Deaths linked to mental health beds crisis as cuts leave little slack in system

At least eight people have died in the past two years after problems accessing psychiatric beds for mental health patients in crisis, an investigation by Community Care and BBC News has found.

The deaths include seven suicides and one homicide linked to bed pressures since March 2012. We also identified a ninth case where a woman took her own life after being denied a bed at a crisis house, a residential facility used to offer a community-based alternative to hospital.

New figures we obtained from mental health trusts show that 468 beds have been closed over the past year, bringing the total closures to more than 2,100 since April 2011. And fresh data on bed demand shows that admission wards for acutely unwell adults have run at an average monthly occupancy level of 101% for the past two years. Several trusts have hit occupancy rates of over 120% some months. The recommended level is 85%.

When wards run over 100% occupancy it is usually because trusts have filled beds temporarily freed-up by patients sent on short-term home leave. The strategy risks no bed being available for the patient on leave if they relapse and need admission.

Research by Community Care also established that health secretary Jeremy Hunt was warned about the dangers of mental health beds not being available in a ‘prevention of future deaths’ report sent to him by a senior coroner in December 2013. The coroner issued the report following the suicide of a patient who had been assessed as needing ‘urgent admission’ but faced an eight day wait for a bed. A copy was also sent to Sir David Nicholson, NHS England chief executive at the time.

Hunt’s reply to the coroner, which can be downloaded here, said that the government was “clear” that acute beds “must always be available for people who need them”.

We found that Hunt’s assertions do not match the reality of the mental health system that is overseen by his government and NHS England. Mental health trusts are under severe strain after having their funding from NHS commissioners cut by 2.3% in real-terms between 2011-12 and 2013-14. Clinical decision-making is being compromised due to resource shortages and frontline care teams are too often being left to hold the risk.

Email to NHS England regional director Anne Rainsberry

An email we obtained under Freedom of Information laws reveals that a chief executive of a mental health trust wrote to NHS England this summer after one of her senior officials came to tell her that “yet again there were no mental health beds in London in either the NHS or private sector”.

In the email, Wendy Wallace, head of Camden and Islington NHS Foundation Trust, bemoans NHS England’s lack of interest in the problem. “I could not envisage a situation where all the acute beds in London were full and there was not even an investigation into the situation, nor a plan of action, so much for parity of esteem!” she wrote.

Wallace’s trust closed 125 beds, including 54 for acute admissions, between March 2012 and September 2013.

NHS England’s mandate from government for 2014-15 requires it to make “rapid progress” on working with local commissioners to deliver mental health crisis services that are as “accessible, responsive and high quality as other health emergency services.” Earlier this year Health Service Journal revealed NHS England recommended local commissioners should cut the tariff for mental health trusts by 1.8% in 2014-15, compared to a 1.5% cut for acute trusts. NHS sector leaders claim that plans for the 2015-16 tariff published this week raise further concerns about mental health funding.

Our investigation is based on an analysis of coroners’ reports and data obtained under the Freedom of Information Act from 52 of 58 mental health trusts in England and 181 of the 211 NHS clinical commissioning groups.

Social workers said our findings were “appalling” and accused the government of failing to act sufficiently on 18 months of warnings from professional bodies about both bed pressures and cuts to vital community mental health services. Campaigners said three years of cuts had left mental health services “on the edge” and investment from NHS commissioners was urgently needed.

In response to our findings, care minister Norman Lamb issued a statement saying the government had made “huge progress” on boosting crisis care and was going “further than ever before” to put mental health on a par with physical health. He pointed to the government’s crisis care concordat policy and the fact the coalition is introducing the first ever waiting time standards for mental health services in 2015-16 as examples.

The waiting time standards referred to by Lamb will require 75 per cent of people awaiting talking therapies to start treatment within six weeks and at least 50 per cent of people going through their first episode of psychosis get help within two weeks of referral. With four weeks to go until the crisis care concordat’s first target – for services in every local area to have signed-up to commit to the policy by the end of the year – less than a third of local areas have signed such a commitment. Lamb said yesterday that he is confident the policy is on track and areas that do not sign-up will be “named and shamed”.

In a statement, NHS England said the solution to improving care was not about “beds, or buildings” but “finding the right solution for each patient”. The organisation did not address several key issues we put to them, including the fact that eight deaths in England had been linked to bed pressures and that NHS England was alerted to the fact there were no mental health beds in London or the private sector on several occasions over the past year.

Lives lost

64-year-old Pauline Binch died after delays finding her a bed. Her husband says she was “badly let down”

Death by suicide is complex and not driven by a single cause. Each case will have impacted friends, families and other loved ones and will also affect the frontline care teams involved.

We have identified seven suicides where problems securing beds at a hospital played some role. We publish details here not to sensationalise or simplify complicated cases, but to try and inform about how care can be seriously impacted by the system-wide pressure on mental health beds that ministers and senior NHS England officials have known about for some time.

64-year-old Pauline Binch from Nottingham started to develop mental health problems in 2010. Following an attempt to take her life on 24 September 2013 a psychiatrist said that an inpatient admission was required and a request was sent to a bed manager. No bed was available between 24 and 29 September. On 30 September one became available but the trust couldn’t contact Pauline and the bed was given to another patient.

A bed was not found on 1, 2 or 3 October. At 8.45PM on 3 October, Pauline’s body was discovered at her home. The investigation into her death concluded: “Bed managers were aware of the severity of risk in PB’s case but (with the exception of several hours on 30 Sept 2013) could not find a bed to admit her to.”

Pauline’s husband John told us she had been “badly let down” by the system.

“There was one doctor who said, ‘she’s going to kill herself if she isn’t admitted to hospital’. It’s there in black and white. But still no bed. If they’re saying she needs a bed, why can’t she have a bed?” he said.

An NHS investigation summary obtained by Community Care under the Freedom of Information Act examined the death of a Sheffield man who took his own life in July 2013. The report found that it was “not possible” to say if a bed would have changed the outcome but concluded that problems securing hospital admission had exacerbated the man’s anxieties and prevented his care team offering “what they felt was necessary to manage risk” in the lead-up to his death.

A coroner’s review of another case we identified, where a patient took her own life in August 2013 after not being able to get a bed at a crisis house, concluded that “on the balance of probability an admission would have made a difference in this case”.

The warnings to Jeremy Hunt and NHS England

Jeremy Hunt said the government was clear that ‘acute beds must always be available for those that need them’ after a coroner raised concerns following a patient suicide

Jeremy Hunt and Sir David Nicholson were alerted to the dangers of beds not being available for mental health patients in a ‘report to prevent future deaths’ sent to them on 13 December last year.

Senior coroner Nigel Meadows issued the report following an inquest into the death of Stephanie Daniels. The 32-year-old took her own life while on a mental health unit in Manchester on March 24 2012. The coroner identified several issues with her care – one of which was bed availability.

Ten days before her death her care team assessed her as needing an ‘urgent inpatient admission’ but were told no beds were available. She faced an eight day wait before a bed was eventually found, an issue the coroner’s report warned left patients without “the appropriate nursing and clinical input” or medication review that a hospital admission would provide. The delayed admission meant the patient may have been far more unwell than they would have had a bed been available immediately, the report added.

It was in Hunt’s official response to this report, sent on 13 February 2014, that he said “we are clear that acute beds must always be available for people who need them”. He also told Meadows that it “should already be the case” that patients don’t have to wait for beds – a situation our evidence shows has repeatedly not reflected the reality of services.

The risks of high occupancy and community cuts

Graph from a briefing prepared for care minister Norman Lamb showing one trust had 11 patients waiting for a bed at any one time. Patients faced an average wait of 3.4 days for a bed. The longest wait was 17 days.

The deaths our research identified are a reminder of the dangers of both bed shortages and the cuts to crisis and community mental health services that can be key to preventing admissions.

Yet, more than a year after a Community Care and BBC News investigation into bed closures and high occupancy in October 2013 prompted a leading psychiatrist to warn that the system was “in crisis” and “unsafe”, new data obtained from mental health trusts and clinical commissioning groups suggests too little has changed in the 12 months since. As well as the information reported above, we also found that:

• Patients continue to be sent miles for beds: A report we obtained under FOI (download it here) that had been prepared for Norman Lamb by Birmingham and Solihull mental health trust showed that the trust sent 99 patients to out-of-area hospitals in the first six months of 2014 due to its own wards being full. The placements were an average distance of 119 miles away and had led to over 20,000 miles in return patient transport journeys and “significant difficulties” for families and friends. In May, David Cameron was asked about this issue during Prime Minister’s Questions after Community Care and BBC News revealed some trusts were sending patients over 200 miles for care.
• Admissions are being delayed over two weeks: The briefing for Lamb also revealed that, in May of this year, bed pressures meant the trust had 11 people waiting for admission at any one time. The maximum wait was 17 days and the average was 3.4 days.
• Crisis house provision is lacking: Data we obtained from 181 NHS clinical commissioning groups showed that less than a third (29%) commissioned a crisis house service.
• Home treatment teams are not sufficiently funded: A report by Mental Health Strategies, a consultancy group that analyses issues for mental health trusts and NHS commissioning groups, warns that too many home treatment team are funded at levels that are “simply insufficient” to meet demand. The resource shortage means many services do “not offer a realistic alternative to admission” or “offer ‘home treatment’ in any meaningful sense”, the report said. Our research last year found that these teams had seen budgets cut by 1.7% in real-terms while their referrals had risen 16%.

Limited progress on crisis care concordat

The government said all local areas would sign a commitment to its crisis care concordat by the end of the year. The areas marked red had not made the commitment as of Friday 28 November

Our research also found that the government’s key flagship policy to improve crisis services – the crisis care concordat – has made limited progress since its introduction in February. The government said every local area must have a ‘declaration statement’ in place by the end of this year. The statement is a commitment by local services to meet the concordat’s principles.

With just over four weeks to go until the year-end deadline, 49 of 154 local areas – less than a third – have published a declaration statement (in the map above, these areas are marked yellow). Only nine areas, less than 6%, have published an ‘action plan’ outlining how they intend to make their commitment to the concordat work in practice.

Speaking at a concordat progress update event in central London yesterday, Norman Lamb told Community Care he would “name and shame” areas that did not sign up to its principles. In a bid to ensure the end of year target is met, Lamb said he was also requesting weekly progress reports and linking commitment to the concordat to services’ entitlement to NHS winter pressures funding.

“The idea that a local area could fail to do this would really be shocking in my view. It is an imperative that they do so. They won’t be fined as such but they will be identified as areas that have completely failed to do what is right. If there are any areas that haven’t done it there will be an intense focus on those areas from me and from others and I will want to see the people involved in those areas to understand why they haven’t signed up and what the barriers are to that,” he said.

The same day Lamb was speaking at the London concordat event, a group set up by staff and service users to protest against cuts to services at the mental health trust that serves the minister’s north Norfolk constituency were holding their own event. The meeting in Norwich was set up to mark a year since the campaign launched with an open letter warning that services had been ‘decimated’ by a cost-savings drive.

Over the past 12 months social workers involved in the campaign have repeatedly alerted Lamb and local commissioners to a series of concerns over services, including the fact professionals have felt unable to practice safely and legally due to pressure on beds and cuts to community and crisis teams.

One of the deaths we identified involved a 20-year-old man who was under the care of the trust’s services at the time of his death.

Social worker and mental health sector reaction

Faye Wilson, chair of the British Association of Social Workers’ mental health forum, said that our findings were a “disgraceful testimony” to a lack of action by the government and NHS England to address severe problems in the mental health system that social workers and other professional bodies have warned about for over 18 months.

“If people were dying like this in acute care, Jeremy Hunt would be on the television every week. What else needs to happen for proper action to get taken? What worse evidence can there be than people losing their lives?,” she said.

“The government has announced another mental health taskforce this week, but what else do they need to know about this? We know what the problems are. The evidence is there and it is extremely worrying that it has taken hard work by a few investigative journalists to bring it together and bring it to public attention,” she added.

Wilson called on the government to introduce a moratorium on bed closures and make efforts to understand the complexity of need facing services. Fair funding for mental health trusts was also urgently needed to ensure community services can be strengthened, she added.

“But we also need to recognise that there are some people who are incredibly ill who will need a bed rather than these incredibly simplistic arguments that beds must be closed and everyone should be treated at home,” she said.

Steve Chamberlain, chair of The College of Social Work’s network of Approved Mental Health Professionals – a group that produced evidence on bed pressures back in May 2013 – said: “This is an appalling situation which tragically just confirms our daily experience across much of the country. This is evidence that the lack of beds and community resources for people with acute mental ill health is costing lives and that mental health crises are as life-threatening as physical illnesses.”

“If people were dying of heart attacks because they could not be admitted to a hospital bed there would be a national outcry. Mental health must be given the same importance as physical conditions,” he added.

Paul Farmer, chief executive of mental health charity Mind, said our findings showed the “real and tragic consequence” of people not getting the help they needed, when they needed it.

“A mental health emergency is as life-threatening as a physical health emergency but parts of the NHS are clearly struggling to provide an adequate emergency response. It costs lives,” he said.

“Historical under-funding for mental health services compounded by cuts over three consecutive years have left services on the edge. Initiatives like the crisis care concordat can make a huge difference but only if services are properly funded. We desperately need to see investment in NHS mental health services yet, worryingly, Monitor’s proposals for the 2015/16 tariff include more cuts. Mental health services cannot continue to make savings without further compromising the safety and dignity of people trying to access care.”

The official responses in full

Care and support minister Norman Lamb (Credit: Steve Meddle/Rex Features)

Asked to respond to our findings, Norman Lamb said in a statement: “We are going further than ever before to put mental health on a par with physical health. We’re introducing the first ever waiting time standards for mental health services and are getting every local area to make sure people are treated in the right place at a time of crisis. We’ve made huge progress but we want to go further to make sure everyone gets the care they need and to ensure that mental health gets treated fairly in the allocation of resources.”

Dr Martin McShane, NHS England’s director for people with long-term conditions, said: “Spending on mental health is now going up in real terms after years when services were under real pressure. One result is big falls in the number of people in mental health crisis ending up in police cells. As we expand services patients are also able use NHS-funded beds in the independent sector.

“But the long-term solution is not just about beds, or buildings, as highlighted in Sir Stephen Bubb’s recent report [this is a reference to a report on transforming learning disability care Post-Winterbourne View], but about finding the right solution for each patient.”

In December last year, McShane – who is also co-chair of the government’s taskforce to improve children’s mental health services – said mental health trusts were “delivering better value” in response to a Community Care and BBC News investigation that found trusts’ budgets had been cut by 2.3% in real-terms over two years.

The Samaritans’ 24-hour helpline is 08457 909090.

More than 18 months of warnings