Shortage of tier 4 paediatric mental health beds
NHS England received 2 coroners' reports about this hazard between 15 Nov 2023 and 3 Feb 2026.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The availability, nationally, of Tier 4 beds in paediatric mental health facilities”
Original on judiciary.uk ↗ NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The NHS Planning Guidance 2022/23 outlined the need for Lead Provider Collaboratives (LPCs) and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive care Units to meet the needs of their local population.”
Stated timescale: 2022/23
“I note that you have received satisfactory evidence from East Suffolk and North Essex NHS Foundation Trust, the East of England Provider Collaborative and Northgate High School concerning the measures they have put in place to address the failures identified during the course of the Inquest.”
- 2 years 3 months later
Raised again · 1st time
Ellame Ford-Dunn↗
3 Feb 2026 · Joanne Andrews · West Sussex, Brighton and Hove
Identical hazardConfidence 0.90 · higha different coroner“I heard that there are insufficient numbers of Tier 4 Paediatric Mental Health beds available for the children and young people who have been assessed as requiring this level of admission.”
Original on judiciary.uk ↗ Repeated from the earlier report:TierPaediatricMentalHealthbeds
NHS England responded.Response (PDF) ↗
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2023 → 2026Ellame Ford-Dunn2 years 3 months after Madeleine Savory · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a shortage of Tier 4 paediatric mental health beds leading to delayed admissions for children needing that level of care.
Madeleine Savory · 15 Nov 2023
“The availability, nationally, of Tier 4 beds in paediatric mental health facilities”
Original on judiciary.uk ↗ Ellame Ford-Dunn · 3 Feb 2026
“I heard that there are insufficient numbers of Tier 4 Paediatric Mental Health beds available for the children and young people who have been assessed as requiring this level of admission.”
Original on judiciary.uk ↗
Stated action · timescale: 2022/23
“The NHS Planning Guidance 2022/23 outlined the need for Lead Provider Collaboratives (LPCs) and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive care Units to meet the needs of their local population.”
Stated action
“I note that you have received satisfactory evidence from East Suffolk and North Essex NHS Foundation Trust, the East of England Provider Collaborative and Northgate High School concerning the measures they have put in place to address the failures identified during the course of the Inquest.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2023 → 2026 | 0.83 | 0.23 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.