Martyn Stringer
PFD Report
All Responded
Ref: 2024-0448
All 1 response received
· Deadline: 2 Oct 2024
Coroner's Concerns (AI summary)
A severe and frequent lack of suitable beds for compulsory mental health detention prevents patients from receiving critical care, with beds sometimes denied due to anticipated demand.
View full coroner's concerns
As you will note from the Conclusion, an application for compulsory detention for Martyn could not be completed due to the unavailability of beds despite extensive searches nationally.
My findings were that: ‘It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to Martyn.’
And also that: ‘in my view highly likely that Martyn would have benefitted from a further admission to hospital – as he had previously – and he would have prevented from further relapse and ultimately taking the actions he did on the morning of the 27 March.’
I heard evidence from experience mental health professionals that the lack of beds for those requiring detention under the Mental Health Act was a frequent occurrence.
In my view, you should consider a review of sufficiency of provision for suitable placements for those requiring compulsory treatment.
My findings were that: ‘It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to Martyn.’
And also that: ‘in my view highly likely that Martyn would have benefitted from a further admission to hospital – as he had previously – and he would have prevented from further relapse and ultimately taking the actions he did on the morning of the 27 March.’
I heard evidence from experience mental health professionals that the lack of beds for those requiring detention under the Mental Health Act was a frequent occurrence.
In my view, you should consider a review of sufficiency of provision for suitable placements for those requiring compulsory treatment.
Responses
Action Planned
NHS England is addressing mental health bed availability through investment in community, crisis, and acute mental health services, and directing systems to reduce average length of stay in adult acute mental health wards. They are supplementing this with further investment to recommission inpatient care and have established a Quality Transformation Programme to improve access and quality of mental health pathways. (AI summary)
NHS England is addressing mental health bed availability through investment in community, crisis, and acute mental health services, and directing systems to reduce average length of stay in adult acute mental health wards. They are supplementing this with further investment to recommission inpatient care and have established a Quality Transformation Programme to improve access and quality of mental health pathways. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Martyn Harvey Stringer who died on 29 March 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 August 2024 concerning the death of Martyn Harvey Stringer on 29 March 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Martyn’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Martyn’s care have been listened to and reflected upon.
Your Report raises concerns over the issue of availability of inpatient mental health beds.
The number of mental health beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system, in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary.
In some local areas there is a need for more beds. This is being addressed in part through investment in new units, however, this should be considered as part of a transformational approach. This is supported by the NHS Long Term Plan (LTP), which has seen an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards, in order to deliver more timely access to local beds.
To address the wider system issues that impact on health services, a further £1.6 billion has been made available via the Better Care Fund from 2023-2025. This funding can be used to support mental health inpatient services as well as the wider system, National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
26/09/2024
which should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.
This is being supplemented by a further £42 million recurrent investment from 2024/25 for all Integrated Care Boards (ICBs) in the country, to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.
NHS England’s South East region have also established a Quality Transformation Programme relating to Urgent and Emergency Care and Flow. The aim of this programme is to improve access and quality of the mental health crisis and acute adult pathway, including improving patient flow and capacity. The region is engaged with the national Quality Transformation Programme designed to help systems transform their current service offer. The national programme is built upon the cornerstones of good mental healthcare, continuity of care, therapeutic relationships and a relentless commitment to mental health care, meeting the needs of all people.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Martyn, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 August 2024 concerning the death of Martyn Harvey Stringer on 29 March 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Martyn’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Martyn’s care have been listened to and reflected upon.
Your Report raises concerns over the issue of availability of inpatient mental health beds.
The number of mental health beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system, in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary.
In some local areas there is a need for more beds. This is being addressed in part through investment in new units, however, this should be considered as part of a transformational approach. This is supported by the NHS Long Term Plan (LTP), which has seen an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards, in order to deliver more timely access to local beds.
To address the wider system issues that impact on health services, a further £1.6 billion has been made available via the Better Care Fund from 2023-2025. This funding can be used to support mental health inpatient services as well as the wider system, National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
26/09/2024
which should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.
This is being supplemented by a further £42 million recurrent investment from 2024/25 for all Integrated Care Boards (ICBs) in the country, to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.
NHS England’s South East region have also established a Quality Transformation Programme relating to Urgent and Emergency Care and Flow. The aim of this programme is to improve access and quality of the mental health crisis and acute adult pathway, including improving patient flow and capacity. The region is engaged with the national Quality Transformation Programme designed to help systems transform their current service offer. The national programme is built upon the cornerstones of good mental healthcare, continuity of care, therapeutic relationships and a relentless commitment to mental health care, meeting the needs of all people.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Martyn, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Sent To
- NHS England
Response Status
Linked responses
1 of 1
56-Day Deadline
2 Oct 2024
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 5 April 2023 an Inquest was opened into the death of Martyn Harvey Stringer who died on the 29 March 2023. On the 25 July 2024 I concluded an Inquest into his death at the end of a 3-day hearing.
Circumstances of the Death
The immediate circumstances are that: On 24 March 2023, Martyn was detained by police in Sussex after being found at where he had ostensibly gone to take his own life. He was taken to Eastbourne District General Hospital. There he was assessed and deemed liable for detention under Section 2 of the Mental Health Act. However, there were no available mental health beds nationally and a suitable placement could not be found for him. Having been at the hospital since Friday evening, he contacted family members on Sunday, 26 March who collected him and brought him back to his home in Oxfordshire. On 27 March 2023, Martyn left his home and stepped in front of a lorry on the A4074. Witnesses described his actions as deliberate. The medical cause of death was determined following a post-mortem examination to be multi-organ failure and polytrauma resulting from a road traffic collision
Action Should Be Taken
In my opinion, action should be taken to prevent future deaths, and the coroner believes that your organisations have the power to take such action.
Copies Sent To
who in my opinion should receive it
You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 07 August 2024 Mr N Graham HM Senior Coroner
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.