Mental Health patients died because of a lack of beds and staff


April 10, 2018 | By Jim Gladman | ,

April 10, 2018 | By Jim Gladman | ,

In the last 6 years, it has been identified in England and Wales that failings in NHS treatment for mental health problems contributed to the death of 45 patients.

The Guardian has reported that a lack of beds, staff and specialist services has contributed to the deaths of numerous mental health patients. This is based on the Prevent Future Deaths report (PFDs) which is made by Coroners at the conclusion of inquests.

Coroners are under a duty to prepare a PFD report where he or she considers that action to prevent future deaths should be taken. The coroner must produce the report when the investigation has revealed something which raises the concern that there is a risk of deaths in the future and that action should be taken to eliminate or reduce that risk.

The Guardian identified frequent failings such as:

  • Poor communications between agencies and/or staff
  • Lack of a protocol or policy for staff to follow
  • Staff not following protocols or policies
  • Lack of appropriate care or continuity of care
  • Poor record-keeping
  • Poor communications with the patient and/or the patient’s family
  • Poor risk assessment
  • Poor care plan or no care plan
  • Issues around discharge
  • Staff shortages or a lack of funding, available facility or available beds
  • Delays in providing necessary treatment
  • Poor training
  • Ignoring the concerns and fears of family and friends, or the fears of the patient’s GP
  • Failure to provide appropriate medication

Examples where patients have died due to a facility/beds shortage

Senior Coroner (Birmingham and Solihull), Louise Hunt who said in one inquest: “There were no inpatient beds available. I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did.” The mental health trust could not provide a bed for Patricia Cleghorn so she had to be treated at home and she was permitted to give herself powerful morphine-based drugs, even though she had threatened to take her own life a number of times. She died after taking an overdose and then being given another drug by an unsupervised healthcare assistant.”

In another case Assistant Coroner (Exeter and Greater Devon), Lydia Brown, concluded that a failure to provide a bed contributed to the death of Wendy Telfer and said: “It is accepted that the problem of psychiatric inpatient beds is a national one, but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.”

When Jonathan Meaney was admitted to hospital after taking an overdose, a doctor from the mental health trust’s liaison psychiatry team said that he needed to be admitted. Senior Coroner (Inner North London), Mary Hassell, said: “However, no bed was found for him and Mr Meaney told the assessing mental health nurse that he would prefer to leave and was discharged. He went home and the following day took his own life.”

Coroner (Mid Kent). Allison Summers reported on the death Lorna Cullen after she left the A&E department when an assessment of her mental state was delayed because the liaison psychiatry service had only one nurse on duty. The Coroner noted: “Demand … far exceeded the available staffing provision.”

We have represented families at inquests where a number of the “frequent failings” have contributed to the cause of death.

You should seek legal advice if you think that the death of a loved one may have been caused by medical error or mistake. The medical negligence team at Switalskis can help you with this, and can offer advice and assistance if the coroner decides to hold an inquest. Call us on 0800 138 0458 or send us a message via the contact form below.

Read more at:




The Chief Coroner’s Guidance No.5 on Reports To Prevent Future Deaths


Jim Gladman

Jim Gladman is a solicitor within our Clinical Negligence team in Huddersfield and specialises in Medical Inquests. He joined Switalskis in January 2010 and has over twenty years' experience in Clinical and Medical Negligence claims. Jim's profile