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recurance

Emma Morris

21 May 2024 · Coroner Sarah Murphy · Cheshire

This report repeats 2 earlier warnings, and was raised again 2 times later. See the linked reports.

The coroner's concerns

  1. 1. lack of inpatient mental health beds

    “The gatekeeping assessment included a mental health state examination, where it was the clinical opinion of the mental health practitioner from the Crisis Resolution Home Treatment Team, that Ms [name redacted] required an inpatient hospital admission to a mental health ward as there was an immediate risk to her safety as she was found to be a high risk of walking in front of a car. Whilst Ms [name redacted] agreed to an informal admission, this was not possible at the time of assessment as there were no beds”

Linked reports

Repeats an earlier warningAnthony Watson12 Feb 2019 · 5 years 3 months earlier
Closely relatedConfidence 0.86 · high

Earlier report

“Mr [name redacted] was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area.”
Original on judiciary.uk ↗

This report

“The gatekeeping assessment included a mental health state examination, where it was the clinical opinion of the mental health practitioner from the Crisis Resolution Home Treatment Team, that Ms [name redacted] required an inpatient hospital admission to a mental health ward as there was an immediate risk to her safety as she was found to be a high risk of walking in front of a car. Whilst Ms [name redacted] agreed to an informal admission, this was not possible at the time of assessment as there were no beds”
Full chain: Delayed transfer of acute mental health prisoners to secure units
Repeats an earlier warningCharlotte Swift11 May 2021 · 3 years earlier
Closely relatedConfidence 0.90 · high

Earlier report

“[the deceased] was in urgent need of medical treatment by way of an inpatient bed at a specialist unit for those with eating disorders. Although she had been accepted for such a placement a bed did not become available before she died.”
Original on judiciary.uk ↗

This report

“The gatekeeping assessment included a mental health state examination, where it was the clinical opinion of the mental health practitioner from the Crisis Resolution Home Treatment Team, that Ms [name redacted] required an inpatient hospital admission to a mental health ward as there was an immediate risk to her safety as she was found to be a high risk of walking in front of a car.”
Full chain: Delayed transfer of acute mental health prisoners to secure units
Raised again laterMatthew Sheldrick (2)16 Dec 2024 · 7 months later
Identical hazardConfidence 0.92 · high

This report

“this was not possible at the time of assessment as there were no beds available nationally within the NHS or privately.”

Later report

“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.”
Original on judiciary.uk ↗
Full chain: Delayed transfer of acute mental health prisoners to secure units
Raised again laterSapphire Bernard5 Feb 2025 · 9 months later
Identical hazardConfidence 0.96 · high

This report

“there were no beds available nationally within the NHS or privately. As an inpatient admission was not possible, the option was to attend the Accident and Emergency Department”

Later report

“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds.”
Original on judiciary.uk ↗
Full chain: Delayed transfer of acute mental health prisoners to secure units

Responses

2024-0282-Response-from-NHS-England.pdf ↗· NHS England

Stated action

“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 system1 in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error