Juan Martin
11 Jun 2024 · Coroner Priya Malhotra · Inner West London
This report repeats 6 earlier warnings, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. insufficient mental health bed capacity
“bed capacity remains an ongoing problem and has not been resolved”
2. future deaths due to mental health bed shortage
“genuine risk of future deaths directly connected to a shortage of mental health bed spaces in London”
3. delayed bed allocation
“no suitable bed was identified until approximately after 15:00 on 12 April 2022”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed”
This report
“Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022, which then became unavailable.”
Closely relatedConfidence 0.90 · high
Earlier report
“The prolonged wait Mr [name redacted] had was a result of lack of bed capacity.”
This report
“bed capacity remains an ongoing problem and has not been resolved.”
Closely relatedConfidence 0.90 · high
Earlier report
“as identified that there were no beds available in Suffolk, or anywhere else in the country at the time.”
This report
“bed capacity remains an ongoing problem and has not been resolved.”
Identical hazardConfidence 0.90 · high
Earlier report
“It was during the prolonged wait in the Emergency Department for a mental health bed that Mr [name redacted] left.”
This report
“The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”
Closely relatedConfidence 0.85 · high
Earlier report
“[the deceased] was kept in an acute hospital setting at Salford Royal Hospital awaiting a mental health bed due to a shortage of mental 2 health beds”
This report
“Witnesses confirmed that no suitable bed was identified until approximately after 15:00 on 12 April 2022,”
Closely relatedConfidence 0.90 · high
Earlier report
“Despite recognising Mr [name redacted] needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT' RCA report identified no remedial action.”
This report
“The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”
Closely relatedConfidence 0.90 · high
This report
“The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved. The Matron provided one recent example where a patient waited for 7 days”
Later report
“I am concerned of the continuing lack of Mental Health Unit inpatient beds in Suffolk, and more widely throughout England and Wales.”
Identical hazardConfidence 0.90 · high
This report
“The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”
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.”
Closely relatedConfidence 0.90 · high
This report
“The Matron in Acute and Urgent Care confirmed bed capacity remains an ongoing problem and has not been resolved.”
Later report
“patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds.”
Responses
2024-0315-Response-from-DHSC.pdf ↗· South West London and St George's Mental Health NHS Trust
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.”
2024-0315-Response-from-SW-London-and-St-Georges-Mental-Health-NHS-Trust.pdf ↗· South West London and St George's Mental Health NHS Trust
2024-0315-Response-from-SW-London-ICB.pdf ↗· South West London Integrated Care Board
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.”