Coroner warns government over mental health bed shortages following suicide
A coroner has written to the health secretary following the suicide of a mental health patient who was placed in an out-of-area hospital due to a lack of local beds.
Alison Mutch, senior coroner for South Manchester, wrote a Prevention of Future Deaths (PFD) report to Victoria Atkins following the conclusion of the inquest into the death of Shahzadi Khan in February last year.
Khan was detained under the Mental Health Act in December 2022 due to her mental state. A lack of local beds meant she was placed in a privately-run mental health hospital in Norfolk, where she remained until her discharge to her family home a month later.
Her diagnosis on discharge was mania with psychotic symptoms. The inquest heard that her placement out of area contributed to disjointed and inadequate discharge planning to support her in the community, exacerbated by poor communication between the team managing out of area placements and the local team. As a result, the aftercare planning did not take place in accordance with the Mental Health Act.
On top of this, the health professionals involved in her care within Greater Manchester Mental Health NHS Foundation Trust failed to recognise that she needed to be referred onto the Trafford Shared Care pathway. A referral would have ensured she received support and care for at least 12 weeks when she returned to the community. Mutch said there was no clear reason for this failure.
Khan was seen twice by the Home-Based Treatment Team (HBTT), then discharged back to her GP. Within a week of that discharge, which meant she had been left with no mental health support, she had deteriorated significantly. On 9th February her GP sent her to hospital for emergency assessment, only for her to be discharged home to be seen again by the HBTT.
‘There was still no recognition of the fact that the Trafford policy was not being followed,’ Mutch wrote in her PFD report. On 14th February 2023 Khan took a fatal overdose of prescribed zopiclone at home.
Mutch listed three ‘matters of concern’ in her PFD report:
- The national shortage of mental health beds
- A lack of awareness of the menopause as a factor in worsening mental health for some women
- The mental health trust covering a number of areas, each with its own systems and pathways
‘The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual,’ Mutch wrote, ‘and that private beds were being used on a regular basis due to a shortage of NHS beds.’
The PFD report said that as a result, patients’ families could not easily stay in contact, leading to feelings of isolation and difficulties getting information to clinicians. In addition, notes could not easily be shared as non-NHS providers and out-of-area NHS providers might be using different electronic systems.
‘Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication,’ the PFD report added.
‘The inquest heard that due to its size the mental health trust covers a number of areas,’ Mutch wrote. ‘Each area has its own systems and pathways. Lack of understanding of these pathways by coordinating teams meant that patients were not being moved onto the correct pathway for care.
‘The inquest heard that this was compounded by a lack of awareness by the Trafford HBTT of the local pathway for a patient such as Ms Khan and the need for a clear discharge plan to be in place that was understood by all those involved in a patient’s care including her family and mental health care workers.’
The inquest returned drug toxicity as the medical cause of Khan’s death.
Image: Emily Underworld
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