A lack of beds, staff and specialist services affected the care of dozens of mental health patients who later died, the Guardian can reveal. Coroners have identified 45 cases in England and Wales in the last six years in which someone’s NHS treatment for mental health problems was affected by those problems.
Some of the deaths occurred due to the NHS not being able to either care for the person in a bed in their home area or provide the type of care that they needed. Treatment for eating disorders and for maternal mental ill-health, were two of the affected services.
The 45 cases represent one in six (16.6%) of the 271 deaths of mental health patients which, the Guardian yesterday disclosed, have prompted coroners to issue legal warnings to NHS bodies – in the form of prevention of future deaths notices (PFDNs) – after hearing evidence that failings in care preceded a person’s death.
The revelation of these 45 cases has prompted claims that mental health services are failing to keep up with rising demand, because of underfunding, despite pledges to boost budgets and improve care.
“The background to these  tragic deaths is an underfunded and struggling mental health system,” said Wendy Burn, president of the Royal College of Psychiatrists.
Louise Hunt, the senior coroner for Birmingham and Solihull, said that one patient, Patricia Cleghorn, would have lived if the NHS had been able to find her a bed. Cleghorn, who died in December 2015, was being treated at home, and allowed to keep and self-administer powerful morphine based medications, because Birmingham and Solihull mental health trust could not provide a bed. That was despite her having threatened several times to take her own life. She died after taking an overdose and then being given another drug by an unsupervised healthcare assistant.
In matters of concern that Hunt listed in her PFDN relating to Cleghorn’s death, she said: “There was no inpatient beds available. I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did.”
Similarly, Lydia Brown, the assistant coroner for Exeter and Greater Devon, found that the NHS’s inability to find a bed for 44-year-old Wendy Telfer contributed to her death in March 2016. “The Devon partnership trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years,” the PFDN says. “It is accepted that the problem of psychiatric inpatient beds is a national one, but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.”
Jonathan Meaney was admitted to the Royal Free hospital, in London, on 13 March 2017 after taking an overdose. A doctor from Camden and Islington mental health trust’s liaison psychiatry team said that the 50-year-old needed to be admitted. The PFDN from Mary Hassell, the inner north London senior coroner, said: “However no bed was found for him and on 15 March Mr Meaney told the assessing mental health nurse that he would prefer to leave and was discharged. He went home and the following day took his own life.”
Lisa Inkin, aged 21, died in 2013 after she was repeatedly sent to London for “out of area” care, far away from her home in Kent, because the local NHS could not find her a bed.
David Knight died in 2015 after being sent “out of area” for psychiatric care when the NHS in Cornwall had no beds available. A lack of acute hospital beds in the Cornwall area had previously been cited by coroners reporting on the deaths of James Adams and George Taylor in 2012 and 2013 respectively.
Lorna Cullen died in 2012 after leaving the A&E unit of the Medway Maritime hospital in Kent when an assessment of her mental state was delayed bcause the liaison psychiatry service had only one nurse on duty. “Demand … far exceeded the available staffing provision,” ruled the Mid Kent coroner, Allison Summers.
The 45 cases identified also include deaths where the patient was unable to get specialist care for eating disorders, addiction problems and mental illness relating to childbirth. Jaroslaw Rogala, for instance, died in 2016 after the NHS in south-west London could not find anywhere to send him for specialist treatment for his alcohol addiction and mental health problems.
“These appalling cases suggest a direct link between Tory cuts to NHS mental health services and deaths which could have been prevented,” said Barbara Keeley, the shadow cabinet minister for mental health. “These unacceptable failings could have been averted and lives saved with properly funded mental health services, so that patients had timely access to treatment, were not shunted out of area or delayed in getting vital, often life-saving, treatment.”
Keeley and the Liberal Democrat MP Norman Lamb, the former health minister, are urging Jeremy Hunt, the health and social care secretary, to start an inquiry into the Guardian’s disclosures. But the Department of Health and Social Care declined to say if Hunt would be doing so, or respond to the disclosure of the 45 deaths linked to unavailability of staff, beds or services and long waits to access care.
The Department of Health said: “We know there are challenges in accessing some mental health services. That’s why we introduced one of the world’s first waiting-time standards for mental health, with the latest stats showing that we are exceeding our targets for access to talking therapies. We’re committed to ending inappropriate ‘out of area’ placements by 2020, and this is supported by our record amounts of funding into services – spending £11.6bn last year alone, with a further £1bn on top of this by 2021.”
• In the UK the Samaritans can be contacted on 116 123. In the US the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at www.befrienders.org