Sapphire Bernard
5 Feb 2025 · Coroner Penelope Scofield · West Sussex, Brighton and Hove
This report repeats 9 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of inpatient beds
“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”
2. delay in finding psychiatric bed
“In [the deceased]'s case a bed was not found for her within a 19-day period”
3. unsuitable A&E environment for mental health patients
“The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed”
4. A&E environment harmful to autistic and neurodiverse patients
“The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse. The environment in A&E can exacerbate and cause further deterioration in their mental health”
5. repeat deaths due to A&E psychiatric bed waits affecting transgender autistic patients
“This is a second recent Inquest that I have heard where a death occurred following a lengthy wait in A&E for a psychiatric bed. In both cases the patients were transgender and had a diagnosis of autistic spectrum disorder”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed.”
This report
“In [the deceased]'s case a bed was not found for her within a 19-day period.”
Identical hazardConfidence 0.96 · high
Earlier report
“There remains still a national lack of provision of inpatient beds for mentally il! children and adolescents including those who suffer from eating disorders.”
This 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.”
Identical hazardConfidence 0.90 · high
Earlier report
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
This 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.”
Closely relatedConfidence 0.90 · high
Earlier report
“The Coroner is aware, although not from evidence obtained in respect of Mr. [name redacted] case as the inquest is yet to take place, that inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available.”
This 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.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“the NHS are unable to provide a place of safety for those who are suffering from Asperger's syndrome, or indeed other forms of autism, when they are also suffering additional mental health problems such as bipolar”
This report
“The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse.”
Identical hazardConfidence 0.90 · high
Earlier report
“there are about 12 hours of delay following a 22.00 s2 Mental Health Act assessment built into the system if there is no bed”
This report
“In [the deceased]'s case a bed was not found for her within a 19-day period”
Identical hazardConfidence 0.92 · high
Earlier report
“at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community”
This 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”
Closely relatedConfidence 0.92 · high
Earlier report
“there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds.”
This 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.”
Identical hazardConfidence 0.96 · high
Earlier 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”
This 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.”
Closely relatedConfidence 0.80 · moderate
This report
“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health”
Later report
“The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area”
Responses
2025-0070-Response-from-NHS-England.pdf ↗· NHS England
Stated action · Winter 2024/25
“We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements.”
2025-0070-Response-from-NHS-Sussex-Integrated-Care-Board-.pdf ↗· NHS Sussex Integrated Care Board