PFD report

JAGJEET SINGH · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 4 Nov 2024•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of sufficient mental health bed capacity
    Part of recurring concern: Insufficient psychiatric inpatient bed capacity
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 recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Publish statutory guidance supporting safe discharge from mental health and learning disability and autism inpatient settings.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 6 November 2024.
  2. Action

    Expand delivery of mental health care in community settings through new models of care and support.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 6 November 2024.
  3. Action

    Provide recurrent funding to Integrated Care Boards to recommission inpatient care under locally appropriate therapeutic models.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 November 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    NHS England is responsible for addressing the reported concerns about mental health bed availability.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of sufficient mental health bed capacity

Wider context from the report

“Mr Singh was an inpatient on a mental health ward at the Homerton Hospital from 20 August 2023 until 6 March 2024, initially under s.2 of the Mental Health Act and then as an informal patient. On three occasions he spent time on medical wards for infected leg ulcers, arising from his IV drug use. During these periods his mental health bed was, understandably, allocated to other patients. However, on discharge from the medical ward, there was no mental health bed available for him and he either went home or, as his property was uninhabitable for a period of time, was accommodated in a Travel Lodge at the cost of the Trust, returning to the mental health ward for meals and medication. Mr Singh did not like the Travel Lodge and on one occasion was evicted. He therefore slept on a coach in the mental health ward and appears to have spent at least one night sleeping rough. I heard that a bed on the mental health ward should have been available for Mr Singh when he was discharged from the medical wards but that there is a chronic shortage of mental health beds and not just in London but nationally. It was described to me as a crisis. ”

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity.

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

Publish statutory guidance supporting safe discharge from mental health and learning disability and autism inpatient settings.

Verbatim wording from the response

“It is also important that when people are discharged, this happens in a way that considers their needs on discharge and any risks to their safety. To help support safe and timely discharge decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support safe discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults.”

Source location

Response from DHSC
Page 2 · response
Published 6 November 2024

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

Expand delivery of mental health care in community settings through new models of care and support.

Verbatim wording from the response

“As part of our mission to build an NHS fit for the future, we will make sure more mental health care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital.”

Source location

Response from DHSC
Page 2 · response
Published 6 November 2024

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 recurrent funding to Integrated Care Boards to recommission inpatient care under locally appropriate 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
Page 2 · response
Published 6 November 2024

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 in new mental health inpatient units to address local bed shortages.

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 and additionally as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and 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
Page 1 · response
Published 6 November 2024

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 is responsible for addressing the reported concerns about mental health bed availability.

Verbatim wording from the response

“I understand your concerns about a bed on the mental health ward not being available for Mr Singh when he was discharged from the medical wards. I note that you have also addressed these matters of concern to the Chief Executive of NHS England. I look forward to seeing her response and working with NHS England where appropriate, to avoid a repetition of the tragic events of this case.”

Source location

Response from DHSC
Page 1 · response
Published 6 November 2024

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

Individual trusts and local health systems are responsible for assessing and managing mental health bed capacity, patient flow and specialist rehabilitation availability.

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 and the availability of specialist personality disorder rehabilitation units. I recognise that mental health services have been under significant strain in recent years due to the rise in demand.”

Source location

Response from DHSC
Page 1 · response
Published 6 November 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Use the Regulation 28 Working Group to discuss reports and share key learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 6 November 2024.
  2. 2

    Engage with North East London Integrated Care Board about mental health inpatient bed concerns and system arrangements.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 November 2024.

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

Use the Regulation 28 Working Group to discuss reports and share key learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Jagjeet, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 6 November 2024

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 with North East London Integrated Care Board about mental health inpatient bed concerns and system arrangements.

Verbatim wording from the response

“My Clinical Quality regional colleagues in London are engaging with North East London Integrated Care Board on the concerns raised in your Report and system arrangements for mental health inpatient beds.”

Source location

Response from NHS England
Page 2 · response
Published 6 November 2024

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026