were no beds available nationally. She was therefore under the care of the Crisis Resolution Home Treatment Team at the time of death.

The gatekeeping assessment included a mental health state examination, where it was the clinical opinion of the mental health practitioner from the Crisis Resolution Home Treatment Team, that Ms Morris required an inpatient hospital admission to a mental health ward as there was an immediate risk to her safety as she was found to be a high risk of walking in front of a car. Whilst Ms Morris agreed to an informal admission, this was not possible at the time of assessment as there were no beds available nationally within the NHS or privately.

As an inpatient admission was not possible, the option was to attend the Accident and Emergency Department or to remain in the community whilst waiting for an inpatient mental health bed to become available. Ms Morris had been informed that if she attended the Accident and Emergency Department, there could be a wait of three days for an inpatient mental health bed to become available. Ms Morris did not wish to wait in the Accident and Emergency Department for three days. A safety plan was agreed that Ms Morris would stay overnight with a family member, and would remain under the care of the Crisis Resolution Home Treatment Team who would review the following morning. The family felt that it was pushed for Ms Morris to stay overnight with a family member as there was no alternative to keep her safe.

During the course of the inquest, I heard that there is national pressure on hospital trusts as there is a national increase in people waiting for inpatient beds. I am therefore concerned that there is a risk of future deaths as it is not possible to access inpatient mental health beds at the time of clinical need.