Lack of inpatient mental health beds
Avon and Wiltshire Mental Health Partnership NHS Trust received 2 coroners' reports about this hazard between 20 Apr 2015 and 7 Aug 2016.
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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014”
Original on judiciary.uk ↗ Avon and Wiltshire Mental Health Partnership NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“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.”
Web search (Tavily): No evidence found either way
Bringing care closer to home:reducing inappropriate out of area placements in mental health services ↗- 1 year 4 months laterIdentical hazardConfidence 0.90 · higha different coroner
“provision of in-patient beds is subject fo the funding provided by the Bristol Clinical Commissioning Group (CCG).”
Original on judiciary.uk ↗ Avon and Wiltshire Mental Health Partnership NHS Trust responded.Response (PDF) ↗
- All reports to Avon and Wiltshire Mental Health Partnership NHS Trust
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.
2015 → 2016Rohan Fitzsimons1 year 4 months after Andrew Farrow · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that insufficient inpatient mental‑health bed capacity prevented timely admission or assessment of patients expressing suicidal intent. The core issue is the unavailability of beds when clinical need arises.
Andrew Farrow · 20 Apr 2015
“no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014”
Original on judiciary.uk ↗ Rohan Fitzsimons · 7 Aug 2016
“provision of in-patient beds is subject fo the funding provided by the Bristol Clinical Commissioning Group (CCG).”
Original on judiciary.uk ↗ 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.”
Stated action
“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.”
What happened next: No evidence found either way
The Trust states it monitors bed pressures and out of area placements while working with commissioners and NHS England to manage the situation optimally.
“Inappropriate out of area placements (IOAPs) have a significant emotional, economic and health impact on patients and carers, and negatively impact patient outcomes.”
No evidence found does not mean the action did not happen.
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 Avon and Wiltshire Mental Health Partnership NHS Trust 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 |
|---|---|---|---|---|
| 2015 → 2016 | 0.79 | 0.35 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Avon and Wiltshire Mental Health Partnership NHS Trust
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.