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 an 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 suicide and repeated self-harm including two previous serious attempts to take his own life, on May 29, 2023.
Following a formal Mental Health Act (MHA) assessment at Basildon Hospital the following day, Jack’s admission to a Mental Health Assessment Unit was confirmed as urgent and necessary for appropriate assessment, 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 on-going very high level of risk of suicide, 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 required in-patient bed anywhere in Essex. Evidence confirmed that demand for such beds outstripped supply and that this had been and remained a chronic issue, 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 death “was directly contributed” to by the non-availability, over several days, of a mental health bed.
Essex coroner Sean Horstead has issued a statement to the department of health and social security warning a lack of bed space could lead to further tragedies. He said: “The evidence confirmed that a lack of available in-patient beds for high-risk mental health patients who, as was acknowledged at the time, cannot be managed safely in the community, is a chronic and on-going situation in Essex and, the inquest was told, nationally.
“Had an in-patient bed been made available, he would probably not have died. Jack’s death was avoidable. Absent the provision of available mental health in-patient beds for very high-risk patients that formal Mental Health Act assessments have clinically determined cannot be managed safely in the community, then further avoidable deaths by suicide amongst this cohort of vulnerable patients appears inevitable.”
Jack’s case was included in a Lampard Inquiry submission in September 2024. The Lampard Inquiry is examining 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 and 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. The words we read at Jack’s funeral and the impact on us. We did not know that there was a gap in our life until you were born, and you filled it. You filled it with your love, your light and your joy. You filled it with your innocence and curiosity. You filled it with your laughter, your humour and your intelligence.
“‘You filled it with your kindness, your thoughtfulness and your compassion. You did not have an easy life, and, despite that, we watched you courageously and fiercely battle your way in this world, whilst we wrapped you with love, care, and protection. We could not be prouder of you Jack Peatling. You were perfect and we are better people for having had the privilege of loving you, and being loved by you, for more than 20 years.”
“We will miss you, Jack Peatling. We will miss your magnificent mind, and your big blue eyes that sparkled like stars and sunshine with love, life and laughter. We will miss your cheeky grin. We will miss holding you close and talking with you. We will miss your presence. We will miss everything about you. We will never forget you and we will always love you. Be as mischievous and inquisitive now as you were in life. Be free and happy and be at peace. Our hearts are broken.
Describing the concerns with Jack’s care, he added: “So much was wrong with Jack’s care throughout his dealings with the mental health teams, but we thought a corner had been turned when we were told he needed to be admitted immediately, and Jack agreed. At last, there was hope that he might get the help he needed before he killed himself. The following days, with daily visits, were unbearable. 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. When we asked for … help in the interim we were told whilst he was waiting for a bed, he could not access other services, and that there was a waiting list for psychological assessments within the community.
“We want to know why he wasn’t allocated a bed. Were there no other beds anywhere … in the area or another area? Were others prioritised over Jack because Jack was at home, or was the prioritisation because others were more at risk? How did the Mental Health Services prioritise the allocation of this resource?”
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.”
For confidential support, Samaritans can be contacted for free around the clock 365 days a year on 116 123.
