“Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) 5…”

The coroner’s concerns

– 1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) 5 spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU. Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments. 2. Safe space: The inquest heard how 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. This means that acutely ill mental health patients are often left for long periods without any specialist care, support or observation. Consideration should be given to setting up a safe space where patients can wait for a bed or PDU space which is able to cater for their special needs and keep them safe. 3. Multi agency protocol for informal missing patients: The inquest heard how there is no agreed protocol to deal with informal patients who abscond from emergency departments. Consideration should be given to setting up an agreed protocol so that all agencies involved understand their respective roles and responsibilities. 4. WMP Missing person investigations: The inquest heard how on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr Hamilton as a missing person when he was reported as missing. On both occasions he should have been treated as a high risk missing person. This raises a serious concern that staff do not understand when people should be classified as missing. Consideration should be given to ensuring staff properly understand how to assess if someone should be treated as a missing person and WMP should consider whether further training is required. 5. WMP risk assessments for missing persons: When Mr Hamilton was first reported as missing no risk assessment was undertaken about his level of risk to himself. The call had confirmed he was at risk of harming himself. The leads to a concern that staff do not understand when and how to risk assess incidents and when to identify high risk incidents.

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, 2023-0013

Added to Minute Book

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