Source · Prevention of Future Deaths

Ben Shipley

Ref: 2023-0140 Date: 27 Apr 2023 Coroner: Ian Pears Area: West Yorkshire Western Responses identified: 0 / 2 View PDF

A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in A&E for hours, unable to be legally detained and without appropriate specialist care.

Date 27 Apr 2023
56-day deadline 22 Jun 2023 est.
Responses identified 0 of 2
Mental Health related deaths Railway related deaths

Coroner's concerns

AI summary
A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in A&E for hours, unable to be legally detained and without appropriate specialist care.
View full coroner's concerns
Ben was assessed at 22.00 on 28th August 2019. It seems to me that there are about 12 hours of delay following a 22.00 s2 Mental Health Act assessment built into the system if there is no bed. Presumably this would be longer if Ben had been assessed earlier in the night shift. I am told beds do not become available over night. This means Ben cannot be legally detained as the section 2 is not complete until there is a bed. He is therefore subject to the goodwill of the A&E (who are not trained in mental health) and the goodwill of the family (who are similarly not trained in mental health). [REDACTED].

Report sections

Investigation and inquest
On 03 September 2019 I commenced an investigation into the death of Ben Alan SHIPLEY aged 22. The investigation concluded at the end of the inquest on 23 February 2023.

The conclusion of the inquest was that:   Ben Alan Shipley died on 29th August 2019 having been struck by a train at Milne Viaduct East End after absconding from Huddersfield Royal Infirmary’s Clinical Decisions Unit at 12.30. Ben voluntarily came to A&E on 28th August 2019 at 19.27 after suffering a mental health crisis. He was assessed by 2 mental health psychiatrists and a mental health nurse. He was deemed to require a section 2 detention under the Mental Health Act, but was to remain in A&E for his own safety until a bed was sourced. After a prolonged search, using various communications methods, for a bed lasting approximately 17 hours, Ben absconded from A&E, where he travelled to a railway, [REDACTED]
Circumstances of the death
Ben is a 22yr old single man who lived with his family in Lepton, Huddersfield.   On the 28th of August Ben was seen by his GP who referred Ben to the ‘Single Point of Access’ service. On the 29th of August Ben was at the hospital with is parents, waiting to be sectioned under the mental health act when he ran away. His parents reported him as a missing person.   That afternoon Ben was struck by a train in a rural area of Huddersfield. His life was pronounced extinct at 14:14hrs.

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Report details

Reference
2023-0140
Date of report
27 April 2023
Coroner
Ian Pears
Coroner area
West Yorkshire Western

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Jun 2023 (estimated).

Sent to

NHS England
NHS Improvement

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