Rohan Fitzsimons
7 Aug 2016 · Coroner Peter Harrowing · Avon
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of in-patient mental health beds
“The Avon & Wiltshire Mental Health Partnership NHS Trust (AWP) told the Inquest that the provision of in-patient beds is subject fo the funding provided by the Bristol Clinical Commissioning Group (CCG).”
2. delayed Mental Health Act Assessment
“The Inquest heard evidence that no Mental Health Act Assessment was carried out on the Deceased when it was determined to be necessary because no bed was available and that this was a situation which commonly occurred.”
3. potential suicide due to delayed assessment
“Inthe case of the Deceased the assessment was not performed until four days after it was deemed necessary and was only carried out once a bed was available. Whilst the Inquest did not hear evidence to indicate that the delay in carrying out the Mental Health Act Assessment contributed to the Deceased taking his own life it must follow that in some circumstances such a delay could lead to an individual taking their own life before the assessment was performed and a bed was made available.”
4. inadequate bed provision
“The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment.”
5. lack of coordinated response to bed shortage
“The CCG should work with AWP in carrying out this review and determine what action can and should be taken when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment but no bed is available. Ifa person meets the criteria for a Mental Health Act Assessment such an assessment should be carried out promptly and not be delayed for an indeterminate period owing to a lack of beds.”
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
“The CCG should review urgently its commissioning of in-patient mental health beds so as to ensure, in so far as reasonably practicable, that a bed is available when a person who satisfies the criteria for a Mental Health Act Assessment needs to be detained following that assessment.”
Identical hazardConfidence 0.90 · high
Earlier report
“no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014”
This report
“provision of in-patient beds is subject fo the funding provided by the Bristol Clinical Commissioning Group (CCG).”