James Oliver Sheppard · Prevention of Future Deaths report

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Issued 8 May 2025•Gloucestershire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised1

  1. Insufficient psychiatric unit bed capacity
    Part of recurring concern: Insufficient psychiatric inpatient bed capacity

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Department of Health and Social Care

    Shift mental health treatment toward community and crisis services through new care and support models to reduce hospital admissions.

  2. Department of Health and Social Care

    Commit £26 million in capital investment to open new mental health crisis centres.

  3. Gloucestershire Health and Care NHS Foundation Trust

    Implement measures improving bed-management structure and efficiency and reducing out-of-area placements.

  4. Gloucestershire Health and Care NHS Foundation Trust

    Formally acknowledge the importance of adequate inpatient-care access at the Contract Management Board meeting with the Integrated Care Board.

  5. Gloucestershire Health and Care NHS Foundation Trust

    Continue reducing average inpatient length of stay to improve psychiatric bed availability and utilisation.

  6. Gloucestershire Health and Care NHS Foundation Trust

    Continue implementing steps to provide the best possible quality of care.

  7. Gloucestershire Health and Care NHS Foundation Trust

    Engage with the local Integrated Care Board on improving local inpatient capacity and access.

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

  1. Department of Health and Social Care

    Local trusts, health systems and integrated care boards are responsible for assessing and managing capacity and reducing delays in mental health services.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Gloucestershire Health and Care NHS Foundation Trust

    Commissioning and determining total psychiatric bed resources are responsibilities of the wider local and national health system.

    Redirects 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

Insufficient psychiatric unit bed capacity

Wider context from the report

“There appear to be insufficient beds available in psychiatric units to meet patient demand ”

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity.

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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

Shift mental health treatment toward community and crisis services through new care and support models to reduce hospital admissions.

Verbatim wording from the response

“As part of our mission to build an NHS fit for the future, we will focus treatment away from hospital and inpatient care and improve community and crisis services, making sure more mental health crisis 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. This will hopefully reduce delays, though increasing bed availability, for those who need inpatient care the most.”

Source location

Response from DHSC
Page 1 · response
Published 21 May 2025

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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

Commit £26 million in capital investment to open new mental health crisis centres.

Verbatim wording from the response

“As announced in the Budget, we are committing £26 million in capital investment to open new mental health crisis centres, reducing pressure on busy A&E services and ensuring people have the support they need when they need it.”

Source location

Response from DHSC
Page 2 · response
Published 21 May 2025

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 measures improving bed-management structure and efficiency and reducing out-of-area placements.

Verbatim wording from the response

“We are grateful for the acknowledgement during your concluding remarks at the inquest that the Trust is responsible for delivery of psychiatric beds locally and issues of commissioning and total levels of available resource are responsibilities held in the wider health system locally and nationally. As such, our response is focused on what we can influence. As examined during the hearing, particularly in consideration of the witness testimony provided by ████████, significant work has been undertaken over the past few years to manage mental health bed capacity and patient flow within the Trust.”

Source location

Response from Gloucestershire Health & Care NHS Foundation Trust
Page 1 · response
Published 21 May 2025

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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

Formally acknowledge the importance of adequate inpatient-care access at the Contract Management Board meeting with the Integrated Care Board.

Verbatim wording from the response

“In its ongoing efforts to improve the position locally, the Trust has also engaged in discussions with the local Integrated Care Board (NHS Gloucestershire ICB) and the development of an inpatient strategy is one of the agreed priorities for the Integrated Care System this year. We will ensure that the importance of adequate access to inpatient care is formally acknowledged through our Contract Management Board meeting with the ICB.”

Source location

Response from Gloucestershire Health & Care NHS Foundation Trust
Page 2 · response
Published 21 May 2025

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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 reducing average inpatient length of stay to improve psychiatric bed availability and utilisation.

Verbatim wording from the response

“Although bed availability and resourcing continue to present challenges across mental health wards nationally, the measures implemented by the Trust have improved the structure and efficiency of bed management systems and significantly reduced the use of Out of Area Placements over the past three years, clearly demonstrating the Trust commitment towards an ongoing improvement of processes to ensure that every possible effort is made to ensure that those patients who require in-patient mental health care have access to a bed as quickly as possible. Our further work is focused on reducing, wherever possible, the average length of stay of inpatients to ensure that the current number of beds are being used as efficiently and effectively as possible. The Trust will be monitored nationally on this measure as part of NHS England’s Performance Assessment Framework.”

Source location

Response from Gloucestershire Health & Care NHS Foundation Trust
Page 1 · response
Published 21 May 2025

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

Continue implementing steps to provide the best possible quality of care.

Verbatim wording from the response

“As a Trust, the safety and wellbeing of those we provide service to is paramount and despite the unfortunate circumstances in which this query has arisen, we welcome the opportunity you have provided for us to further address the issue of beds availability in psychiatric units. We will also note the response you receive from the Department of Health and Social Care on this issue which we are aware presents a challenge to mental health providers across the country. We have taken this opportunity, as we do with all inquests, to learn from this and continue to implement steps to ensure that we provide the best possible quality care.”

Source location

Response from Gloucestershire Health & Care NHS Foundation Trust
Page 2 · response
Published 21 May 2025

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 the local Integrated Care Board on improving local inpatient capacity and access.

Verbatim wording from the response

“In its ongoing efforts to improve the position locally, the Trust has also engaged in discussions with the local Integrated Care Board (NHS Gloucestershire ICB) and the development of an inpatient strategy is one of the agreed priorities for the Integrated Care System this year. We will ensure that the importance of adequate access to inpatient care is formally acknowledged through our Contract Management Board meeting with the ICB.”

Source location

Response from Gloucestershire Health & Care NHS Foundation Trust
Page 2 · response
Published 21 May 2025

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

Local trusts, health systems and integrated care boards are responsible for assessing and managing capacity and reducing delays in mental health services.

Verbatim wording from the response

“I expect individual trusts and local health systems to effectively assess and manage bed capacity through the ‘flow’ of patients being discharged or moving to another setting.”

Source location

Response from DHSC
Page 1 · response
Published 21 May 2025

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

Commissioning and determining total psychiatric bed resources are responsibilities of the wider local and national health system.

Verbatim wording from the response

“We are grateful for the acknowledgement during your concluding remarks at the inquest that the Trust is responsible for delivery of psychiatric beds locally and issues of commissioning and total levels of available resource are responsibilities held in the wider health system locally and nationally. As such, our response is focused on what we can influence. As examined during the hearing, particularly in consideration of the witness testimony provided by ████████, significant work has been undertaken over the past few years to manage mental health bed capacity and patient flow within the Trust.”

Source location

Response from Gloucestershire Health & Care NHS Foundation Trust
Page 1 · response
Published 21 May 2025

Open published response
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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