Stephen Kennedy
7 Feb 2019 · Coroner Louise Hunt · Birmingham and Solihull
This report repeats 3 earlier warnings, and was raised again 6 times later. See the linked reports.
The coroner's concerns
1. lack of psychological therapy for emotional unstable personality disorder
“1. The deceased suffered from emotional unstable personality disorder and was in crisis for most of 2018. The recommended treatment for his condition was psychological therapy. He had not had any psychological input since 2010. The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services. He had to be under the community mental health team to be able to access psychological services. There were periods when he was under the care of the”
2. unavailability of acute inpatient beds
“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. The availability of acute beds is a serious concern.”
Linked reports
Identical hazardConfidence 0.92 · high
Earlier report
“The deceased could not be admitted to hospital as there were no inpatient beds available.”
This 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.”
Closely relatedConfidence 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
“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.”
Closely relatedConfidence 0.90 · high
Earlier report
“During the course of the evidence it became apparent that mental health in-patients still do not have access to therapy from a qualified Psychologist, despite the fact that this has been raised in previous Regulation 28 PFD Forms.”
This report
“The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services.”
Identical hazardConfidence 0.90 · high
This report
“There were no beds available and as a result he had further episodes of self-harm and suicide attempts.”
Later 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.”
Closely relatedConfidence 0.90 · high
This report
“There were periods when he was under the care of the community mental health team but at this time he remained on a long waiting list for psychological services.”
Later report
“The Court heard that patients continue to experience lengthy waits if referred for psychological therapies, both locally and nationally. In the Tameside area, the current average wait was thought to be around one year from referral.”
Closely relatedConfidence 0.85 · high
This 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.”
Later 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”
Identical hazardConfidence 0.95 · high
This report
“There were no beds available and as a result he had further episodes of self-harm and suicide attempts. The availability of acute beds is a serious concern.”
Later 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 suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient.”
Identical hazardConfidence 0.90 · high
This 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.”
Later report
“no bed was available in August 2022”
Identical hazardConfidence 0.90 · high
This 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.”
Later report
“In May 2023, when it was felt Mr [name redacted] required an informal admission into hospital, no beds were available.”
Responses
2019-0039-Response-by-Birmingham-and-Solihull-CCG.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
Stated action
“The CCG has recently provided a comprehensive report to the HM Senior Coroner for Birmingham and Solihull on mental health services in the area, in response to a Regulation 28 report to prevent future deaths.”
2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
Stated action · September 2019
“From September 2019, subject to recruitment, we anticipate to be in a position whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist within their team”
2019-0039-Response-by-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · 2020/21
“On the availability of beds in the acute mental health sector, we are aware that the number of mental health beds overall have reduced and this is in large part due to the growth of care in the community. It may also be of interest to note that mental health bed occupancy rates have remained stable at between 87.1 per cent and 90.8 per cent (from Quarter 1, 2010-11 to Quarter 3, 2018-19), and that latest data for Quarter 3, 2018-19 shows a bed occupancy of 88.5 per cent. However, it remains the”