Ms Lake said despite hearing evidence from the NSFT about steps being taken to increase the number of beds available and thus prevent future deaths, she added: “Despite these steps, there remain insufficient beds available to meet patient needs.

“At the time of Mr Taylor’s death, there were 13 patients waiting for beds. At the time of the investigation, there were seven patients waiting for beds. There are peaks and troughs with these numbers every day, but overall there remains a shortage of beds.”

Ms Lake said she believed it was a national problem, not limited to Norfolk and Suffolk NHS Trust.

NSFT’s Mr Deery said: “Since Malcom’s sad death, additional safety meetings are now being held in the morning so that staff can discuss patients waiting for a bed, escalate cases where necessary and identify alternatives in within the wider system.

“We have also increased the frequency of patient flow meetings we hold with our system partners to ensure patients are receiving care in the most appropriate place to meet their needs.

“It was clear that there were significant pressures on mental health beds both locally and nationally at the time of Malcolm’s sad death.”

He said the trust would now look at the coroner’s findings to see if steps could be taken to prevent a similar incident.

Norfolk and Suffolk NHS Foundation Trust must respond to the coroner by December 23, detailing action taken or proposed in a timetable, or explaining why no action has been taken.