NSFT: Coroner fears more deaths as lessons not learnt

Haverhill mum Nicola Rayner died in 2023 after a psychiatrist was unable to admit her to a mental health ward because no beds were available.

Just days before, a mental health nurse at the local hospital had also tried to admit Ms Rayner, but again no bed was available.

Senior coroner Nigel Parsley, who led an inquest into Ms Rayner's death, has now written a Prevention of Future Deaths report to the Department for Health and Social Care, expressing strong concern that more lives were at risk and warned that lessons were not being learnt by the Norfolk and Suffolk Foundation Trust.

In the report, Mr Parsley said: “During the course of the inquest the evidence revealed matters given rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.

“Nicola’s case is not an isolated one.

“Evidence was heard from NSFT that on the day of the inquest itself (February 23), the availability of bed provision for informal Mental Health patients had failed to improve at all.

“The court heard on February 23, the Operational Pressure Escalation Level was at its highest level (Four Black) and, in Suffolk alone, there were 20 patients on a list waiting for an informal inpatient Mental Health bed.

“Just as on the June 6, 2023, there were no other available informal Mental Health beds anywhere else in the country.”

Ms Rayner was on a waiting list to be admitted at the time of her death, with no bed availability locally or nationally.

The senior coroner added: “The facts of Nicola’s case mirror those of another tragic Suffolk case, for which I produced a Prevention of Future Death Report in October 2020.

“I am therefore concerned, that any measures that may have been taken in the intervening period since October 2020, have neither adequately, or effectively, addressed this clear and continuing local and national risk of future deaths occurring.”

The investigation into Ms Rayner’s death determined the cause of death was “suicide, resulting directly from a lack of mental health bed provision in Suffolk and nationally”.

Cath Byford, deputy chief executive at NSFT (Image: NSFT)

Cath Byford, deputy chief executive and chief people officer at NSFT, said: “Our thoughts are with Nicola's family at this difficult time.

"We would like to pass our condolences to them and assure them that we are taking action to improve following her sad death.

“We would encourage Nicola's family to get in touch if they have any further questions or we can support them in any other way.”

If you need urgent mental health support call NHS 111 and select option 2 or the Samaritans on 116 123. Both services are available 24 hours 7 days a week.