Andrew Farrow
20 Apr 2015 · Coroner Peter Hatvany · Wiltshire & Swindon
A similar concern from this report was raised again 5 times later. See the linked reports.
The coroner's concerns
1. lack of available inpatient mental health beds
“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.”
2. unaddressed suicidal ideation
“He was known to have suicidal ideation but no actual plan had been formulated.”
3. unavailable inpatient mental health beds
“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.”
Linked reports
Identical hazardConfidence 0.90 · high
This report
“no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014”
Later report
“provision of in-patient beds is subject fo the funding provided by the Bristol Clinical Commissioning Group (CCG).”
Closely relatedConfidence 0.85 · high
This report
“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.”
Later report
“In May 2023, when it was felt Mr [name redacted] required an informal admission into hospital, no beds were available.”
Identical hazardConfidence 0.90 · high
This report
“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.”
Later report
“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.”
Identical hazardConfidence 0.90 · high
This report
“had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes”
Later report
“Despite these steps there remain insufficient beds available to meet patient need.”
Identical hazardConfidence 0.90 · high
This report
“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”
Later report
“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.”
Responses
2015-0147-Response-by-Avon-and-Wiltshire-NHS-Trust.pdf ↗· Avon and Wiltshire Mental Health Partnership NHS Trust
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.”