Shahzadi Khan
31 Jan 2024 · Coroner Alison Mutch · Manchester South
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. placement out of area without adequate discharge planning
“shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds”
2. lack of awareness of menopause as mental health risk factor
“deterioration was in part due to her going through the menopause and that had there been better awareness of this as a factor in mental health deterioration for some women and better support in place, interventions could have taken place at an earlier stage and been more effective”
3. misalignment with local care pathways
“Lack of understanding of these pathways by coordinating teams meant that patients were not being moved onto the correct pathway for care”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“there was a national shortage of acute mental health beds necessitating the use of out of county placements for patients requiring hospitalization for their mental health treatment”
This report
“a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual”