Coroner’s Report Links Man’s Death to Lack of Mental Health Beds

A coroner has stated that a man’s death could have been prevented if a bed had been available for him at a mental health facility. Timothy De Boos, an Ipswich resident, experienced a mental health crisis in February, but an NHS team determined he did not require admission, and he passed away four days later. In his report for the prevention of future deaths, senior Suffolk coroner Nigel Parsley expressed concern regarding the “continuing lack of mental health unit inpatient beds.” Anthony Deery, chief nurse at Norfolk and Suffolk NHS Foundation Trust (NFST), commented: “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 described it as “unacceptable that too many people are not receiving the mental health care they need.” Mr. Parsley noted that the patient had a “prolonged history of being mentally unwell” and received a schizophrenia diagnosis in 2004. The coroner indicated that Mr. De Boos, his family, and his mental health care coordinator all wished for him to be admitted voluntarily after his crisis on February 2. During the patient’s recent inquest hearing, the coroner was informed that the crisis resolution and home treatment team acted as the “gatekeepers” for admissions but could not assess him until the following day. Upon their assessment, they “deemed he was no longer in a mental health crisis” and decided against admission. He died on February 6. “Had Tim been admitted to a mental health unit on 2 February 2024, his tragic death would not have occurred,” Mr. Parsley affirmed. He further remarked that admission would have been impossible at that time anyway, as five individuals were already awaiting a bed at the same unit. The coroner voiced apprehension that the perspectives of an “experienced mental health professional, a patient’s family, and the patient themselves, is deemed insufficient evidence for an admission.” Mr. Parsley directed his letter to the Department of Health and Social Care (DHSC) and provided a copy to the NSFT. A DHSC spokesperson conveyed that 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,” the spokesperson added. “This government is working to get the NHS back on its feet and improve conditions for staff.” The spokesperson mentioned that £26 million was allocated in the Budget for new mental health crisis centres, and 8,500 staff are being recruited to reduce mental health waiting lists. Mr. Parsley stated that the scarcity of beds was “not a new problem,” having been an issue highlighted in two other reports he authored over the past four years. Nicola Rayner died in June 2023, with the coroner concluding her suicide resulted from “a lack of mental health bed provision in Suffolk and nationally.” Piotr Kierzkowski died in December 2019, one day after experiencing a mental health crisis, during a period when no beds were available in England. Mr. Deery further stated: “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.”