Amanda Vickers
PFD Report
All Responded
Ref: 2014-0052
All 1 response received
· Deadline: 31 Mar 2014
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
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)
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)
View full response
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Sent To
- NHS Cumbria Clinical Commissioning Group
Response Status
Linked responses
1 of 1
56-Day Deadline
31 Mar 2014
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 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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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.