The death of a 20-year-old described as a “beautiful soul” was directly contributed to by the non-availability of an in-patient bed in a Mental Health Assessment Unit, a report has concluded.
Jack Peatling spent six days at home awaiting a bed before taking his own life on June 5, 2023.
A prevention of future deaths report says he had been diagnosed with anxiety and depression and had made previous attempts at taking his own life and repeated self-harm, including two previous serious attempts on May 29, 2023.
Following a formal assessment at Basildon Hospital the next day, Jack’s admission to a Mental Health Assessment Unit was documented as urgent and necessary for the proper evaluation, management and treatment of his anxiety and depression and his impulsive suicide attempts.
With the agreement of Jack and his mother, the assessment determined that, in the context of his continuous very high level risk, with high levels of impulsivity, Jack could not be safely managed in the community.
Over the next six days, the Essex Partnership University NHS Foundation Trust (EPUT) were unable to identify the needed in-patient bed anywhere in Essex.
Evidence established that the need for such beds outstripped supply and that this had been and remained a chronic problem, locally and nationally.
As it was acknowledged by the professionals involved that his risk of suicide could not be safely managed in the community, it was ruled that Jack’s demise was “avoidable” and “had an in-patient bed been made available, he would probably not have died”.
Essex coroner Sean Horstead has stated to the Department of Health and Social Security, warning that a lack of bed space could lead to further tragedies.
In response, a Government spokesman said the Department of Health and Social Care has instructed the NHS to prioritise improving the availability of mental health beds.
Jack’s case was included in a Lampard Inquiry submission in September 2024. The Lampard Inquiry is investigating deaths at NHS-run inpatient units in Essex between 2000 and 2023.
His father, Jamie, told the hearing: “Jack had so much to offer this world, and he died. We do not have the words to describe the loss of Jack on our family. Jack completed our world and built on that. He was the most beautiful soul and yet so troubled. The gap, grief and guilt that we feel as a family is indescribable.
“He was our world, and without him the sun has gone down, and our hearts are broken. We are left feeling as though we were responsible for not fighting harder for him to get the support he needed and wanted.
“He was so brave.”
Describing the problems with Jack’s care, Jamie added that the family thought a corner had been turned when they were told he needed to be admitted immediately, and Jack agreed.
“The following days, with daily visits, were unbearable,” he explained.
“Every day, Jack became more anxious, every day Jack would say that he was struggling more with increased anxiety, every day Jack would say that he would likely kill himself, and every day being told that there was no bed available.
“We were told that Jack was high priority, and despite this high priority, nothing changed. The mental health team agreed he needed to be admitted immediately, noting that his impulsive behaviour increased his risk, but there were no beds, and he was not admitted.”
A Department of Health and Social Care spokesperson said: “Our deepest sympathies are with Jack’s family and friends. We’ve instructed the NHS to prioritise improving the availability of mental health beds, and we are investing £75 million this year to reduce inappropriate out-of-area placements so that patients can receive care closer to home.
“To reduce the number of mental health inpatients and ensure people are getting appropriate care, we are working to provide the mental health support they need in the community, including by recruiting 8,500 more mental health workers and investing £26 million in new mental health crisis centres.”
This is clearly not true, though, because back in September 2017, a 20-year-old died at Chelmsford Mental Health Unit – he hung himself.
Investigations were then expanded with officers confirming that they were looking at 25 deaths, and MPs called for a public inquiry after concerns were raised at patients’ inquests.
After Matthew Leahy was discovered hanging at the Linden Centre in Chelmsford, Essex, detectives began looking into the deaths of seven people in the care of North Essex Partnership NHS Foundation Trust.
The investigation was then expanded to investigate the deaths of up to 25 people at nine additional mental health units run by the trust since 2000.
Norman Lamb and Priti Patel, who served as several of the families’ local MPs, pushed Health Secretary Jeremy Hunt to launch a public investigation.
The Care Quality Commission report found that there was room for improvement, and that there were too many areas at the Linden Centre where patients could hang themselves.
Matthew Leahy was not allowed any visitors, not even his own family, not for the first seven days, because they considered it an adjustment.
Mental health patients require the support of their family, or even a close friend if they don’t have family. They don’t need to be stressed out any more than is needed, but sadly, their idea of treatment is to medicate and leave them like vegetables. This is not the 18th century anymore, and admittedly, they know more about mental health than they used to, but it’s really all a guessing game. Unfortunately, this poor soul died a week after being admitted.
Some have called the Linden Ward ‘the sleepy ward’ because all the patients are bored, and most of the patients were left drifting.
It was said that some of the staff were good with the patients, but the majority didn’t have a lot going on in terms of treatment.
Some of the patients are even bullied out of the hospital because there just isn’t enough room, so there’s a lot of pressure to get these patients out.
This doesn’t surprise me. The psychiatrists and nurses in the UK are now so poor in attitude and skills that they are just an embarrassment. Not that the psychiatrists do much, but the nurses should at least make some kind of effort. Unfortunately, now they are just lazy or have the wrong motivation, ie they are there for the money and not to work.
I’m not saying that they are all bad; there are some good ones, but they are very few and far between.
Then there was the neglect caused by repeated failures to assess a woman going through a mental health crisis, which contributed to her death by suicide at Pitsea Station in Basildon after being struck by a train while she was suffering a decline in her mental health.
There were indeed mistakes made that contributed to her death. She had been released from a long-term mental hospital to a care home on April 11, 2023.
EPUT’s mental health services were informed by Mrs Steedman on April 15 that she wanted to end her life by ‘jumping in front of a train’. Her mental health continued to worsen in May, and this was escalated to mental health services on or about May 8, but they failed to reply.
By May 10, Mrs Steedman was in a mental health crisis, but mental health services again failed to attend and conduct an assessment of her. Mental health services failed to complete a mental health assessment on May 11. The next morning, she redirected a taxi to Pitsea railway station, where she killed herself.
On April 27, the care home alerted the mental health team and the council’s social care team that there was a chance Mrs Steedman could divert a taxi to leave carers’ supervision. However, this crisis was not escalated, and no risk assessment was conducted.
Sadly, mental health is not an exact science, but there should be more facilities and more suitable training. However, unless we go back to bedlam, locking people away forever, we can’t stop people from taking their own lives, but there does need to be more that we can do, and that we must do for these people.
Jamie Harding, aged 31, took his own life. The Essex Coroner, who investigated the death of Jamie, cautioned that until steps were taken by Essex Partnership University NHS Foundation Trust (EPUT), there was an ongoing danger that more mental health patients could perish.
Jamie took his own life in June 2022, hours after being released from Basildon Hospital, where he had attended A&E, asking to be admitted for his own safety.
The inquest found the assessment carried out on him in A&E was “inadequate”, and that there was also a string of “significant and repeated failures” in the care and treatment provided to Jamie in the six months before his death.
The Coroner found that the string of failures and missed opportunities by EPUT amounted to “neglect”, and this directly contributed to Jamie’s death.
Jamie’s mother, Carolyn Claydon, said: “Losing Jamie was devastating. We miss him every day and are still traumatised by how badly he was let down by those who should have been providing him with the treatment he desperately needed, and who should have kept him safe.”
But nothing changes; the mental health system is broken and failing.
There are close to 551,000 people in England with more severe mental illness (SMI), such as schizophrenia or bipolar disorder.
I understand that people might fall through the cracks from time to time, but that is just not good enough – we need to do better, much better!
THE MONTHLY MOSQUITO 