7 Jun 2022 Mena Tekloe Marim Teferi · Prevention of Future Deaths report West London
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Concerns raised 1
Insufficient capacity and resources to meet mental health service demand View source
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
Mena Tekloe Marim Teferi · 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
Mena Tekloe Marim Teferi died by suicide at home on 10 October 2021, after being referred to a mental health service but not seen or contacted before her death. The service was described as critically under-resourced, with demand substantially exceeding capacity and resulting in failures to meet service obligations.
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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 capacity and resources to meet mental health service demand
Wider context from the report “The mental health services went through a transformation process during the Covid pandemic. It became apparent that the anticipated level of direct referrals to the service from primary care was many times in excess of those predicted. The expectation was 6 per day, at the peak this rose to 30 and has currently reduced to 13-14 daily, so remains over 100% above the anticipated level.
The inquest was advised that the service was failing to meet the service demands due to insufficient capacity . The decision was made to enter this onto the Trust’s risk register, and this remains the situation. The critical features remain a high demand for services and a lack of resources .
This court has been told on many occasions that there is an intention for “parity” of mental health services with physical health services, but this is not apparent and the service is unable to meet its obligations now or going forward . This is greater than a “long waiting list” issue and is not a situation that can be explained exclusively by the covid pandemic. A more significant risk to individuals requiring mental health services has now arisen than existed before the transformation programme; it creates a real concern that lives will be lost as a consequence, and no solution was offered to the court during the inquest. The service is set up to deal with less than half of the referrals that it receives, leading to inevitable failings that currently cannot be rectified .
” Source location Mena Tekloe Marim Teferi · Prevention of Future Deaths report
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23 Mar 2022 Laura Jane Medcalf · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of sufficient mental health staffing to keep wards staffed and fully operational View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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
Department of Health and Social Care
Expand and diversify mental-health workforce roles, meeting the target for 19,000 new staff.
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Department of Health and Social Care
Invest in growing the mental-health workforce toward NHS Mental Health Implementation Plan commitments.
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Department of Health and Social Care
Publish and fund the Mental Health Recovery Action Plan to expand services, reduce waiting times and strengthen the NHS workforce.
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Department of Health and Social Care
Commission NHS England to develop a long-term NHS workforce plan addressing staffing requirements, supply gaps and retention.
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Laura Jane Medcalf · 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
Laura Jane Medcalf died on 17 February 2021 after being found unresponsive in her mental health ward bed, following a period of repeated self-harm incidents and signs of deteriorating mental health. The investigation concluded that her death was suicide, contributed to by failures to recognise her deteriorating mental health and increased risk, and to take effective steps to reduce that risk. Concerns also included shortages of mental health beds and staffing challenges affecting services.
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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 sufficient mental health staffing to keep wards staffed and fully operational
Wider context from the report “2. The inquest heard that during the period of time that Laura Medcalf was an in-patient on a mental health ward there were significant staffing challenges . Those challenges were part of a national picture of availability of mental health staff . Against this background and in order to keep the ward staffed and fully operational the trust had to move staff from other mental health services; use agency/bank staff and use leadership and management staff to backfill for nursing staff .
” Source location Laura Jane Medcalf · 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 Expand and diversify mental-health workforce roles, meeting the target for 19,000 new staff.
Verbatim wording from the response “The Department is also fully committed to attracting, training, and recruiting the mental health workforce of the future. Through our plans set out in Implementing the Five Year Forward View for Mental Health¹ and Stepping Forward to 2020/2021: The mental health workforce plan for England², the Department have expanded and diversified the types of roles that are available.” Source location Response from Department of Health and Social Care
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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 Invest in growing the mental-health workforce toward NHS Mental Health Implementation Plan commitments.
Verbatim wording from the response “In addition to the level of growth set out in “Stepping Forward”, the NHS Mental Health Implementation Plan 2019/20–2023/24³ sets out the need for the mental health workforce to grow by over 27,000 during this time frame to support the expansion and transformation of NHS mental health services and give an extra two million people the mental health support they need. The Department invested £111 million in 2021/22 to grow the mental health workforce towards delivering these ambitious commitments. You may also wish to note that Health Education England and NHS England have been working with integrated care systems (ICSs) to confirm plans to 2024. This will aim to ensure a system-wide effort to meet the Mental Health Implementation Plan ambition, looking across service models, supply, retention, and recruitment.” Source location Response from Department of Health and Social Care
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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 Publish and fund the Mental Health Recovery Action Plan to expand services, reduce waiting times and strengthen the NHS workforce.
Verbatim wording from the response “You also raise the matter of Covid-19 measures, including lockdown. The Covid-19 pandemic required the Government to put a number of unprecedented measures in place, including shielding, social distancing and local and national lockdowns. We know that the pandemic and these measures have had, and will continue to have, an impact on the mental health and wellbeing of many people. That is why we published our Mental Health Recovery Action Plan⁴ in March 2021, backed by an additional £500 million for 2021/22, to accelerate our expansion plans in order to address waiting times for mental health services, give more people the mental health support they need, and invest in the NHS workforce.” Source location Response from Department of Health and Social Care
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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 NHS England to develop a long-term NHS workforce plan addressing staffing requirements, supply gaps and retention.
Verbatim wording from the response “Finally, for the workforce as a whole, we have commissioned NHS England to develop a high-level long-term workforce plan. The plan will look at the mix and number of staff required across all parts of the country for the whole NHS workforce and will set out the actions and reforms that will be needed to reduce supply gaps and improve retention. NHS England are engaging with a broad range of stakeholders in developing this plan and it is due to be completed by the end of 2022.” Source location Response from Department of Health and Social Care
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19 Nov 2020 PAUL HILLS · Prevention of Future Deaths report North East Kent
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Concerns raised 1
Insufficient local availability of mental health treatment View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
PAUL HILLS · 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
Paul Hills was found deceased at home in his garage on 24 April 2020 after suspending himself from a rafter. He had a history of post-traumatic stress disorder, reported episodes and dry runs of self-harm, and was receiving treatment. Concerns included inadequate risk assessment and care-plan updates, failure to document or share escalating risk information, insufficient planning for remote treatment during the COVID-19 pandemic, and limitations affecting local treatment and communication.
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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 availability of mental health treatment
Wider context from the report “6. Evidence was heard during the inquest that RAF Manston was being decommissioned and this impacted on the treatment available locally for Sgt Hills and impacted on communications with the DCMH and the sharing of relevant information.
” Source location PAUL HILLS · Prevention of Future Deaths report
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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 site's planned decommissioning had no impact on patient care, communications or referral information because key staff remained in place.
Verbatim wording from the response “I note your concern, but I hope I can rectify any misunderstanding created at the Inquest about the planned closure of RAF Manston. Department of Community Mental Health clinicians were aware that the Defence Fire Training Development Centre Manston¹ was being decommissioned. Some confusion may have arisen about the gap between the MOD-wide announcement of the planned closure of the site and the planned decommissioning date itself. The decommissioning of the Centre did not begin until November 2020. Before and during April 2020 the Centre was still carrying out its assigned training tasks and all key staff remained in place. There was no impact on any patient care as a result of the planned decommissioning of the Manston base.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
Open published response
Concerns raised 2
Failure to guarantee funding to properly resource CAMHS View source Lack of available urgent mental health services for 16- and 17-year-olds 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
NHS South Yorkshire Integrated Care Board Sheffield Children'S NHS Foundation Trust Sheffield Health Partnership University NHS Foundation Trust
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 South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
Complete and approve the business case for the CAMHS Home Intensive Treatment Team.
View source
NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
Recruit nursing staff for the new CAMHS Home Intensive Treatment Team.
View source
NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
Reconfigure the existing Sheffield Treatment and Recovery Service into a CAMHS Home Intensive Treatment Team for young people up to age 18.
View source
NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
Establish a Mental Health Liaison Team supporting 0–18-year-olds attending designated emergency departments, with out-of-hours cover.
View source
NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation Trust
Implement the temporary care pathway change agreed with Sheffield Health and Social Care NHS Foundation Trust.
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Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation Trust
Implement jointly approved policy arrangements providing out-of-hours emergency home treatment to eligible 16- and 17-year-olds requiring crisis intervention.
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Aryan Akhgar · 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
Aryan Akhgar, aged 17, died on 6 March 2018 after hanging himself with the intent to take his own life. The report identified a gap in urgent mental health services for 16- and 17-year-olds in Sheffield: although an urgent response was recommended on 9 January 2018, the first visit by mental health professionals did not occur until 15 January 2018. The report also raised concern that funding for additional CAMHS resources was not guaranteed.
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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 Failure to guarantee funding to properly resource CAMHS
Wider context from the report “5.1 A gap in services was identified for 16 and 17 years old’s with urgent mental health issues, such as Aryan had. On 9th January 2018, Aryan was assessed as requiring urgent mental health input, commencing the next day. This was not available as a service for under 18’s in Sheffield and Aryan did not receive any contact from Child and Adolescent Mental Health Services (CAMHS) until 15th January 2018. In evidence I was told that additional resources in the CAMHS service were close to agreement in order to prevent this kind of problem arising in the future. However, this would be subject to a commissioning process from the Clinical Commissioning Group for Sheffield which could not be guaranteed.
5.2 It was accepted in evidence by the Medical Director of the Sheffield Children’s Hospital on behalf of CAMHS that such additional resource was required. The delivery of the necessary funding to properly resource the CAMHS team was not guaranteed .
” Source location Aryan Akhgar · 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 Lack of available urgent mental health services for 16- and 17-year-olds
Wider context from the report “5.1 A gap in services was identified for 16 and 17 years old’s with urgent mental health issues , such as Aryan had. On 9th January 2018, Aryan was assessed as requiring urgent mental health input, commencing the next day. This was not available as a service for under 18’s in Sheffield and Aryan did not receive any contact from Child and Adolescent Mental Health Services (CAMHS) until 15th January 2018. In evidence I was told that additional resources in the CAMHS service were close to agreement in order to prevent this kind of problem arising in the future. However, this would be subject to a commissioning process from the Clinical Commissioning Group for Sheffield which could not be guaranteed.
5.2 It was accepted in evidence by the Medical Director of the Sheffield Children’s Hospital on behalf of CAMHS that such additional resource was required. The delivery of the necessary funding to properly resource the CAMHS team was not guaranteed.
” Source location Aryan Akhgar · 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 Complete and approve the business case for the CAMHS Home Intensive Treatment Team.
Verbatim wording from the response “At the time of writing, the business case for the HITT team has been completed and was approved by the CCG on 7th May 2019, with a plan to begin a phased implementation from the autumn 2019. The service will be evaluated to ensure that it meets the needs of the young people who are its service users.” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-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 Recruit nursing staff for the new CAMHS Home Intensive Treatment Team.
Verbatim wording from the response “The CCG and the Trust recognise that there is urgency to the situation and are working closely to ensure that there is no delay to its implementation noting also the temporary change in pathway agreed between Sheffield Children’s NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has already begun to recruit nursing staff to the new service in anticipation of its formal commissioning.” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-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 Reconfigure the existing Sheffield Treatment and Recovery Service into a CAMHS Home Intensive Treatment Team for young people up to age 18.
Verbatim wording from the response “Sheffield Children’s NHS Foundation Trust and NHS Sheffield Clinical Commissioning Group have been working collaboratively to develop a robust long term solution to the issues you have highlighted. The two organisations have considered the potential models and have agreed the most appropriate way forward to be through the reconfiguration of the existing Sheffield Treatment and Recovery (STAR) Service into a CAMHS Home Intensive Treatment Team (HITT).” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-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 Establish a Mental Health Liaison Team supporting 0–18-year-olds attending designated emergency departments, with out-of-hours cover.
Verbatim wording from the response “This new team will be responsible for children and young people up to the age of 18 years and will be aligned with, and where appropriate, undertake, joint working with the Home Intensive Treatment Services provided by Sheffield Health and Social Care NHS Foundation Trust. In addition the Mental Health Liaison Team will support 0-18 year olds attending either Sheffield Children’s or the Northern General Hospital’s Emergency Departments. Access to the HITT will be within 24 hours when required whilst the Liaison Team will operate to meet the demands through the Emergency Departments with an on call rota in place for out of hours.” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-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 Implement the temporary care pathway change agreed with Sheffield Health and Social Care NHS Foundation Trust.
Verbatim wording from the response “The CCG and the Trust recognise that there is urgency to the situation and are working closely to ensure that there is no delay to its implementation noting also the temporary change in pathway agreed between Sheffield Children’s NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has already begun to recruit nursing staff to the new service in anticipation of its formal commissioning.” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-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 Implement jointly approved policy arrangements providing out-of-hours emergency home treatment to eligible 16- and 17-year-olds requiring crisis intervention.
Verbatim wording from the response “1. An addendum to the Transitions Policy has been jointly approved by both Trusts that ensures that emergency home treatment will be provided to 16/17 year olds by Sheffield Health and Social Care’s adult services, should they require crisis intervention out of hours and where they are not known to Child and Adolescent Mental Health Services which mirrors that already present for those known to the Services. This was implemented with effect from January 2019.” Source location 2019-0115-Response-by-Sheffield-Childrens-NHS-Trust
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18 Dec 2018 Natalie Zara HUNTER · Prevention of Future Deaths report Isle of Wight
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Concerns raised 1
Insufficient out-of-hours mental health/Crisis staffing View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Isle of Wight NHS Trust
Fill staffing vacancies with bank and agency cover to provide a 24-hour site-based service.
View source
Isle of Wight NHS Trust
Evaluate the most effective approach to providing safe 24-hour cover.
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Isle of Wight NHS Trust
Prepare and secure approval for a business case developed with the CCG and local authority for a revised out-of-hours care model.
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AI-generated summary
Natalie Zara HUNTER · 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
Natalie Zara HUNTER, who had a history of mental health and alcohol-related problems and 18 previous serious suicide attempts, was found deceased in her apartment on 16 March 2018 after suspending herself by a ligature. The report raised concerns about delayed or missing discharge summaries from the Isle of Wight NHS Trust, affecting continuity of GP and mental health care, and about insufficient out-of-hours mental health and crisis staffing on the Isle of Wight.
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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 out-of-hours mental health/Crisis staffing
Wider context from the report “5. During the course of the live evidence I heard from ████████, Service Manager for Community Mental Health Services at the Isle of Wight NHS Trust, in connection with the lack of sufficient numbers of out-of-hours mental health or Crisis staff which are available across the Isle of Wight . His evidence (which has since been supplemented by up-to-date figures), was that the team currently comprises of 11.1 full-time equivalent Band 6 mental health staff members, but it really requires 15.74 full-time equivalent appropriately qualified staff members which would necessitate 4.64 full-time equivalent additional staff to be funded and recruited in order to be able to offer a full and effective service.
6. The evidence was that there are currently insufficient funds in order for a full complement of out-of-hours mental health/Crisis staff to be deployed which is affecting the way in which the Mental Health service operates and delivers care to those who need it out-of-hours.
7. Accordingly, I have concerns that those who are vulnerable with mental health issues and who need to be seen out-of-hours are currently not in receipt of an adequately staffed out-of-hours mental health provision .
” Source location Natalie Zara HUNTER · Prevention of Future Deaths 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 Fill staffing vacancies with bank and agency cover to provide a 24-hour site-based service.
Verbatim wording from the response “• All staffing vacancies have been filled with bank and agency cover to ensure there is a 24 hour site based service (not deployable).” Source location 2018-0392-Isle-of-Wight-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 Evaluate the most effective approach to providing safe 24-hour cover.
Verbatim wording from the response “• The service is constantly evaluating the most effective way to provide safe 24hr cover.” Source location 2018-0392-Isle-of-Wight-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 Prepare and secure approval for a business case developed with the CCG and local authority for a revised out-of-hours care model.
Verbatim wording from the response “• A Business case has been prepared in collaboration with the CCG and local authority, and has been signed off by the Mental Health Divisional Board and Quality Committee. This will change the model of care for the single point of access, the community mental health team and result in the creation of a new wellbeing service. The aim of the new model is to improve access, responsiveness and quality of 24/7 service provision.” Source location 2018-0392-Isle-of-Wight-NHS-Trust
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4 Oct 2018 Bradley Jordache Morgan · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2
Excessive staff caseloads in mental health services View source Chronic underfunding of mental health services 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. 4
NHS Birmingham and Solihull Integrated Care Board
Work with partners to address recruitment and retention challenges so services are appropriately resourced.
View source
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
Provide additional investment to expand commissioned mental-health service capacity and provision.
View source See 1 more action
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AI-generated summary
Bradley Jordache Morgan · 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
Bradley Jordache Morgan was declared dead on 13 May 2018 after falling from the eighth-floor balcony of his home; the medical cause of death was multiple blunt injuries. He had a history of mental illness and was considered at high risk of suicide and self-harm, but was not reviewed by the community mental health team after a missed appointment. Concerns included communication and follow-up failures, excessive staff caseloads, and underfunding of mental health services creating a risk to life.
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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 Excessive staff caseloads in mental health services
Wider context from the report “3. Despite the comprehensive action plan evidence was given by the Medical Director of the Birmingham Women’s and Children’s NHS Foundation Trust that she was concerned that even with the processes and training identified in the action plan similar circumstances could arise again due to the pressures placed on staff who carry caseloads well in excess of the national average as a result of demand on the service .
” Source location Bradley Jordache Morgan · 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 Chronic underfunding of mental health services
Wider context from the report “4. The evidence given was that chronic underfunding of mental health services is creating a risk to life .
5. The strain on the systems of Mental Health Services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” Source location Bradley Jordache Morgan · Prevention of Future Deaths 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 Work with partners to address recruitment and retention challenges so services are appropriately resourced.
Verbatim wording from the response “8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.” 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 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
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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 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 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
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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 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
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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 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
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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 There is currently no evidence that insufficient funding contributed to the deaths.
Verbatim wording from the response “7.8 It is noted from the Coroner’s letter and the Regulation 28 reports that under funding may be a contributing factor to these deaths. The CCG is still awaiting detailed investigation reports into all of the deaths. However, at this stage there is no evidence that a lack of funding contributed to the deaths of the individuals concerned. This has been confirmed by BSMHFT in their letter to the Coroner, dated 28 September 2018.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
4 Oct 2018 Michael Paul Wheeler · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Underfunding of mental health services View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
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 Underfunding of mental health services
Wider context from the report “4. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction may arise from underfunding of mental health services .
5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” Source location Michael Paul Wheeler · 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 Work with partners to address recruitment and retention challenges so services are appropriately resourced.
Verbatim wording from the response “8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.” 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 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 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
×
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 There is currently no evidence that insufficient funding contributed to the deaths.
Verbatim wording from the response “7.8 It is noted from the Coroner’s letter and the Regulation 28 reports that under funding may be a contributing factor to these deaths. The CCG is still awaiting detailed investigation reports into all of the deaths. However, at this stage there is no evidence that a lack of funding contributed to the deaths of the individuals concerned. This has been confirmed by BSMHFT in their letter to the Coroner, dated 28 September 2018.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
4 Oct 2018 Stephen Peter Jackson · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Under-funding of mental health services View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Stephen Peter Jackson · 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 Peter Jackson was found deceased at home on 11 August 2018 after sending his mother a text message saying “sorry”; drugs paraphernalia and a suicide note were present, and the provisional cause of death was a diamorphine overdose. The report raised concerns that he was not seen by mental health clinicians after his GP requested an urgent appointment, despite reported low mood and negative thoughts, and that delays and possible under-funding of mental health services posed a risk of future deaths.
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 Under-funding of mental health services
Wider context from the report “4. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction, future deaths may arise due to under-funding of mental health services .
5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
6. In addition to this report letters are enclosed from the Medical Directors of both Trusts setting out their concerns.
” Source location Stephen Peter Jackson · 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 Work with partners to address recruitment and retention challenges so services are appropriately resourced.
Verbatim wording from the response “8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.” 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 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 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
×
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 Director of Public Health will lead the suicide prevention strategy addressing system-wide suicide prevention responsibilities.
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
×
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 There is currently no evidence that insufficient funding contributed to the deaths.
Verbatim wording from the response “7.8 It is noted from the Coroner’s letter and the Regulation 28 reports that under funding may be a contributing factor to these deaths. The CCG is still awaiting detailed investigation reports into all of the deaths. However, at this stage there is no evidence that a lack of funding contributed to the deaths of the individuals concerned. This has been confirmed by BSMHFT in their letter to the Coroner, dated 28 September 2018.” 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
Underfunding of mental health services View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
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 Underfunding of mental health services
Wider context from the report “5. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction may arise from underfunding of mental health services .
6. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” 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 Work with partners to address recruitment and retention challenges so services are appropriately resourced.
Verbatim wording from the response “8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.” 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 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 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
×
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 There is currently no evidence that insufficient funding contributed to the deaths.
Verbatim wording from the response “7.8 It is noted from the Coroner’s letter and the Regulation 28 reports that under funding may be a contributing factor to these deaths. The CCG is still awaiting detailed investigation reports into all of the deaths. However, at this stage there is no evidence that a lack of funding contributed to the deaths of the individuals concerned. This has been confirmed by BSMHFT in their letter to the Coroner, dated 28 September 2018.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
4 Oct 2018 Michael William Cooper · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2
Under-funding of mental health services View source Insufficient funding to maintain staff and resources under service demand View source
This report raised 5 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. 4
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
Provide additional investment to expand commissioned mental-health service capacity and provision.
View source
NHS Birmingham and Solihull Integrated Care Board
Work with partners to address recruitment and retention challenges so services are appropriately resourced.
View source
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 See 1 more action
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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 Under-funding of mental health services
Wider context from the report “5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” Source location Michael William Cooper · 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 funding to maintain staff and resources under service demand
Wider context from the report “4. Despite a detailed root cause analysis investigation with a comprehensive action plan arising from Mr. Cooper’s case, without increased funding similar circumstances could arise again due to the pressures placed on staff and resources arising from demand for the service .
” 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 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 Work with partners to address recruitment and retention challenges so services are appropriately resourced.
Verbatim wording from the response “8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.” 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 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 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
×
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 There is currently no evidence that insufficient funding contributed to the deaths.
Verbatim wording from the response “7.8 It is noted from the Coroner’s letter and the Regulation 28 reports that under funding may be a contributing factor to these deaths. The CCG is still awaiting detailed investigation reports into all of the deaths. However, at this stage there is no evidence that a lack of funding contributed to the deaths of the individuals concerned. This has been confirmed by BSMHFT in their letter to the Coroner, dated 28 September 2018.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.