24 Jul 2019 Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of suitable acute mental health beds for young adults View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of suitable acute mental health beds for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative. The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her;
” Source location Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report
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27 Feb 2019 Peter George Garvin · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Insufficient local psychiatric beds View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Peter George Garvin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter George Garvin, who was under the care of a Community Mental Health Team while his medication was prescribed by his GP, entered the Regent’s Canal on 31 January 2018 with the intention of taking his own life. The report identifies concerns about communication between the CMHT and GP, insufficient local psychiatric beds, discharge from NHS care after seeking private psychiatric treatment, and the lack of an early carer’s assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient local psychiatric beds
Wider context from the report “2. That there should be sufficient local beds so that such a vulnerable person should not have to be hospitalised so very far from home.
” Source location Peter George Garvin · Prevention of Future Deaths report
Open source report
12 Feb 2019 Anthony John William Watson · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2
Unavailability of suitably proximate out-of-area inpatient mental health beds View source Insufficient numbers of inpatient mental health beds in Birmingham and Solihull View source
Linked responses
NHS Birmingham and Solihull Integrated Care Board NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS Birmingham and Solihull Integrated Care Board
Maintain reciprocal arrangements enabling access to out-of-area inpatient beds when local beds are unavailable.
View source
NHS Birmingham and Solihull Integrated Care Board
Participate as an active partner in the Sustainability and Transformation Partnership and Mental Health Programme Delivery Board.
View source
NHS England
Eliminate out-of-area placements for non-specialist acute inpatient care caused by local bed pressures by 2021.
View source
NHS England
Provide clinically led support, including local workshops, to help systems safely and sustainably reduce out-of-area placements.
View source See 1 more action
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AI-generated summary
Anthony John William Watson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony John William Watson, who had recurrent depression and anxiety and was displaying psychosis and suicidal thoughts, died after cutting his wrists and neck and jumping from a first-floor window on 21 October 2018. He sustained an unsurvivable head injury and died in hospital the following day. The principal concern was that no inpatient mental health bed was available locally despite the need for immediate admission, while out-of-area beds were considered too distant, particularly for older patients and their families.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of suitably proximate out-of-area inpatient mental health beds
Wider context from the report “1. Mr Watson was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area. Three days later there was still no bed available. Mr Watson was not offered a bed out-of-area.
2. This report has similar themes to the 7 reports issued by the Birmingham and Solihull Coroners on 4/10/18.
3. However, the impact of Mr Watson’s age is a new issue.
4. I heard evidence that:
a. Younger and older adults will not normally be admitted as inpatients on mixed units. Beds on young adult units may have been available on 18-22 October 2018 but these were not considered.
b. Beds in neighbouring areas are unavailable because of contractual issues. The closest out of area option is at least 70 miles away. Although Mr Watson was not offered an out of area bed, his wife was confident that had one been offered he would have declined because 70 miles was so far away. Whilst this distance is likely to deter a patient of any age from accepting the offer, it is particularly problematic for elderly patients and their families.
c. Whilst remedial action is underway in response to the concerns raised in the 7 reports issued on 4/10/18, currently it still remains the position that at least one patient every day in Birmingham and Solihull is advised they require an immediate admission for inpatient mental health treatment but no bed is available within the area.
5. The lack of inpatient beds is a resource issue. My ongoing concerns are that (a) there are insufficient numbers of beds in Birmingham and Solihull, and (b) out-of-area beds are too far away .
” Source location Anthony John William Watson · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient numbers of inpatient mental health beds in Birmingham and Solihull
Wider context from the report “1. Mr Watson was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area . Three days later there was still no bed available . Mr Watson was not offered a bed out-of-area.
2. This report has similar themes to the 7 reports issued by the Birmingham and Solihull Coroners on 4/10/18.
3. However, the impact of Mr Watson’s age is a new issue.
4. I heard evidence that:
a. Younger and older adults will not normally be admitted as inpatients on mixed units. Beds on young adult units may have been available on 18-22 October 2018 but these were not considered.
b. Beds in neighbouring areas are unavailable because of contractual issues. The closest out of area option is at least 70 miles away. Although Mr Watson was not offered an out of area bed, his wife was confident that had one been offered he would have declined because 70 miles was so far away. Whilst this distance is likely to deter a patient of any age from accepting the offer, it is particularly problematic for elderly patients and their families.
c. Whilst remedial action is underway in response to the concerns raised in the 7 reports issued on 4/10/18, currently it still remains the position that at least one patient every day in Birmingham and Solihull is advised they require an immediate admission for inpatient mental health treatment but no bed is available within the area .
5. The lack of inpatient beds is a resource issue. My ongoing concerns are that (a) there are insufficient numbers of beds in Birmingham and Solihull , and (b) out-of-area beds are too far away.
” Source location Anthony John William Watson · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain reciprocal arrangements enabling access to out-of-area inpatient beds when local beds are unavailable.
Verbatim wording from the response “2.7 The CCG has reciprocal arrangements in place for patients to access out of area beds when there are no local beds available. This arrangement is delivered through the MERIT Vanguard, which arose out of the Department of Health New Models of Care Programme and is a partnership between four NHS mental health providers in the Midlands (Birmingham and Solihull Mental Health NHS Foundation Trust, Black Country Partnership NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust and Coventry and Warwickshire Partnership NHS Trust). The Vanguard has sought to improve crisis care through more flexible use of bed stock across the region and by seeking to embed ‘recovery principles’ in practice.” Source location 2019-0044-Response-by-Birmingham-and-Solihull-CCG
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate as an active partner in the Sustainability and Transformation Partnership and Mental Health Programme Delivery Board.
Verbatim wording from the response “3.2 The CCG recognises that there has been increased demand for mental health services since 2016, and has responded to this additional pressure with increased funding and through working with Forward Thinking Birmingham (providers of mental health services across Birmingham and Solihull for those aged up to 25), BSMHFT and the local Sustainability and Transformation Partnership (the STP) to look at different ways of working throughout the system. The CCG will continue to monitor the situation to ensure that all partnership working across Birmingham and Solihull is focussed on improving access and the quality of care.” Source location 2019-0044-Response-by-Birmingham-and-Solihull-CCG
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Eliminate out-of-area placements for non-specialist acute inpatient care caused by local bed pressures by 2021.
Verbatim wording from the response “In recognition of the importance of continuity of care and the proximity to existing support networks, NHS England has committed to eliminating the practice of sending people out of area for non-specialist acute inpatient care due to local bed pressures by 2021. This applies to older adult beds, as well as general adult and psychiatric intensive care units (PICUs) and is underpinned by the expectation that there is always local capacity to meet the needs of individuals requiring this type of support.” Source location 2019-0044-Response-by-NHS-England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinically led support, including local workshops, to help systems safely and sustainably reduce out-of-area placements.
Verbatim wording from the response “The reduction of out of area placements (OAPs) is a high priority both nationally and locally and I can confirm as part of the 2019/20 NHS Operational Planning and Contracting Guidance all Sustainability and Transformation Partnerships (STPs) are reviewing their plans and trajectories for reducing these placements. Over the last year we have been working jointly with NHS Improvement to provide a clinically-led support offer to assist areas in their work to reduce OAPs. This has involved local workshops run by clinical experts with the necessary experience of leading complex system change, which is required to enable the safe and sustainable reduction of OAPs. Birmingham and Solihull STP are engaged with this support offer and participated in a bespoke clinically-led workshop in March 2019.” Source location 2019-0044-Response-by-NHS-England
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The CCG cannot immediately ensure sufficient inpatient bed capacity because capacity and flow depend on factors beyond investment alone, including care models and practice.
Verbatim wording from the response “4.4 The CCG further recognises that these measures will not provide an immediate solution which ensures there is always sufficient bed capacity, as there are other considerations that impact on the system. Achieving improved capacity and flow cannot be realised solely through investment and must be supported by optimised models of care and practice such as those described above.” Source location 2019-0044-Response-by-Birmingham-and-Solihull-CCG
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Bed availability is not simply determined by the number of locally commissioned beds, but largely by whole-system pathway management and community-service investment.
Verbatim wording from the response “I can confirm that evidence from those areas which maintain local bed availability suggests that this is not simply down to the number of locally commissioned beds, but largely related to the effective management of the whole system pathway and investment in local services, in particular community alternatives. As such, I also wanted to reassure you about the specific steps we are taking to improve access to, and quality of, crisis and community mental health care as part of the NHS Long Term Plan, which includes a specific focus on provision for older adults:” Source location 2019-0044-Response-by-NHS-England
Open published response
7 Feb 2019 Stephen Anthony Kennedy · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Unavailability of acute inpatient beds View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham and Solihull Mental Health NHS Foundation Trust Department of Health and Social Care NHS Birmingham and Solihull Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
NHS Birmingham and Solihull Integrated Care Board
Commission system-simulation modelling with partner organisations to identify solutions and priorities for mental-health demand and capacity.
View source
NHS Birmingham and Solihull Integrated Care Board
Fund individual Section 117 health-and-social-care packages where required to facilitate hospital discharge.
View source
NHS Birmingham and Solihull Integrated Care Board
Hold weekly and daily peak-period delayed-discharge escalation calls with providers and local-authority social-work teams.
View source
NHS Birmingham and Solihull Integrated Care Board
Provide additional investment to BSMHFT above contract value to increase mental-health service capacity.
View source
NHS Birmingham and Solihull Integrated Care Board
Negotiate 2019/20 contract measures to improve capacity through investment and service development.
View source
NHS Birmingham and Solihull Integrated Care Board
Keep mental-health service pressures under review and develop new initiatives to manage patient flow and improve services.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Review patient flow to mitigate risks associated with unavailable inpatient beds.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Reduce delayed discharges to improve acute bed availability.
View source
Birmingham and Solihull Mental Health NHS Foundation Trust
Appoint patient flow coordinators to mitigate inpatient bed availability risks.
View source See 6 more actions
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AI-generated summary
Stephen Anthony Kennedy · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Anthony Kennedy had a history of emotional unstable personality disorder, depression and frequent self-harm, and his condition deteriorated during 2018. He was found hanging at his home on 08/10/18 and was declared deceased. Concerns included that psychological therapy was unavailable because of service structures and long waiting lists, and that a lack of acute inpatient beds contributed to further episodes of self-harm and suicide attempts.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of acute inpatient beds
Wider context from the report “2. In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts. The availability of acute beds is a serious concern .
” Source location Stephen Anthony Kennedy · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission system-simulation modelling with partner organisations to identify solutions and priorities for mental-health demand and capacity.
Verbatim wording from the response “3.5 The CCG has recognised and reacted to the increased demand for mental health services. To date, this has included:” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund individual Section 117 health-and-social-care packages where required to facilitate hospital discharge.
Verbatim wording from the response “3.5.3 Supporting operational initiatives to reduce delayed transfers of care, where CCG funding of individual packages of care under Section 117 (jointly funded packages of health and social care) are required to facilitate discharge from hospital.” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly and daily peak-period delayed-discharge escalation calls with providers and local-authority social-work teams.
Verbatim wording from the response “3.5.4 Weekly, and daily peak period, delayed discharge escalation calls with providers and local authority social work teams, in order to escalate any delays and for swift resolution.” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional investment to BSMHFT above contract value to increase mental-health service capacity.
Verbatim wording from the response “3.5.9 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase).” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Negotiate 2019/20 contract measures to improve capacity through investment and service development.
Verbatim wording from the response “3.6 It is acknowledged, through contract review meetings, there have been discussions with BSMHFT about funding and capacity, as capacity and demand issues are discussed through the contract review mechanism. Contract negotiations for services provided in 2019/20 have focused on measures to improve capacity through investment and service development and improvement.” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Keep mental-health service pressures under review and develop new initiatives to manage patient flow and improve services.
Verbatim wording from the response “4.4 The CCG will continue to keep under review the pressures on mental health services and the need to develop new initiatives to manage patient flow and improve services.” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review patient flow to mitigate risks associated with unavailable inpatient beds.
Verbatim wording from the response “On the matter of bed availability, it is recognised that at times patients are unable to access a bed at the point of clinical decision making and that this can lead to increased risk, despite best efforts to manage patients safely in an alternative environment. We are undertaking a number of initiatives to try to mitigate this risk including:-” Source location 2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce delayed discharges to improve acute bed availability.
Verbatim wording from the response “On the matter of bed availability, it is recognised that at times patients are unable to access a bed at the point of clinical decision making and that this can lead to increased risk, despite best efforts to manage patients safely in an alternative environment. We are undertaking a number of initiatives to try to mitigate this risk including:-” Source location 2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint patient flow coordinators to mitigate inpatient bed availability risks.
Verbatim wording from the response “On the matter of bed availability, it is recognised that at times patients are unable to access a bed at the point of clinical decision making and that this can lead to increased risk, despite best efforts to manage patients safely in an alternative environment. We are undertaking a number of initiatives to try to mitigate this risk including:-” Source location 2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local NHS organisations are responsible for providing mental health services, while NHS England commissions specialised services.
Verbatim wording from the response “You will know that the provision of mental health services is a matter for the NHS locally, except where specialised services are required and NHS England is the responsible commissioner. You have issued your report to the Birmingham and Solihull Mental Health NHS Foundation Trust and the Birmingham and Solihull Clinical Commissioning Group (CCG), and I expect the local NHS to take firm action to respond to the concerns and learn from Stephen’s death to ensure the safety of healthcare services.” Source location 2019-0039-Response-by-Department-of-Health-and-Social-Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local commissioners are responsible for determining acute mental health bed provision according to their populations’ needs.
Verbatim wording from the response “On the availability of beds in the acute mental health sector, we are aware that the number of mental health beds overall have reduced and this is in large part due to the growth of care in the community. It may also be of interest to note that mental health bed occupancy rates have remained stable at between 87.1 per cent and 90.8 per cent (from Quarter 1, 2010-11 to Quarter 3, 2018-19), and that latest data for Quarter 3, 2018-19 shows a bed occupancy of 88.5 per cent. However, it remains the responsibility of local commissioners to determine the levels of service provision based on the needs of their local populations, and I note that the NHS in Birmingham and Solihull has taken action to commission a further 32 inpatient beds.” Source location 2019-0039-Response-by-Department-of-Health-and-Social-Care
Open published response
Concerns raised 1
Lack of identifiable beds for mentally disordered patients in cases of special urgency View source
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AI-generated summary
David Reginald Bert Stacey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Reginald Bert Stacey died after sustaining chest injuries in a road traffic collision on 27 November 2017. Before the collision, he had been assessed under the Mental Health Act and was left alone after the assessment team departed. Concerns included a failure to communicate that a bed was available, the assessment team leaving before safeguards were in place, and the lack of an identifiable facility for cases of special urgency in Leicestershire.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of identifiable beds for mentally disordered patients in cases of special urgency
Wider context from the report “An expert was instructed to advise on the psychiatric aspect of Mr Stacey’s death. One of the issues he identified was a failure to identify availability of a bed for cases of special urgency . This is a statutory requirement under section 140 of the Mental Health Act 1983 that the relevant health bodies (local Clinical Commissioning Group and Local Health Board) give advice to every social services authorities within the area of arrangements that are in force for the reception of mentally disordered patients in cases of special urgency . The expert was in no doubt that Mr Stacey would have fulfilled the ‘special urgency’ category. It transpires from my further communication with the Leicestershire Partnership Trust that there is no such facility in Leicestershire . It would appear to be a statutory requirement that is currently being ignored and I am concerned that another similar situation might arise when there are no beds available to or identifiable by, the local Trust .
” Source location David Reginald Bert Stacey · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prepare and publish a report supporting CCGs and local authorities to improve implementation of section 140 requirements.
Verbatim wording from the response “We are committed to improving the implementation of requirements under section 140 of the Mental Health Act and, in response to the findings in Sir Simon Wessely’s Independent Review of the Mental Health Act², we are preparing a report to support CCGs and local authorities to make these improvements. This will be published as soon as it is possible to do so.” Source location David-Stacey-Response-from-the-Department-of-Health-and-Social-Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities, providers, NHS commissioners, police and ambulance services are responsible for agreeing a joint local policy for section 140 admissions.
Verbatim wording from the response “On the use of section 140 beds, as you identify in your report, clinical commissioning groups (CCGs) have a duty to notify local authorities of the arrangements in place for the reception of patients in cases of special urgency. The Mental Health Act 1983: Code of Practice¹, includes guidance on how the use of section 140 beds should be managed locally. The Code makes clear that local authorities, providers, NHS commissioners, police forces and ambulance services should ensure that a clear, joint policy, is in place for the safe and appropriate admission of people in the local area in cases of special urgency. This should be agreed at board level and each party should appoint a named senior lead.” Source location David-Stacey-Response-from-the-Department-of-Health-and-Social-Care
Open published response
24 Oct 2018 Maximilien Conrad Kohler · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Severe shortage of inpatient psychiatric beds for children and adolescents View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Maximilien Conrad Kohler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Maximilien Conrad Kohler, known as Max, was found hanging by a belt from a pull-up bar at his home on 5 May 2018 and died despite resuscitation. The report identified concerns about delayed or incorrect diagnosis, over-reliance on questionnaires in assessing diagnosis and self-harm risk, limited services and support for people with ASD and their parents, and shortages of NHS inpatient psychiatric beds for children and adolescents.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Severe shortage of inpatient psychiatric beds for children and adolescents
Wider context from the report “5. That there is a severe shortage of inpatient psychiatric beds for children and adolescents in the NHS .
” Source location Maximilien Conrad Kohler · Prevention of Future Deaths report
Open source report
4 Oct 2018 Michael Paul Wheeler · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Unavailability of inpatient mental health beds for patients requiring inpatient treatment View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS Birmingham and Solihull Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS Birmingham and Solihull Integrated Care Board
Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
View source
NHS Birmingham and Solihull Integrated Care Board
Commission an independent review of inpatient journeys to identify alternatives to admission and reduce avoidable discharge delays.
View source
NHS Birmingham and Solihull Integrated Care Board
Support delayed-transfer initiatives through funded Section 117 care packages and escalation calls with providers and social-work teams.
View source
NHS Birmingham and Solihull Integrated Care Board
Provide additional investment to expand commissioned mental-health service capacity and provision.
View source
NHS Birmingham and Solihull Integrated Care Board
Continue supporting out-of-area NHS and independent hospital admissions when locally commissioned beds are unavailable and admission is necessary.
View source See 2 more actions
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Michael Paul Wheeler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Paul Wheeler died after jumping from a fourth-floor window at his brother’s home on 26 July 2018, following increasing paranoia and bizarre behaviour. The principal concerns were that he was not reviewed by a psychiatrist, had no treatment plan, and had no planned review on 26 July; broader concerns were raised about pressures on mental health services, including the availability of urgent psychiatric reviews and inpatient beds.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of inpatient mental health beds for patients requiring inpatient treatment
Wider context from the report “2. The Coroner is aware, although not from evidence obtained in respect of Mr. Wheeler’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT who are currently operating at 109% capacity and are often not available . Consequently, patients who would otherwise have been offered in-patient treatment, are having to be managed by the HTTs . Partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day. One particular problem in the Birmingham and Solihull area is that the occurrence of psychosis is more than 3 times higher than the national average. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
” Source location Michael Paul Wheeler · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
Verbatim wording from the response “5.4.1 An independent system simulation modelling exercise, which was jointly commissioned with FTB and BSMHFT, to develop an informed response on the best solutions to address the demand and where investment should be prioritised. This followed a sharp increase in demand for inpatient beds in 2016.” Source location Birmingham-and-Solihull-CCG-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission an independent review of inpatient journeys to identify alternatives to admission and reduce avoidable discharge delays.
Verbatim wording from the response “5.4.2 An independent review of patients’ journeys into and out of inpatient mental health beds was commissioned by the STP. The review considered whether alternatives to admission could have been used and whether patients stayed in hospital longer than necessary. The review found that in both cases, improvements could be made to help avoid unnecessary admissions and reduce the time taken to discharge patients.” Source location Birmingham-and-Solihull-CCG-Response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support delayed-transfer initiatives through funded Section 117 care packages and escalation calls with providers and social-work teams.
Verbatim wording from the response “5.4.3 Supporting operational initiatives to reduce delayed transfers of care, where CCG funding of individual packages of care under Section 117 (jointly funded packages of health and social care) are required to facilitate discharge from hospital.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional investment to expand commissioned mental-health service capacity and provision.
Verbatim wording from the response “5.4.8 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting out-of-area NHS and independent hospital admissions when locally commissioned beds are unavailable and admission is necessary.
Verbatim wording from the response “5.4.5 Continuing to support the use of admissions to other NHS mental health trusts within the MERIT Vanguard³ and to independent hospitals, where no locally commissioned beds are available, and an admission is deemed necessary.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
4 Oct 2018 William Peter Edge · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Unavailability of inpatient mental health beds View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS Birmingham and Solihull Integrated Care Board NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
NHS Birmingham and Solihull Integrated Care Board
Incorporate learning-from-deaths and demand-and-capacity improvement plans into contracts as service-delivery improvement plans.
View source
NHS Birmingham and Solihull Integrated Care Board
Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
View source
NHS Birmingham and Solihull Integrated Care Board
Commission an independent review of inpatient journeys to identify alternatives to admission and reduce avoidable discharge delays.
View source
NHS Birmingham and Solihull Integrated Care Board
Support delayed-transfer initiatives through funded Section 117 care packages and escalation calls with providers and social-work teams.
View source
NHS Birmingham and Solihull Integrated Care Board
Provide additional investment to expand commissioned mental-health service capacity and provision.
View source
NHS Birmingham and Solihull Integrated Care Board
Continue supporting out-of-area NHS and independent hospital admissions when locally commissioned beds are unavailable and admission is necessary.
View source See 3 more actions
×
AI-generated summary
William Peter Edge · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Peter Edge was found hanging in the shed at his home in Birmingham on 18 August 2018, after an ambulance crew attempted resuscitation. He had depression, a history of self-harm, and had attempted to hang himself the previous day before being assessed and discharged with a referral to the home treatment team. Concerns included the home treatment team being unable to return when his wife reported that he was in imminent danger, and wider pressures on inpatient beds and home treatment services, including a stated risk to life when patients cannot be attended as required.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of inpatient mental health beds
Wider context from the report “3. The Coroner is aware, although not from evidence obtained in respect of Mr. Edge’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available . Consequently patients who would otherwise have been offered in-patient treatment are having to be managed by the HTTs , partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day which in turn is putting pressure on out of hours services. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
4. The fact that at the current time HTTs cannot attend patients when required creates a risk to life.
” Source location William Peter Edge · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate learning-from-deaths and demand-and-capacity improvement plans into contracts as service-delivery improvement plans.
Verbatim wording from the response “8.1.12 Ensuring action plans relating to learning from deaths and improvement plans for managing demand and capacity are incorporated into contracts as service delivery improvement plans.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
Verbatim wording from the response “5.4.1 An independent system simulation modelling exercise, which was jointly commissioned with FTB and BSMHFT, to develop an informed response on the best solutions to address the demand and where investment should be prioritised. This followed a sharp increase in demand for inpatient beds in 2016.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission an independent review of inpatient journeys to identify alternatives to admission and reduce avoidable discharge delays.
Verbatim wording from the response “5.4.2 An independent review of patients’ journeys into and out of inpatient mental health beds was commissioned by the STP. The review considered whether alternatives to admission could have been used and whether patients stayed in hospital longer than necessary. The review found that in both cases, improvements could be made to help avoid unnecessary admissions and reduce the time taken to discharge patients.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support delayed-transfer initiatives through funded Section 117 care packages and escalation calls with providers and social-work teams.
Verbatim wording from the response “5.4.3 Supporting operational initiatives to reduce delayed transfers of care, where CCG funding of individual packages of care under Section 117 (jointly funded packages of health and social care) are required to facilitate discharge from hospital.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional investment to expand commissioned mental-health service capacity and provision.
Verbatim wording from the response “5.4.8 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting out-of-area NHS and independent hospital admissions when locally commissioned beds are unavailable and admission is necessary.
Verbatim wording from the response “5.4.5 Continuing to support the use of admissions to other NHS mental health trusts within the MERIT Vanguard³ and to independent hospitals, where no locally commissioned beds are available, and an admission is deemed necessary.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Funding is not the sole cause of the identified failures, and the link between funding and the deaths cannot currently be validated.
Verbatim wording from the response “5. Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase). In 2018/19 the CCG provided additional investment in BSMHFT amounting to £3,117,000 (2.4% increase) and FTB amounting to £2,881,000 (9.3% increase). Further funding discussions are ongoing but at present the CCG is unable to validate a link between funding and the deaths presented. However, the CCG continuously monitors this position and demand in order to ensure it is responsive to any increase in demand where funding would be either the sole, or contributory solution.” Source location NHS-England-Response.pdf
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Clinical Commissioning Group will lead the shared demand analysis needed to assess demand, capacity and funding constraints.
Verbatim wording from the response “Funding alone is not the issue but there is agreement that in order to answer the question of the likely attribution of funding constraint on risk within services, all stakeholders need to be party to a shared demand analysis (with an extended invitation to partners from health and Justice, local authority and schools) and a ‘Suicide prevention strategy’. The Demand analysis will be led by the CCG and the Suicide prevention strategy will be led by the Director of Public Health.” Source location NHS-England-Response.pdf
Open published response
4 Oct 2018 Michael William Cooper · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Lack of available inpatient mental health beds View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS Birmingham and Solihull Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS Birmingham and Solihull Integrated Care Board
Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
View source
NHS Birmingham and Solihull Integrated Care Board
Commission an independent review of inpatient journeys to identify alternatives to admission and reduce avoidable discharge delays.
View source
NHS Birmingham and Solihull Integrated Care Board
Support delayed-transfer initiatives through funded Section 117 care packages and escalation calls with providers and social-work teams.
View source
NHS Birmingham and Solihull Integrated Care Board
Provide additional investment to expand commissioned mental-health service capacity and provision.
View source
NHS Birmingham and Solihull Integrated Care Board
Continue supporting out-of-area NHS and independent hospital admissions when locally commissioned beds are unavailable and admission is necessary.
View source See 2 more actions
×
AI-generated summary
Michael William Cooper · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael William Cooper was found dead at home on 22 June 2018 from constriction by a ligature around the neck. The report describes concerns about the lack of face-to-face follow-up and immediate action despite indications of high suicide risk, as well as shortages of inpatient beds, team capacity and funding in mental health services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of available inpatient mental health beds
Wider context from the report “1. The Home Treatment Team advised on the 13th March 2018 that Mr. Cooper should be admitted for inpatient mental health treatment. However, this could not happen on the day as there was no bed available . The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives. In the absence of an inpatient bed, Mr. Cooper was managed with medication and home treatment team visiting twice a day. Whilst awaiting admission, he was offered an out-of-area bed on the 16th March 2018 but he declined this as he felt it would be detrimental to him to be so far from his wife and family. The Coroner is aware, although this was not an issue that came out in evidence in this case, that placing patients in out of area beds not only causes difficulty for maintaining the patient's support and visits from family and friends which can be prejudicial to their mental health, but also affects their continuity of care thus creating a risk to life.
” Source location Michael William Cooper · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
Verbatim wording from the response “5.4.1 An independent system simulation modelling exercise, which was jointly commissioned with FTB and BSMHFT, to develop an informed response on the best solutions to address the demand and where investment should be prioritised. This followed a sharp increase in demand for inpatient beds in 2016.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission an independent review of inpatient journeys to identify alternatives to admission and reduce avoidable discharge delays.
Verbatim wording from the response “5.4.2 An independent review of patients’ journeys into and out of inpatient mental health beds was commissioned by the STP. The review considered whether alternatives to admission could have been used and whether patients stayed in hospital longer than necessary. The review found that in both cases, improvements could be made to help avoid unnecessary admissions and reduce the time taken to discharge patients.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support delayed-transfer initiatives through funded Section 117 care packages and escalation calls with providers and social-work teams.
Verbatim wording from the response “5.4.3 Supporting operational initiatives to reduce delayed transfers of care, where CCG funding of individual packages of care under Section 117 (jointly funded packages of health and social care) are required to facilitate discharge from hospital.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional investment to expand commissioned mental-health service capacity and provision.
Verbatim wording from the response “5.4.8 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting out-of-area NHS and independent hospital admissions when locally commissioned beds are unavailable and admission is necessary.
Verbatim wording from the response “5.4.5 Continuing to support the use of admissions to other NHS mental health trusts within the MERIT Vanguard³ and to independent hospitals, where no locally commissioned beds are available, and an admission is deemed necessary.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
19 Jan 2018 William Myers · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Insufficient availability of inpatient psychiatric beds for complex individuals View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
William Myers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient availability of inpatient psychiatric beds for complex individuals
Wider context from the report “Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist. There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised.
” Source location William Myers · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate cross-service bed-management systems and meetings covering capacity, transfers, discharge planning, incidents and shared learning.
Verbatim wording from the response “• To monitor the use of Adult, Older Adult and PICU inpatient beds and ensure that there are robust bed management systems and process in place across Greater Manchester Mental Health Inpatient services. That there are clear policies and procedures, including bed management meetings to monitor inpatient progress, discharge planning and transfers of care when clinically appropriate.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce out-of-area placements and create local inpatient capacity to limit transfers and preserve continuity.
Verbatim wording from the response “• To reduce the use of Out of Area Placements and create capacity within the Trust Inpatient Services, to enable service users requiring inpatient care to be admitted as close to home as possible. Consistent with their needs, recovery focused and reduce the possibility of service users being transferred between units and teams unless it clinically indicated or in an emergency. We are aware that Out of Area Placements have a significant impact on continuity of care and the reduction of Out of Area Placements is a key work stream for the trust.” Source location 2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.