Trust strengthens support guidance after man dies

The coroner said the shortage of inpatient psychiatric beds in Surrey presented a risk of future deaths

A Surrey NHS Trust says it has "strengthened guidance" after its own investigation into the death of a man awaiting a psychiatric assessment.

Jonathan Harris, 52, had paranoid schizophrenia and took his own life on 27 June 2022.

Coroner Anna Crawford ruled earlier this month that Mr Harris "would not have died had an inpatient psychiatric hospital bed been available" days prior.

Graham Wareham, chief executive of the Surrey and Borders Partnership NHS Foundation Trust said, following Mr Harris' death, guidance had been strengthened to provide those awaiting a bed with "daily face-to-face support".

Risk of future deaths

In a report published on 20 March on Mr Harris' death, Ms Crawford said a reduction in the frequency of Mr Harris' anti-psychotic medication, requested by him in May 2022, was premature.

The coroner said Mr Harris’ mental health "continued to deteriorate" and on 24 June 2022 it was decided by the community mental health team that he required an assessment under the Mental Health Act.

However, there were no psychiatric inpatient beds available and the assessment did not take place.

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

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The coroner said the shortage of inpatient psychiatric beds in Surrey, in the context of a national shortage, presented a risk of future deaths.

The coroner requested action to be taken by NHS England within 56 days of the report being sent.

NHS England said: "We are working to the deadline set by the coroner at this stage."

Mr Wareham said: "Our trust is committed to making sure we provide a range of high-quality inpatient and community services for people of all ages in crisis."

The chief executive explained following Mr Harris' death it had strengthened guidance to "make sure" community teams were co-ordinating and providing daily support to those awaiting a bed.

"In the community we have introduced new services to reach and support people before they become more unwell and in need of an inpatient bed," Mr Wareham said.

This includes a short-stay service for adults who would benefit from care and support in a non-clinical environment.

Mr Wareham also said a new adult inpatient mental health service in Chertsey, which will provide 64 beds, was under construction.