Lack of psychiatric bed contributed to man's death

A coroner has warned of a shortage of psychiatric beds in Surrey hospitals after a man took his own life.

Jonathan Harris, 52, who suffered from paranoid schizophrenia, died on 27 June, 2022.

If an inpatient psychiatric hospital bed had been available just days earlier, Mr Harris would not have died, coroner Anna Crawford ruled.

She said the inquest "heard that there is an ongoing shortage of available inpatient psychiatric beds in Surrey".

Following the hearing, a Prevention of Future Deaths (PFD) report was issued to NHS England rather than to Surrey and Borders Partnership.

About 35,000 inquests take place in England and Wales each year. In a fraction of those - about 450 - the coroner writes a PFD, or Regulation 28, report.

NHS England said it is working to the coroner’s deadline of 56 days to respond with the action it will take or proposed to take following the death of Mr Harris.

Bed shortages for mental health patients in Surrey, as well as nationwide, have been an ongoing issue for NHS Trusts.

Following a lengthy psychiatric inpatient stay in Camberley in November 2021, Mr Harris was under the care of Surrey Heath Community Mental Health Recovery Service, which is part of Surrey and Borders Partnership NHS Foundation Trust.

He was prescribed anti-psychotic medication, but in early 2022 he made a request for his medication to be reduced, the Local Democracy Reporting Service said.

The reduction, in May 2022, was “premature”, according to the coroner.

Mr Harris had reportedly shown signs of appearing “suspicious” when he was seen by the Surrey Heath Mental Health Team (MHT) on May 4.

The team was also aware that Mr Harris was moving house, meaning a move to a new community mental health team.

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His mental health continued to deteriorate and the MHT decided in June 2022 that he required an assessment under the Mental Health Act.

No inpatient bed was available and the assessment did not take place.

If he had been assessed he would have been detained under the Mental Health Act and admitted to hospital.

The coroner said: “Mr Harris would not have taken his own life had he remained well, and the relapse of his paranoid schizophrenia contributed to his death.

“Mr Harris would not have died had an inpatient psychiatric hospital bed been available on either 24, 25 or 26 June 2022.

“The court also heard that there is an ongoing shortage of available inpatient psychiatric beds in Surrey and that this is in the context of a national shortage of inpatient psychiatric beds.

"The court is concerned that both of these matters present a risk of future deaths.”

NHS England has said £1.6bn has been made available from 2023 to 2025 to support mental health inpatient services as well as the wider system.

It said the funding "should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally".

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