Man died due to lack of mental health beds - report

A man would not have died had a bed been found for him at a mental health unit, a coroner has said.

Timothy De Boos, from Ipswich, experienced a mental health crisis in February, but an NHS team decided he did not need admission and he died four days later.

In his prevention of future deaths report, senior Suffolk coroner Nigel Parsley said he was concerned about the "continuing lack of mental health unit inpatient beds".

Anthony Deery, chief nurse at Norfolk and Suffolk NHS Foundation Trust (NFST), said: "We are very sorry for the distress that Timothy's tragic loss has caused and would like to offer our sincere condolences to his family.

The government said it was "unacceptable that too many people are not receiving the mental health care they need".

Mr Parsley said the patient had a "prolonged history of being mentally unwell" and was diagnosed with schizophrenia in 2004.

The coroner said Mr De Boos, his family and his mental health care coordinator all wanted him to be admitted voluntarily after he experienced the crisis on 2 February

At the patient's recent inquest hearing, the coroner said he was told that the crisis resolution and home treatment team were the "gatekeepers" for any admission, but could not see him until the following day.

When they did see him, they "deemed he was no longer in a mental health crisis" and decided against admission.

He died on 6 February.

"Had Tim been admitted to a mental health unit on 2 February 2024, his tragic death would not have occurred," said Mr Parsley.

He commented that the admission could not be actioned at the time anyway, because there was already five people waiting for the same unit.

The coroner raised concerns that the views of an "experienced mental health professional, a patient's family, and the patient themselves, is deemed insufficient evidence for an admission".

Mr Parsley addressed his letter to the Department of Health and Social Care (DHSC) and sent a copy to the NSFT.

A DHSC spokesperson said its "deepest sympathies were with all those who knew and loved Timothy".

"It is unacceptable that too many people are not receiving the mental health care they need, and we know that waits for mental health services are far too long," they said.

"This government is working to get the NHS back on its feet and improve conditions for staff."

The spokesperson said £26m was announced in the Budget for new mental health crisis centres and 8,500 staff were being recruited to cut mental health waiting lists.

Mr Parsley said the lack of beds was "not a new problem", having been an issue in two of his other reports that he had written in the last four years.

Nicola Rayner died in June 2023, with the coroner ruling her suicide was a result of "a lack of mental health bed provision in Suffolk and nationally".

Piotr Kierzkowski died in December 2019, one day after a mental health crisis, at a time when there were no beds available in England.

Mr Deery added: "Whilst Timothy was assessed and considered not to need an inpatient bed, we take note of the coroner's prevention of future deaths report, which was issued to the Department of Health and cites a lack of mental health inpatient beds nationally as an ongoing concern.

"As a trust we are on an improvement journey and have a clear strategic improvement plan. Our new Rivers Centre development at Hellesdon Hospital is part of our journey and will provide an extra 15 beds for people across Norfolk and Suffolk when it opens next month.

"Another part of our improvement plan is the implementation of a new locality-based leadership structure.

"This will enable us to continually improve the quality of care provided in the places where people live, work and access services. It includes significant investment in the care we provide in community settings, an example of which is our recruitment to 14 community matron roles, supporting us to provide safer, kinder and better services to people who need them."

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