Insufficient inpatient bed capacity leading to delayed discharges and patient harm

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. ?Every quote shown was checked by code to appear word for word in the original report.

• 2015 → 2015James Adams6 months after George Taylor · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight the lack of acute psychiatric beds in Cornwall as a safety concern. They describe how this shortage leads to patients being sent out of county or detained inappropriately.

  George Taylor · 2 Feb 2015

  “It was established in evidence that Mr [name redacted] death was not caused by the lack of an acute psychiatric bed.”

  Check it in the source

  James Adams · 7 Aug 2015

  “One continuing difficulty was the "lack of acute psychiatric beds" in Cornwall.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2016David Knight1 year 3 months after James Adams · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight insufficient acute mental health beds leading to patients being placed out of county for care.

  James Adams · 7 Aug 2015

  “One continuing difficulty was the "lack of acute psychiatric beds" in Cornwall.”

  Check it in the source

  David Knight · 14 Nov 2016

  “there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2016 → 2019Stephen Kennedy2 years 3 months after David Knight · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight a shortage of acute mental health beds as a safety concern. The earlier report links the shortage to out‑of‑county placements, while the later report links it to unavailable beds leading to self‑harm.

  David Knight · 14 Nov 2016

  “there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment”

  Check it in the source

  Stephen Kennedy · 7 Feb 2019

  “In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts.”

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  Stated action in the response to the earlier report

  “We will eliminate clinically unnecessary out of area placements for adult acute mental health care by 2020/21 and will reduce significantly delayed transfers of care.”

  Earlier report in the app · Later report in the app

• 2021 → 2022Laura Medcalf11 months after Martin Gibbons · same coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports describe a delay in accessing a mental health bed that leaves a patient in an acute hospital setting, creating risk.

  Martin Gibbons · 21 May 2021

  “It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left”

  Check it in the source

  Laura Medcalf · 28 Apr 2022

  “The inquest heard that [the deceased] was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental 2 health beds”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2020 → 2023Benjamin Stanley2 years 4 months after Piotr Kierzkowski · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports identify insufficient hospital bed capacity as a safety concern. The earlier report focuses on beds for informal admission, while the later report links bed shortages to prolonged A&E waits.

  Piotr Kierzkowski · 12 Oct 2020

  “as identified that there were no beds available in Suffolk, or anywhere else in the country at the time.”

  Check it in the source

  Benjamin Stanley · 4 Feb 2023

  “The Inquest was told that prolonged waits in A&E were also due to a lack of beds with the hospital.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2019 → 2023Stephen Richardson4 years 4 months after Stephen Kennedy · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports highlight the unavailability of acute psychiatric beds leading to risk of self‑harm. The earlier case describes local bed shortages causing further harm; the later case notes a persistent national shortage.

  Stephen Kennedy · 7 Feb 2019

  “There were no beds available and as a result he had further episodes of self-harm and suicide attempts. The availability of acute beds is a serious concern.”

  Check it in the source

  Stephen Richardson · 22 Jun 2023

  “at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2023Stephen Richardson7 years 10 months after James Adams · different coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports highlight a shortage of acute psychiatric beds needed for inpatient mental health care. The earlier report focuses on a local deficit in Cornwall, while the later report describes a nationwide shortage persisting over time.

  James Adams · 7 Aug 2015

  “One continuing difficulty was the "lack of acute psychiatric beds" in Cornwall.”

  Check it in the source

  Stephen Richardson · 22 Jun 2023

  “at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2023Stephen Richardson8 years 5 months after George Taylor · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight a shortage of acute psychiatric beds as a risk factor for patient harm. They differ in geographic scope (Cornwall vs national) and timing of the evidence.

  George Taylor · 2 Feb 2015

  “It was established in evidence that Mr [name redacted] death was not caused by the lack of an acute psychiatric bed.”

  Check it in the source

  Stephen Richardson · 22 Jun 2023

  “at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2023Philip Malone8 years 10 months after George Taylor · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight the ongoing shortage of psychiatric/acute psychiatric beds as a risk to patient safety. They describe how insufficient bed capacity can lead to delayed admissions or out‑of‑area placements, creating a potential for future harm.

  George Taylor · 2 Feb 2015

  “It was established in evidence that Mr [name redacted] death was not caused by the lack of an acute psychiatric bed.”

  Check it in the source

  Philip Malone · 23 Nov 2023

  “Despite recognising Mr [name redacted] needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT' RCA report identified no remedial action.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2020 → 2023Philip Malone3 years 1 month after Piotr Kierzkowski · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight a shortage of psychiatric/inpatient beds that prevents timely admission of patients needing care. The earlier report focuses on unavailable beds for informal admission, while the later report notes the same bed shortage leads to unsafe discharge practices.

  Piotr Kierzkowski · 12 Oct 2020

  “I am therefore concerned in relation to the overall bed capacity for those patients like [the deceased] seeking informal admission”

  Check it in the source

  Philip Malone · 23 Nov 2023

  “My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate”

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  Earlier report in the app · Later report in the app

• 2020 → 2023Philip Malone3 years 2 months after Joseph Cheetham · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight a shortage of available beds leading to delayed admission and unsafe care. The earlier case concerns acute hospital beds causing prolonged ED stays, while the later case concerns psychiatric beds preventing timely admission.

  Joseph Cheetham · 30 Sept 2020

  “Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable.”

  Check it in the source

  Philip Malone · 23 Nov 2023

  “Despite recognising Mr [name redacted] needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT' RCA report identified no remedial action.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2020 → 2024Nicolas Gerasimidis3 years 4 months after Piotr Kierzkowski · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports highlight insufficient inpatient bed capacity preventing informal admission of patients needing mental health care. This lack of beds directly contributed to adverse outcomes in each case.

  Piotr Kierzkowski · 12 Oct 2020

  “I am therefore concerned in relation to the overall bed capacity for those patients like [the deceased] seeking informal admission”

  Check it in the source

  Nicolas Gerasimidis · 30 Jan 2024

  “In May 2023, when it was felt Mr [name redacted] required an informal admission into hospital, no beds were available.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2023 → 2024Nicolas Gerasimidis1 year after Benjamin Stanley · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify a shortage of hospital beds as the core problem. This bed shortage leads to delayed or denied admissions and impacts patient care.

  Benjamin Stanley · 4 Feb 2023

  “lack of beds with the hospital. In Mr [name redacted] case direct entry to a ward would have been in his best interests”

  Check it in the source

  Nicolas Gerasimidis · 30 Jan 2024

  “In May 2023, when it was felt Mr [name redacted] required an informal admission into hospital, no beds were available.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2019 → 2024Nicolas Gerasimidis5 years after Stephen Kennedy · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight the lack of available acute inpatient beds as a critical safety issue. This shortage led to worsened mental health outcomes and increased risk of self‑harm or suicide.

  Stephen Kennedy · 7 Feb 2019

  “In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts.”

  Check it in the source

  Nicolas Gerasimidis · 30 Jan 2024

  “In May 2023, when it was felt Mr [name redacted] required an informal admission into hospital, no beds were available.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2024Nicolas Gerasimidis8 years 9 months after Andrew Farrow · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight that patients needing psychiatric admission could not be accommodated because no hospital beds were available. The earlier case concerned Green Lane Hospital in Devizes, while the later case concerns bed shortages in Cornwall.

  Andrew Farrow · 20 Apr 2015

  “My concern however is that had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014 by North Wiltshire Intensive Services.”

  Check it in the source

  Nicolas Gerasimidis · 30 Jan 2024

  “In May 2023, when it was felt Mr [name redacted] required an informal admission into hospital, no beds were available.”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”

  Earlier report in the app · Later report in the app

• 2016 → 2024Shahzadi Khan7 years 3 months after David Knight · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports describe a national shortage of mental health beds that forces patients to be placed out of their local area. This shared hazard leads to difficulties in communication, support, and risk management.

  David Knight · 14 Nov 2016

  “there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment”

  Check it in the source

  Shahzadi Khan · 31 Jan 2024

  “a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual”

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  Earlier report in the app · Later report in the app

• 2015 → 2024Nicola Rayner8 years 11 months after Andrew Farrow · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight a shortage of mental health beds that prevents patients who wish to be admitted from receiving inpatient care.

  Andrew Farrow · 20 Apr 2015

  “The deceased was under the care of the Avon and Wiltshire Mental Health Partnership. The day before his death the deceased made it clear he wished to be admitted to hospital for his own safety.”

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  Nicola Rayner · 7 Mar 2024

  “Had an informal Mental Health bed been available on the 6th June 2023, and [the deceased] had been admitted as both she and her psychiatrist had wished, her death would not have occurred.”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”

  Earlier report in the app · Later report in the app

• 2022 → 2024Nicola Rayner1 year 10 months after Laura Medcalf · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight insufficient mental health inpatient bed capacity leading to delayed or adverse outcomes for patients needing care. They differ in the specific context: one concerns a general bed shortage causing a patient to remain in an acute hospital, while the other focuses on the lack of an informal mental health bed preventing timely admission.

  Laura Medcalf · 28 Apr 2022

  “The inquest heard that [the deceased] was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental”

  Check it in the source

  Nicola Rayner · 7 Mar 2024

  “Had an informal Mental Health bed been available on the 6th June 2023, and [the deceased] had been admitted as both she and her psychiatrist had wished, her death would not have occurred.”

  Check it in the source

  Stated action in the response to the earlier report

  “the Department is investing £150 million for significant improvements in the mental health estate over the course of the Spending Review (2021). This will be used to support our NHS Long Term Plan ambitions regarding system capacity and pressure reduction. It will cover a range of schemes, including non-medical alternatives to admission, step-down community beds and supported living services.”

  Earlier report in the app · Later report in the app

• 2023 → 2024Juan Martin7 months after Philip Malone · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight an unresolved shortage of psychiatric/mental health bed capacity leading to delayed admissions and increased risk. They differ in geographic focus (Birmingham/Solihull vs. London) and the specific witnesses cited.

  Philip Malone · 23 Nov 2023

  “Despite recognising Mr [name redacted] needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT' RCA report identified no remedial action.”

  Check it in the source

  Juan Martin · 11 Jun 2024

  “The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust initiated a 12- month project with Grant Thornton Consultancy to address local bed shortages and reduce reliance on out-of-area hospital beds”

  Earlier report in the app · Later report in the app

• 2020 → 2024Juan Martin3 years 8 months after Piotr Kierzkowski · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight insufficient mental health bed capacity leading to delayed or denied admission for patients needing inpatient care. The earlier case resulted in a patient being sent home and dying by suicide; the later case describes ongoing delays despite some triage efforts.

  Piotr Kierzkowski · 12 Oct 2020

  “as identified that there were no beds available in Suffolk, or anywhere else in the country at the time.”

  Check it in the source

  Juan Martin · 11 Jun 2024

  “bed capacity remains an ongoing problem and has not been resolved.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2020 → 2024Juan Martin3 years 11 months after John Cheetham · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify insufficient bed capacity as a safety issue leading to prolonged waits and risk of harm. The earlier report focuses on general emergency department bed shortages due to delayed discharges, while the later report highlights ongoing mental health bed shortages in London.

  John Cheetham · 13 Jul 2020

  “The prolonged wait Mr [name redacted] had was a result of lack of bed capacity.”

  Check it in the source

  Juan Martin · 11 Jun 2024

  “bed capacity remains an ongoing problem and has not been resolved.”

  Check it in the source

  Stated action in the response to the earlier report

  “Adoption of a single GM Discharge to Assess Referral Form - Triage of discharge to assess referrals within 30mins - Adherence to the guidance for COVID 19 testing for discharge and PPE requirements - The supply of 2 weeks medication supplies at the point of discharge from an acute hospital - Operation of a next day follow up process following discharge (localities to determine how this is delivered)”

  Earlier report in the app · Later report in the app

• 2021 → 2024Juan Martin3 years 1 month after Martin Gibbons · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that insufficient mental health bed capacity leads to dangerous delays in emergency departments. The core issue is the lack of available beds causing patients to leave or wait excessively.

  Martin Gibbons · 21 May 2021

  “It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left.”

  Check it in the source

  Juan Martin · 11 Jun 2024

  “The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2022 → 2024Juan Martin2 years 1 month after Laura Medcalf · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight a shortage of mental health inpatient beds causing patients to remain in unsuitable settings while awaiting placement.

  Laura Medcalf · 28 Apr 2022

  “[the deceased] was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental 2 health beds”

  Check it in the source

  Juan Martin · 11 Jun 2024

  “Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022,”

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  Earlier report in the app · Later report in the app

• 2022 → 2024Robin Ward2 years 6 months after Laura Medcalf · different coronerClosely relatedConfidence 0.85 · high

  Closely relatedConfidence 0.85 · high

  Both reports highlight a shortage of acute mental health beds leading to patients being held in inappropriate settings or placed far from home. The earlier case focuses on delayed admission to an acute hospital, while the later case notes broader pressures and reliance on out‑of‑area beds.

  Laura Medcalf · 28 Apr 2022

  “The inquest heard that [the deceased] was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental 2 health beds”

  Check it in the source

  Robin Ward · 18 Oct 2024

  “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”

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  Earlier report in the app · Later report in the app

• 2016 → 2024Robin Ward7 years 11 months after David Knight · different coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight insufficient acute mental health bed capacity leading to reliance on out‑of‑area placements.

  David Knight · 14 Nov 2016

  “national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization”

  Check it in the source

  Robin Ward · 18 Oct 2024

  “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2024Malcolm Taylor9 years 6 months after Andrew Farrow · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight a shortage of inpatient psychiatric beds that prevents timely admission of suicidal patients. The later report notes ongoing bed shortages despite trust initiatives.

  Andrew Farrow · 20 Apr 2015

  “had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes”

  Check it in the source

  Malcolm Taylor · 28 Oct 2024

  “Despite these steps there remain insufficient beds available to meet patient need.”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”

  Earlier report in the app · Later report in the app

• 2024 → 2024Jagjeet Singh8 months after Nicola Rayner · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight a shortage of informal/inpatient mental health beds that puts patients at risk of harm.

  Nicola Rayner · 7 Mar 2024

  “Had an informal Mental Health bed been available on the 6th June 2023, and [the deceased] had been admitted as both she and her psychiatrist had wished, her death would not have occurred.”

  Check it in the source

  Jagjeet Singh · 4 Nov 2024

  “a chronic shortage of mental health beds and not just in London but nationally. It was described to me as a crisis.”

  Check it in the source

  Earlier report in the app · Later report in the app

• 2015 → 2024Timothy De Boos9 years 8 months after Andrew Farrow · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight that a shortage of inpatient mental health beds prevented admission despite the patient's and family's request for hospitalization. The core issue is the unavailability of beds leading to denied care.

  Andrew Farrow · 20 Apr 2015

  “had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014”

  Check it in the source

  Timothy De Boos · 13 Dec 2024

  “At the time of Tim's mental health crisis on the 2 February 2024, had the decision to admit him been possible, he still would not have been admitted as there were five other individuals in the queue before him also waiting for admission.”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”

  Earlier report in the app · Later report in the app

• 2024 → 2024Timothy De Boos6 months after Juan Martin · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight a shortage of mental health inpatient beds as a safety concern. The earlier report focuses on London while the later report concerns Suffolk and wider England/Wales.

  Juan Martin · 11 Jun 2024

  “The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved. The Matron provided one recent example where a patient waited for 7 days”

  Check it in the source

  Timothy De Boos · 13 Dec 2024

  “I am concerned of the continuing lack of Mental Health Unit inpatient beds in Suffolk, and more widely throughout England and Wales.”

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  Earlier report in the app · Later report in the app

• 2023 → 2024Timothy De Boos1 year 11 months after Leroy Hamilton · different coronerClosely relatedConfidence 0.86 · high

  Closely relatedConfidence 0.86 · high

  Both reports highlight a shortage of inpatient mental health beds leading to unsafe situations for patients awaiting admission. The earlier report also mentions missing PDU spaces, while the later report focuses solely on the lack of Mental Health Unit beds.

  Leroy Hamilton · 11 Jan 2023

  “Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU.”

  Check it in the source

  Timothy De Boos · 13 Dec 2024

  “I am concerned of the continuing lack of Mental Health Unit inpatient beds in Suffolk, and more widely throughout England and Wales.”

  Check it in the source

  Stated action in the response to the earlier report

  “Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.”

  Earlier report in the app · Later report in the app

• 2024 → 2024Matthew Sheldrick (2)6 months after Juan Martin · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports identify a shortage of inpatient mental health beds causing prolonged waits for patients in emergency settings.

  Juan Martin · 11 Jun 2024

  “The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”

  Check it in the source

  Matthew Sheldrick (2) · 16 Dec 2024

  “There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”

  Check it in the source

  Stated action in the response to the earlier report

  “The Trust (SWLStG) fully acknowledges the concern regarding insufficient bed capacity in London and the reason why the Coroner has cause to raise these concerns.”

  Earlier report in the app · Later report in the app

• 2023 → 2024Matthew Sheldrick (2)1 year 11 months after Leroy Hamilton · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight a shortage of inpatient mental health beds that forces patients to remain in emergency departments for extended periods. The core concern is the same: insufficient bed capacity leading to unsafe ED waits.

  Leroy Hamilton · 11 Jan 2023

  “Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU.”

  Check it in the source

  Matthew Sheldrick (2) · 16 Dec 2024

  “There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds.”

  Check it in the source

  Stated action in the response to the earlier report

  “Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.”

  Earlier report in the app · Later report in the app

• 2022 → 2024Matthew Sheldrick (2)2 years 8 months after Laura Medcalf · different coronerClosely relatedConfidence 0.87 · high

  Closely relatedConfidence 0.87 · high

  Both reports highlight a national shortage of inpatient mental health beds leading to delays in care. The later report specifies the shortage particularly affects autistic and transgender patients needing mixed wards, while the earlier report focuses on general bed shortages causing patients to stay in acute hospitals.

  Laura Medcalf · 28 Apr 2022

  “The inquest heard that [the deceased] was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental 2 health beds”

  Check it in the source

  Matthew Sheldrick (2) · 16 Dec 2024

  “There being a national shortage of mental health beds in particular for Autistic patients and those who are transgender requiring a mixed ward.”

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  Earlier report in the app · Later report in the app

• 2020 → 2025Kenneth Clayton4 years 7 months after John Cheetham · same coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify prolonged emergency department waits caused by insufficient bed capacity due to delayed discharges as a hazard leading to patient harm.

  John Cheetham · 13 Jul 2020

  “The prolonged wait Mr [name redacted] had was a result of lack of bed capacity.”

  Check it in the source

  Kenneth Clayton · 19 Feb 2025

  “As an example the court was told that on the morning the inquest was heard there were patients who had been waiting 40 hours for a bed on a ward.”

  Check it in the source

  Stated action in the response to the earlier report

  “Adoption of a single GM Discharge to Assess Referral Form - Triage of discharge to assess referrals within 30mins - Adherence to the guidance for COVID 19 testing for discharge and PPE requirements - The supply of 2 weeks medication supplies at the point of discharge from an acute hospital - Operation of a next day follow up process following discharge (localities to determine how this is delivered)”

  Earlier report in the app · Later report in the app

• 2021 → 2025Kenneth Clayton3 years 9 months after Martin Gibbons · same coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify a prolonged wait in the Emergency Department for a bed as a contributing factor to patient harm. The earlier case links the wait to a patient leaving the department, while the later case links it to a fall due to unsuitable ED observation conditions.

  Martin Gibbons · 21 May 2021

  “It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left.”

  Check it in the source

  Kenneth Clayton · 19 Feb 2025

  “The inquest heard evidence that a key factor in the fall was the prolonged time Mr [name redacted] was in the Emergency Department waiting for a bed to become available on a ward.”

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  Earlier report in the app · Later report in the app

• 2023 → 2025James Sheppard1 year 11 months after Stephen Richardson · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports highlight a shortage of psychiatric beds needed for acute mental health care. They describe the same insufficiency affecting patient treatment.

  Stephen Richardson · 22 Jun 2023

  “It was clear from the investigation that at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds”

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  James Sheppard · 8 May 2025

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

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  Earlier report in the app · Later report in the app

• 2015 → 2025James Sheppard9 years 9 months after James Adams · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight a shortage of psychiatric beds leading to patients being placed outside their local area or in inappropriate settings. The core issue is insufficient capacity in acute psychiatric provision.

  James Adams · 7 Aug 2015

  “One continuing difficulty was the "lack of acute psychiatric beds" in Cornwall.”

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  James Sheppard · 8 May 2025

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

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  Earlier report in the app · Later report in the app

• 2024 → 2025James Sheppard6 months after Malcolm Taylor · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight a shortage of psychiatric beds relative to patient need.

  Malcolm Taylor · 28 Oct 2024

  “Despite these steps there remain insufficient beds available to meet patient need.”

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  James Sheppard · 8 May 2025

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

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  Earlier report in the app · Later report in the app

• 2024 → 2026Tania Jarman1 year 4 months after Jagjeet Singh · different coronerIdentical hazardConfidence 0.95 · high

  Identical hazardConfidence 0.95 · high

  Both reports identify a shortage of mental health beds as a risk to life. The later report adds detail about referral thresholds but concerns the same core issue.

  Jagjeet Singh · 4 Nov 2024

  “I heard that a bed on the mental health ward should have been available for Mr [name redacted] 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.”

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  Tania Jarman · 12 Mar 2026

  “There is a long standing and well publicised concern that there are fewer mental health beds than patients who are assessed as needing these.”

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  Stated action in the response to the earlier report

  “The number of mental health beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary.”

  Earlier report in the app · Later report in the app

• 2024 → 2026Tania Jarman2 years after Nicola Rayner · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight a shortage of mental health inpatient beds as a risk to patient safety. They describe the same mechanism—lack of available beds leading to avoidable harm or death.

  Nicola Rayner · 7 Mar 2024

  “Had an informal Mental Health bed been available on the 6th June 2023, and [the deceased] had been admitted as both she and her psychiatrist had wished, her death would not have occurred.”

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  Tania Jarman · 12 Mar 2026

  “There is a long standing and well publicised concern that there are fewer mental health beds than patients who are assessed as needing these. I draw your attention to the fact that this situation is ongoing and continues to pose a risk to life.”

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  Earlier report in the app · Later report in the app