Problems accessing mental health bed ‘exacerbated’ crisis that ended in man’s suicide, finds coroner

Coroner says indecision over hospital admission worsened crisis that saw 20-year-old man take his own life

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Problems securing an acute psychiatric bed for a man in mental distress “exacerbated” a crisis that ended with the man taking his own life, a coroner has said.

20-year-old Michael Knight had agreed to be admitted voluntarily into hospital on August 28 last year only for professionals to be told there was no bed available in Norfolk, where he wanted to stay, until the next day. Later that evening, Knight was told a bed had become free but he asked to wait until the next day as planned. In the intervening period he took his own life.

At an inquest held in Norwich this week, coroner Jacqueline Lake said the indecision over Knight’s proposed hospital admission had worsened the crisis.

Lake said: “The tragedy in this case is the fact that, after having gained Michael’s agreement to accept voluntary inpatient care, a bed was not then available. I’m of the view that the situation was then exacerbated by the to-ing and fro-ing which then took place with regard to a bed becoming free, but only for a very short period of time before it was then unavailable.”

Following Knight’s death a serious incident report found that staff followed the “right pathways”. It also found that an acute bed would have been found for Knight if a decision had been made to detain him under the Mental Health Act.

Roz Brooks, director of nursing and patient safety at Norfolk and Suffolk NHS Foundation Trust, said: “I would like to extend our sincerest condolences to Michael Knight’s family. We recognise the tragedy and loss of all those affected by his death including the staff involved in his care. These members of staff made decisions about Michael’s care based on their clinical knowledge and expertise.

“By following the Code of Practice which supports the Mental Health Act, Michael could not be compulsorily admitted or detained against his wishes. Therefore, he maintained the right to choose his treatment options including an informal admission.”

Care and support minister Norman Lamb, whose constituency as MP for north Norfolk is covered by Norfolk and Suffolk NHS Foundation Trust, said: “When a young person dies it is always a tragedy, but all the more so when there is a suspicion that their death could perhaps have been prevented.”

The minister said he wanted to drive improvements in community mental health support but added that “we also have to make sure that beds are available for people who need a higher level of support, particularly in crisis situations like this”.

“Above all, it is important that there is clarity for patients about the care they are receiving – there are few things worse for someone with a mental health condition than to feel that decisions are being made about their care without their involvement, and to feel that they have no control over their situation,” added Lamb.

This week the minister said that the problems professoinals are having accessing psychiatric beds for patients in need are “unacceptable” after an investigation by Community Care and BBC News revealed how bed pressures across the country are harming patient care.

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