Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
George Taylor · 2 Feb 2015 · Andrew Cox, Cornwall
“It was established in evidence that Mr [name redacted] death was not caused by the lack of an acute psychiatric bed.”
judiciary.uk/prevention-of-future-death-reports/george-taylor
What was promised
Stated action 1 · response to George Taylor (2 Feb 2015) · stated timescale: none stated
“I have made NHS England aware of your report.”
judiciary.uk/…/2015-0044-Response-by-Department-of-Health.pdf
Stated action 2 · response to James Adams (7 Aug 2015) · stated timescale: none stated
“Kernow CCG has agreed to carry out a full review both of acute psychiatric beds in Cornwall and the staffing of the place of safety service and will produce an action plan and commissioning strategy”
judiciary.uk/wp-content/uploads/2015/08/James-Adams-Response.pdf
Stated action 3 · response to David Knight (14 Nov 2016) · stated timescale: 2020/21
“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.”
judiciary.uk/…/2016-0414-Response-by-Department-of-Health.pdf
19 further stated actions are listed on the full chain page.
What recurred
- 20 Apr 2015 · Andrew Farrow · Peter Hatvany
- 7 Aug 2015 · James Adams · Emma Carlyon · Identical hazard · confidence 0.90 (high)
- 14 Nov 2016 · David Knight · Emma Carlyon · Identical hazard · confidence 0.90 (high)
- 7 Feb 2019 · Stephen Kennedy · Louise Hunt · Closely related · confidence 0.90 (high)
- 13 Jul 2020 · John Cheetham · Alison Mutch
- 30 Sept 2020 · Joseph Cheetham · Alison Mutch
- 12 Oct 2020 · Piotr Kierzkowski · Nigel Parsley
- 21 May 2021 · Martin Gibbons · Alison Mutch
- 28 Apr 2022 · Laura Medcalf · Alison Mutch · Identical hazard · confidence 0.90 (high)
- 11 Jan 2023 · Leroy Hamilton · Louise Hunt
- 4 Feb 2023 · Benjamin Stanley · Alison Mutch · Closely related · confidence 0.80 (moderate)
- 22 Jun 2023 · Stephen Richardson · Andre Rebello · Identical hazard · confidence 0.95 (high)
- 23 Nov 2023 · Philip Malone · James Bennett · Identical hazard · confidence 0.90 (high)
- 30 Jan 2024 · Nicolas Gerasimidis · Andrew Cox · Identical hazard · confidence 0.95 (high)
- 31 Jan 2024 · Shahzadi Khan · Alison Mutch · Identical hazard · confidence 0.90 (high)
- 7 Mar 2024 · Nicola Rayner · Nigel Parsley · Identical hazard · confidence 0.90 (high)
- 11 Jun 2024 · Juan Martin · Priya Malhotra · Closely related · confidence 0.90 (high)
- 18 Oct 2024 · Robin Ward · Hassan Shah · Closely related · confidence 0.85 (high)
- 28 Oct 2024 · Malcolm Taylor · Jacqueline Lake · Identical hazard · confidence 0.90 (high)
- 4 Nov 2024 · Jagjeet Singh · Melanie Lee · Identical hazard · confidence 0.90 (high)
- 13 Dec 2024 · Timothy De Boos · Nigel Parsley · Identical hazard · confidence 0.90 (high)
- 16 Dec 2024 · Matthew Sheldrick (2) · Penelope Schofield · Identical hazard · confidence 0.90 (high)
- 19 Feb 2025 · Kenneth Clayton · Alison Mutch · Identical hazard · confidence 0.95 (high)
- 8 May 2025 · James Sheppard · Roland Wooderson · Identical hazard · confidence 0.95 (high)
- 12 Mar 2026 · Tania Jarman · Elizabeth Wheeler · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · 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”
Later · 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.”
What happened next
No evidence found either way · stated action 1
“The Health and Social Care Committee's Expert Panel: --- ## Evaluation of Government commitments made on the digitisation of the NHS ## Introduction Governments often make well-publicised policy commitments with good intentions to improve services for the public.”
Evaluation of Government commitments made on the digitisation of the NHS - Health and Social Care Committee · publications.parliament.uk/…/report.html
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“9. Governance Improvement Plan FD Paper SS 10.25 TB/26-27/72”
AGENDA · kentmedwaymentalhealth.nhs.uk/…/public-board-pack-24-september-…
“What staffing factors (including skill mix, staff relationships, working structures) in mental health services are associated with improved patient outcomes (including safety, effectiveness and experience)?”
What staffing structures of mental health services are ... · england.nhs.uk/…/Safer_staffing_mental_health_evidence_review.p…
“People faced barriers in accessing help at a time of crisis”
How are people's mental health needs met in acute ... · cqc.org.uk/system/files?file=20201016b_AMSAT_report.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Inappropriate out of area placements (IOAPs) have a significant emotional, economic and health impact on patients and carers, and negatively impact patient outcomes.”
Bringing care closer to home:reducing inappropriate out of area placements in mental health services · thenhsalliance.org/…/bringing-care-closer-to-home-reducing-inap…
“Out-of-area placements reduced 93%, (from 66.5 to 4.6 per week), avoiding £8.5 million in costs. Average length of stay on London adult mental health wards fell by 17.5%, (53 to 43.9 days).”
A trust-wide quality improvement programme to reduce out-of-area placements, length of stay and costs across inpatient mental health services · pmc.ncbi.nlm.nih.gov/articles/PMC12887397
“The Availability and Supply of Short-Term Care Beds in Long-Term Care Facilities: A Mechanism to Ensure Timely Transfers Out of Hospital for Older Patients in England.”
A Mechanism to Ensure Timely Transfers Out of Hospital ... · journal.ilpnetwork.org/articles/337/files/68ff36d43c198.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “On the availability of beds in the acute mental health sector, we are aware that the number of mental health beds overall have reduced and this is in large part due to the growth of care in the community. It may also be of interest to note that mental health bed occupancy rates have remained stable at between 87.1 per cent and 90.8 per cent (from Quarter 1, 2010-11 to Quarter 3, 2018-19), and that latest data for Quarter 3, 2018-19 shows a bed occupancy of 88.5 per cent. However, it remains the”
“Since 2020 an additional 1,218 additional new acut”
Acute Hospital Inpatient Bed Capacity Expansion Plan · assets.gov.ie/294828/9ffb3b62-6e30-4b08-980a-54e3aaa30ed1.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “My officials have made enquiries with the Care Quality Commission (CQC), the independent regulator of quality, and NHS England and NHS Improvement (NHSEl) and | am aware that regulatory action was taken by the CQC following an inspection at Stepping Hill Hospital in January and February this year”
“A CQC inspection is the Care Quality Commission's assessment of whether your care home is safe, effective, caring, responsive and well-led. In 2026, the CQC is still assessing providers through the Single Assessment Framework, with continuous monitoring and quality statements shaping inspection readiness, but it is also reviewing and refining its framework and methodology.”
CQC Inspections in 2026 - What to Expect and How to Prepare · theaccessgroup.com/…/hsc-cqc-inspection-2026-what-to-expect-and…
“Report by the Comptroller and Auditor General Ordered by the House of Commons to be printed on 11 October 2017”
Care-Quality-Commission-regulating-health-and-social-care-Full-Report.pdf · nao.org.uk/…/Care-Quality-Commission-regulating-health-and-soci…
“A 6-point scoring framework for vendors A 30-day pilot plan you can run next month Procurement traps in pricing, lock-in, hidden fees”
CQC Compliant Care Policies and Procedures: The 2026 Essential Guide - caredaily · caredaily.co.uk/…/cqc-compliant-care-policies-and-procedures-th…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “the Norfolk and Suffolk NHS Foundation Trust has increased capacity through the opening of four crisis house beds in Norwich, with plans to open two additional crisis houses in the coming months, as well as extra ward capacity for older people.”
“An NHS hospital in Norwich has had to close four beds in its high dependency unit because it does not have enough nurses to staff them.”
Nurse shortage forces NHS hospital to shut critical-care beds · theguardian.com/…/nurse-shortage-forces-nhs-hospital-to-shut-cr…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Local bed capacity and crisis care”
“Inappropriate out of area placements (IOAPs) have a significant emotional, economic and health impact on patients and carers, and negatively impact patient outcomes.”
Bringing care closer to home:reducing inappropriate out of area placements in mental health services · thenhsalliance.org/…/bringing-care-closer-to-home-reducing-inap…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Delivering 100 per cent coverage of 24/7, age-appropriate crisis care, via NHS 111, by 2023/24.”
“Please be aware, we've withdrawn our NICE Pathways service. Any reference to this service is historic.”
Transforming urgent and emergency care · stpsupport.nice.org.uk/urgent-emergency-care/index.html
“Mental health crisis care: care of patients in emergency departments ### Date Published: ### Theme: * Mental health, * Emergency care, * Access to care ## Share this page [Share on LinkedIn](https://www.linkedin.com/shareArticle?mini=true&url=https://www.hssib.org.uk/patient-safety-investigations”
Mental health crisis care: care of patients in emergency departments — HSSIB · hssib.org.uk/…/investigation-1-report-2-of-2
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Invested £249 million to ensure every Accident and Emergency department has a mental health liaison team in place by 2020/21;”
“Please be aware, we've withdrawn our NICE Pathways service. Any reference to this service is historic.”
Transforming urgent and emergency care · stpsupport.nice.org.uk/urgent-emergency-care/index.html
“Most people rush to A&E departments for physical injuries or emergencies, but a [small group](https://www.nuffieldtrust.org.uk/news-item/the-changing-terrain-of-mental-health-in-ae-specialised-care-or-the-same-old-bottlenecks) of people visit A&E for a mental health reason.”
Mental health care in A&E: how different is it for children and young people? | Nuffield Trust · nuffieldtrust.org.uk/…/mental-health-care-in-ae-how-different-i…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Recently, (and in part due to concerns raised by your report) NHS England has asked all parts of the country to ensure that they have in place clear written protocols for escalation and actions to be taken when patients are waiting long periods, or a bed cannot be identified.”
“Summary of Changes from Previous Version - Title change from Adult Patient Flow and Escalation Policy (including Full Capacity Protocol) - Appendices removed for: o Capacity and Flow Meetings SOP o National OPEL Framework o NEWS 2 Decision Tool o Capacity Issues in ED o 'One-Over' SOP o Comparative Risk Assessment - Updated action cards (Appendix B) - Updated relevant procedures and policies”
Patient flow and escalation policy · sfh-tr.nhs.uk/…/patient-flow-and-escalation-policy.pdf
“In May 2026, emergency departments in England [recorded an average of 2,241 corridor care instances per day](https://www.england.nhs.uk/statistics/statistical-work-areas/corridor-care-urgent-and-emergency-care-daily-situation-reports/) (rounded to the nearest whole number).”
Corridor Care in NHS Emergency Departments: The 2026 Data · theaccessgroup.com/…/hsc-corridor-care-in-nhs-emergency-departm…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The LMHT has now completed a joint piece of work with their ED colleagues at TGICFT. A triage assessment tool has been implemented which guides the triage nurse to consider the most appropriate pathway for the patient based on their risk/presentation at that time.”
“This prospective single-center observational cohort study assessed older patients (≥ 65 years) using both the standard ED triage system and the ISAR scale. After a 30-day follow-up, triage levels were retrospectively adjusted upward by one level for patients with ISAR scores ≥ 2. The predictive accuracy of the revised triage system was compared to the original system using logistic regression and”
Enhancing emergency department triage for older patients: a prospective study on the integration of the identification of seniors at risk · pmc.ncbi.nlm.nih.gov/articles/PMC12135277
“🎉 KATE AI has supported over 5,000,000 patient visits, helping emergency teams deliver safer, faster, and more informed care. 🎉 [Learn more](/5-million/)”
Optimize Emergency Department Triage for Better Care | Mednition · mednition.com/…/emergency-department-triage-systems-enhance-pat…
“To ensure every ED patient gets the right care at the right time, ENA”
Triage Portfolio | ENA · ena.org/…/triage-portfolio
No evidence found does not mean the action did not happen.
Evidence found · stated action: “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.”
“£150 million will be used to build 150 new facilities to support mental health urgent and emergency care services.”
Mental health services boosted by £150 million government funding - GOV.UK · gov.uk/…/mental-health-services-boosted-by-150-million-governme…
“We are investing at least £2.3 billion of additional funding a year by March 2024 to expand and transform mental NHS health services, so an extra two million people can get mental health support.”
How we are supporting mental health services in England – Department of Health and Social Care Media Centre · healthmedia.blog.gov.uk/…/how-we-are-supporting-mental-health-s…
No evidence found either way · stated action: “we are supporting the NHS to take action to reduce waiting times in A&E, including through adding 5,000 more permanent general and acute beds”
“A staggering 15,860 patients-around 1,300 a month-died in 2025 while in National Health Service (NHS) Accident and Emergency departments who could have survived if timely treatment had been available.”
Preventable deaths of almost 16,000 patients last year in A&E in England - World Socialist Web Site · wsws.org/en/articles/2026/06/12/xybl-j12.html
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “We have achieved the ambition of delivering 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £1 1 billion of dedicated funding”
“And this year we said we deliver 7,000 more, including 5,000 more nurses. It's a massive investment, but it'll be worth every cent.”
We're hiring 950 more nurses to deliver better care in our ... · facebook.com/…/1637890328003591
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The ambition is to improve A&E wait times to 78% of patients being admitted, transferred, or discharged within four hours by March 2025.”
“The 2025/26 NHS Planning Guidance sets out clear priorities to: (1) continue to reduce elective care waiting times, with 65 per cent of patients waiting less than 18 weeks; (2) improve ambulance response and A&E waiting times, with a minimum of 78 per cent of patients seen within four hours, (3) improve patients' access to general practice (GP) and urgent dental care access, including 700,000”
2025/26 NHS priorities and operational planning guidance: what you need to know · thenhsalliance.org/…/202526-nhs-priorities-and-operational-plan…
“Hospitals in England should create”
NHS Backs New A&E Care Areas for Patients Facing Long Waits · medscape.com/…/nhs-backs-new-a-e-care-areas-patients-facing-lon…
“This fact sheet sets out actions the Department of Health and Social Care and NHS England are taking to improve urgent and emergency care (UE”
NHS urgent and emergency care – media fact sheet – Department of Health and Social Care Media Centre · healthmedia.blog.gov.uk/…/urgent-and-emergency-care-media-fact-…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “we have made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.”
“Thank you for registering Please refresh the page or navigate to another page on the site to be automatically logged in Please refresh your browser to be logged in”
‘Outrageous’ backroom deals put progress fighting AIDS at risk, campaigners warn · independent.co.uk/…/aids-hiv-risk-funding-uk-aid-un-b3067986.ht…
“SectorUpdated 26 Aug 2026 # Social care tenders Live UK public sector opportunities in social care, collected daily from Find a Tender, Contracts Finder, Public Contracts Scotland and Sell2Wales.”
Social care tenders: 75 open now, 747 ending within 12 months · BidSkim · bidskim.com/market/social-care
“AGENDA AND REPORTS MAYOR AND CABINET Date: WEDNESDAY, 10 JULY 2024 at 6.00 pm Civic Suite Catford Road London SE6 4RU”
agenda and reports Mayor and Cabinet - Council meetings · councilmeetings.lewisham.gov.uk/…/Agenda+with+reports+10th-Jul-…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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”
“Ireland's Future Health and Social Care Workforce Detailed Department of Health December 2025 2 Table of Contents Note to the Reader 5 Guiding Principles 6 Ministerial Foreword 7 Executive Summary 8 The Case for Change 10 Our population is growing 10 Our population is ageing 11 Our labour force will increase in the next decade 12 Our high reliance on Foreign Educated Workforce 13 Our student”
Ireland's Future Health and Social Care Workforce Detailed · assets.gov.ie/…/Irelands_Future_Health_and_Social_Care_Workforc…
“2024 Annual Performance Plan and Report 2 # Message from the Performance Improvement Officer of the U.S. Department of Health and Human Services The U.S. Department of Health and Human Services (HHS) supports and implements programs that enhance the health, safety, and well-being of the American people.”
FY 2024 Annual Performance Plan and Report · hhs.gov/sites/default/files/fy2024-performance-plan.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “At national level, as part of our mission to build an NHS fit for the future, we will make sure mental health care is delivered in the community wherever possible - through new models of care and support available for those who are struggling - so that more people are prevented from needing to go into hospital.”
The organisation's statement describes a commitment to community-based mental health care but provides no specific timeline or implementation details.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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.”
“Hospital bed capacity management is one of the most [critical operational challenges health systems face](/how-virtual-nursing-solves-the-top-5-nursing-challenges/) today.”
Patient Throughput & Bed Capacity Management in Hospitals · artisight.com/…/bed-capacity-management-in-hospitals-strategies…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “I expect individual trusts and local health systems to effectively assess and manage bed capacity, the 'flow' of patients being discharged or moving to another setting.”
“Trusts are increasingly looking to electronic bed management systems to improve patient flow and increase capacity by providing visibility to flow bottlenecks and helping staff identify available beds as early as possible.”
How electronic bed management can improve patient flow and capacity management in hospitals - Teletracking · teletracking.com/…/how-electronic-bed-management-can-improve-pa…
“Ensure your patients receive the right care, at the right time, in the right location. Bed and Capacity Management Systems are an important part of NHS England's Urgent and Delivery Care Plan.”
The right care, at the right time, in the right location · go.alterahealth.com/en-gb/patientflow
No evidence found does not mean the action did not happen.