Leroy Hamilton
11 Jan 2023 · Coroner Louise Hunt · Birmingham and Solihull
This report repeats 3 earlier warnings, and was raised again 4 times later. See the linked reports.
The coroner's concerns
1. lack of inpatient mental health beds and PDU spaces
“Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces”
2. lack of inpatient beds and PDU spaces
“it is often the case that due to the lack of inpatient beds and PDU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed”
3. lack of agreed protocol for informal missing patients
“there is no agreed protocol to deal with informal patients who abscond from emergency departments”
4. failure to treat missing persons as high risk
“on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr [name redacted] as a missing person when he was reported as missing”
5. lack of risk assessment for missing persons
“When Mr [name redacted] was first reported as missing no risk assessment was undertaken about his level of risk to himself”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her”
This report
“When Mr [name redacted] was first reported as missing no risk assessment was undertaken about his level of risk to himself”
Closely relatedConfidence 0.85 · high
Earlier report
“In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts.”
This report
“it is often the case that due to the lack of inpatient beds and PDU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed”
Closely relatedConfidence 0.85 · high
Earlier report
“Between the 16th March 2019 and the 25th April 2019, a bed could not be found for the Deceased even though he had been assessed and fit for detention.”
This report
“Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU.”
Identical hazardConfidence 0.90 · high
This report
“Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU.”
Later report
“Despite recognising Mr [name redacted] needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity”
Closely relatedConfidence 0.90 · high
This report
“on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr [name redacted] as a missing person when he was reported as missing.”
Later report
“I am not reassured BSMHFT staff are handing attending police officers 'appendix C - risk rating' as required by their missing person policy.”
Closely relatedConfidence 0.86 · high
This report
“Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU.”
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
“Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU.”
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.”
Responses
2023-0013-Response-from-Birmingham-and-Solihull-Integrated-Care-.pdf ↗· Birmingham and Solihull Integrated Care Board
Stated action
“Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.”
2023-0013-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
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”
2023-0013-Response-from-West-Midlands-Police-.pdf ↗· West Midlands Police
Stated action
“WMP is currently setting up a working group with key partner agencies, including mental health agencies and professionals, to discuss and design a joint missing person protocol”