“It was recognised at inquest that there is a frequent need for patients with significant…”

The coroner’s concerns

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— (1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. it was also acknowledged that the training of the physical healthcare staff "needs to improve’, although it must be said that efforts have been made and are continuing to address this issue. From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment, which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation, (2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds. The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in terrn of patient need and geographical location. It is accepted that the problem of psychiatric in-patient 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. The Court was advised that much of the difficulty is delayed discharge of patients, and it is acknowledged that this is a wider issue of social and community care and resources. This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation. Roem 226, Devon County Hall, Topsham Road, Exeter, EX2 4QL Tel 01392 383636 | Fax 01392 383635 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2017-0046

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0