Another new Preventing Future Deaths report, after the tragic death of Stephen Richardson in Liverpool relates to a shortage of acute psychiatric beds. Stephen was a 47-year old man at the time of his death and had suffered with (treatment resistant) schizophrenia since he was 18-years old. Leading up to the 24th May 2019, he had been struggling with his mental health and been deteriorating. He was assessed that day for admission to hospital under the Mental Health Act but there was no acute psychiatric bed available so he was not sectioned that day. A plan was put in place for community support pending a bed becoming available, they hoped, on 26th May but not only did the community support not materialise, neither did the bed. By 29th May he had been visited at home and that determined that he should be prioritised for admission, but he later attempted to harm himself, leading to serious injury.
The jury found that failure to admit Stephen prior to this amounted to a “gross failure”.
There is more detail to the story after this self-injury – if you wish to know of it, I’d refer you to the PFD notice itself which is extremely detailed because the main point in this post is to note the jury’s finding of a gross failure and the notice having been sent to NHS England and to the Secretary of State for Health, Stephen Barclay MP.
There is only one matter of concern listed in the Coroner’s notice —
“It was clear from the investigation that at the time of Stephen 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. The evidence heard has confirmed that that parlous situation has not improved.”
[Bold is my emphasis.]
ARTICLE TWO INQUEST
I am again left wondering about whether the inquest featured on the legal issues to which this arguably gives rise? – it’s never possible to tell from a PFD unless the coroner chose to mention it. This having been a jury-inquest, it was an ‘article 2’ inquest where the right to life was engaged. But in addition to that, I’m left wondering about domestic legal obligations. As I’ve noted before in these circumstance, section 13 and section 140 of the Mental Health Act usually have some relevance.
- Section 13 MHA — the duty of an Approved Mental Health Professional (AMHP) to make an application when certain criteria are met. These criteria make no mention of ‘beds’, but of whether the patient meets the criteria for admission, whether the AMHP has taken in to consideration any views of the patient’s nearest relative and whether the AMHP thinks the application is necessary.
- Section 140 MHA — the idea is, that when an AMHP is satisfied of the s13 criteria, they should have pretty rapid access to the name of the hospital to which the MHA application should be made. This provision requires in law that the NHS makes known to the Local Authority (on whose behalf the AMHP is acting) which hospitals are in a position to admit patient’s in urgent circumstances.
So the idea should be, an MHA assessment takes place and the AMHP ends up deciding the application is required, as per s13 MHA criteria: they then ask the NHS bed manager to identify the hospital providing the bed and the application is made shortly after that. I’ve got no idea whether the Clinical Commissiong Group in Liverpool (now known as the Integrated Care Board) was in compliance with that legal duty. Did they specify to the AMHP service the hospitals to which urgent applications can be made. And crucially, something else is required:
FOI APPLICATIONS
I’ve written before that I’ve been known to undertake enquiries under Freedom of Information laws about whether CCGs / ICBs are complying with their legal duty under s140 MHA. In addition to asking to know the names of the hospitals specified in law, I also ask for policies that may be in place to outline how those specifications can turn in to actual admissions for patients in the real world. I’ve known a number of types of reply: some CCGs have been honest enough to admit they hadn’t heard of s140 MHA and that they would undertake further work and get back to me (they didn’t). Others would list a huge number of hospitals in their mental health trust, as if to suggest that pretty much every hospital they had was specified under s140 for urgent admissions. But the most important part of s140 is arguably not the paper-exercise of compliance with specifying hospitals: it is whether hospital are, in fact, able to admit people urgently when it’s required.
As we see in this sad case involving Stephen, irrespective of whether someone in CCG / ICB had complied with legislation by specifying, the only really important thing in the end, is whether that translates in to an admission where it’s necessary. In this case, the view was obviously taken between the MHA assessment on 24th May and the unfortunate self-injury on 29th May, that no bed was available. Of course, the MH trust can only do its best with the resources made available to it by the CCG. This inquest, as with so many others, comes after a long period where the number of mental health beds has reduced at a time when the number of patients referred to secondary care (ie specialist) mental health services has risen. That background of reducing beds amidst rising demand was specifically explored by the Crisp Commission (2015), set up by the Royal College of Psychiatrists to examine the question “are there enough acute psychiatric beds”.
That report concluded eight years ago: the answer was neither ‘yes’ or ‘no’, because it became obvious during the commissions work (in which I was directly involved) that the answer depended upon whether there was an appropriate mix and balance of inpatient services and outpatient community care. Many areas – but not all – were not striking the balance correctly and the bold emphasis in the quotation above, shows it hasn’t changed since that time. Stephen was indicated for admission, then stated to be the priority, but during that time necessary visits by the community team, to mitigate risk pending admission, did not take place. Ultimately, the law ends up not meaning very much if it cannot prevent outcomes of this kind where we know what is required and are simply prevented from ensuring it.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2023
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 