WESTMINSTER’S coroner has warned a top health chief that “severe resources shortages” – including half of all nursing positions being unfilled – may have contributed to the death of a psychiatric patient.

Professor Fiona Wilcox’s judgment came in the week that NHS chiefs closed a consultation on a plan permanently to shut down the Gordon Hospital. The hospital in Pimlico provided all of the beds for acute mental health patients in the whole of the borough before it was temporarily shut at the start of the Covid-19 pandemic.

NHS chiefs at Central and North West London NHS Foundation Trust say its mental health service can do without the 51 beds provided at the hospital.

But findings made during the investigation into the death of Roberto Bettello will raise alarm bells with managers pushing through the changes despite strong opposition from Westminster City Council.

In a letter to the chief executive of CNWL, Prof Wilcox warned that Mr Bettello may have lived had he not been admitted to St Mary’s Hospital, Paddington, after being arrested during an “acute episode” in Berkeley Square, Mayfair. Authorities dealing with his case, in September 2020, were told there was no “section 136 suite” available in the whole of London for him and so he was admitted to an unsuitable ward.

The 44-year-old died from multiple injuries on September 16 2020 after falling from a window at the Paddington hospital.

Prof Wilcox listed several reasons why a section 136 suite – a secure environment for individuals exhibiting unpredictable behaviours due to their mental health conditions – was not made available to Mr Bettello, including shortages in psychiatric care provision. She wrote: “A section 136 suite was not made available to Roberto that should have been and it was possible that this contributed to his death.

“Evidence from the psychiatric doctor was that there are severe resource shortages in the area in which she now works, with up to 50 per cent of psychiatric nursing staff posts being vacant. All witnesses [to the inquest] confirmed that there are, at times, still shortages of section 136 suites and heavy demand from psychiatrically unwell people despite definite improvements in service.”

Prof Wilcox warned that more tragedies would occur in the future if a catalogue of issues arising from the inquest were not addressed. This included a suite that was available in Hillingdon being overlooked due to “obvious errors” in the way staff used computer systems.

The Extra has reported on the plans not to reopen the Gordon Hospital after it was temporarily closed. The hospital had the kind of suites that were not available to Mr Bettello on the night he died.

The council has strongly opposed the closure with deputy leader and adult social care and public health lead councillor, Nafsika Butler-Thalassis saying in December: “Westminster is an area with one of the highest rates of mental health crisis in the country, and it defies common sense that we may end up with no local acute beds for a resident population of more than 200,000.”

Prof Wilcox did however praise a new approach to section 136 suites within London whereby police can access these directly, and suggested the wider adoption of this practice could improve service provision. But she also strongly criticised CNWL and said the trust had “failed in its duty of candour in relation to provision of evidence in this case”.

A spokesperson from CNWL said: “We send our deepest condolences to the family and loved ones of Roberto Bettello. We are very sorry for any mistakes that were made and opportunities missed while he was under NHS care. We are reviewing the findings of the coroner’s report and will respond formally in due course. We will also continue working with local partners to ensure that any future similar situations are better dealt with.”