Source · Prevention of Future Deaths

Amanda Vickers

Ref: 2014-0052 Date: 3 Feb 2014 Coroner: D LI Roberts Area: Cumbria (North & West) Responses identified: 1 / 1 View PDF

A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the CCG.

Date 3 Feb 2014

56-day deadline 31 Mar 2014 est.

Responses identified 1 of 1

Mental Health related deaths

Coroner's concerns

AI summary

A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the CCG.

View full coroner's concerns

This lady died whilst awaiting a place at 81 Lowther Street Crisis Home. She had been there before and found it therapeutic No space was available, and no date when one might arise_was _known She died whilst waiting for admission The evidence was that and unit TS the only one of its type in the whole county . ItTs understoodhhav this 6-beddded commissioning such facilities. On the balance of probability the CCG is responsible for difference in this case A review of the facilities an admission would have made a number of beds for available is suggested with a view to the provision of a patients such as the deceased

Responses

1 respondent

Cumbria Clinical Commissioning Group NHS / Health Body

PDF

Action Planned

Cumbria Clinical Commissioning Group is reviewing the existing framework for wellbeing and mental health and developing a new mental health strategy in partnership with stakeholders. A review of mental health is due to report by the end of May 2014. (AI summary)

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Report sections

Investigation and inquest

On 28th August 2013 commenced an investigation into the death of Amanda Jane Vickers, age 47 years. The investigation concluded at the end of the inquest on 27th January 2014. The conclusion of the inquest was cause of death 1(a) Hanging: Conclusion: Took her own life whilst the balance of her mind was disturbed.

Circumstances of the death

The deceased had a long history of depression and suicidal ideation. Over the days before her death she had daily contact with her mental health nurse_ She was to be referred to a residential crisis home, but no room was available immediately. On the evening of the 22nd August 2013 the deceased was found hanging by the neck from a fabric ligature attached to a roof beam at her home address

Action should be taken

action should be taken to prevent future deaths and believe you In my opinion have the power to take such action. [ANDIOR your organisation]

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Report details

Reference: 2014-0052
Date of report: 3 February 2014
Coroner: D LI Roberts
Coroner area: Cumbria (North & West)

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 31 Mar 2014 (estimated).

Sent to

NHS Cumbria Clinical Commissioning Group

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.