Recurance · prevention of future deaths reports
Pre-inquest brief
Shortage of tier 4 paediatric mental health beds
The earlier warning
Madeleine Savory · 15 Nov 2023 · Darren Stewart, Suffolk
“The availability, nationally, of Tier 4 beds in paediatric mental health facilities”
judiciary.uk/…/madeleine-savory-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Madeleine Savory (15 Nov 2023) · stated 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 2 · response to Madeleine Savory (15 Nov 2023) · stated timescale: none stated
“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.”
judiciary.uk/…/2023-0452-Response-from-Department-of-Health-and…
What recurred
- 3 Feb 2026 · Ellame Ford-Dunn · Joanne Andrews · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Madeleine Savory · 15 Nov 2023
“The availability, nationally, of Tier 4 beds in paediatric mental health facilities”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.