There is no doubt that services are overstretched. In one in six of the cases, coroners linked the deaths to the lack of staff, beds and specialist services, or to long delays for treatment. Mental health services have been desperately underfunded for too long, and the promised increase in spending is insufficient given the historic shortfall and the surge in demand. The current government, and the coalition before it, promised to prioritise mental health; these figures show how little progress has been made. A leaked green paper recently revealed that the promise of a maximum four-week wait for children (currently left as long as 18 months without care) will not be fully implemented until 2021 due to lack of staff and funding. A dearth of early intervention also leads to heavier demand for more expensive crisis services. It is impossible to provide adequate care without adequate resources. But funding is not a guarantee of quality. Cash alone cannot ensure that agencies and staff communicate as they should (the issue cited most frequently in these coroners’ warnings); nor can it foster a culture of learning from errors. Some NHS bodies are clearly failing to apply the necessary lessons – even when warned about them in the bluntest possible terms.

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