Malcolm John TAYLOR · Prevention of Future Deaths report

On 12 March 2024 I commenced an investigation into the death of Malcolm John TAYLOR aged 76. The investigation concluded at the end of the inquest on 25 October 2024.

The medical cause of death was:

1a) Drowning
1b)
1c)
2) Ischaemic Heart Disease, Cardiomegaly, Liver Fibrosis

The conclusion of the inquest was:

Suicide while suffering from extreme distress

Mr Taylor was referred to Adult Social Services and Mental Health Team in December 2023. He was low in mood following the death of his wife. From February 2024 Mr Taylor's mood worsened and he remained under the care of the Mental Health Team. He was not taking his medication and had psychotic episodes and following assessment it was agreed consideration should be given to his being admitted to a mental health hospital. Mr Taylor expressed thoughts of self harm and suicidal intent. It was deemed appropriate not to carry out a formal Mental Act Assessment until a bed was available due to his paranoid presentation around professionals and concern his risk of self harm would increase. There was an urgent request for a bed to be found in a mental health hospital. On 3 March 2024 Mr Taylor drove to Gorleston ████████ He probably entered the sea at some time between 22.21 and 8 minutes after midnight on 4 March 2024. Mr Taylor was found on the shoreline at Gorleston beach on 4 March 2024. Mr Taylor died from drowning. A bed in a mental health hospital had not been found prior to Mr Taylor's death.

1. Evidence was heard from NSFT as to action they have taken in an attempt to increase the number of beds available and so to prevent future deaths, such as daily meetings of senior staff to discuss caseloads identified at high risk, prioritising those at high risk, weekly meetings with Directors and multi agencies to consider patient flow through the system and discussion with partner organisations to remove barriers to discharge to improve patient flow especially those with social care requirements. Despite these steps there remain insufficient beds available to meet patient need. At the time of Mr Taylor's death there were 13 patients awaiting beds. At the time of inquest, there were 7 patients awaiting beds. There are peaks and lows with these numbers on a daily basis but overall there remains a shortage of beds.
2. Evidence was heard this is a national problem and not limited to Norfolk and Suffolk NHS Trust.