“(brief summary of matters of concern) 1”
Dated 5 Feb 2025, from the coroner for West Sussex, Brighton and Hove. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 2 Apr 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated5 Feb 2025
- Deadline2 Apr 2025
- Published on judiciary.uk7 Feb 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| NHS EnglandNamed in the report as “NHS England & NHS Improvement” | Response publishedPublished on judiciary.uk in February 2025. |
| NHS Sussex Integrated Care Board | Response publishedPublished on judiciary.uk in February 2025. |
The coroner’s concerns
(brief summary of matters of concern) 1. 2. 3. 4. 5. 6 The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds. In Sapphire’s case a bed was not found for her within a 19-day period. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed. The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse. The environment in A&E can exacerbate and cause further deterioration in their mental health This is a second recent Inquest that I have heard where a death occurred following a lengthy wait in A&E for a psychiatric bed. In both cases the patients were transgender and had a diagnosis of autistic spectrum disorder.
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, 2025-0070
- 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
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