Birmingham and Solihull Integrated Care System

Health and care · Health-system partnership

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First report 8 Nov 2023•Latest report 22 Oct 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
3

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
15

Described in responses

Concerns and recipient responses

Statements from Birmingham and Solihull Integrated Care System linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Ricky James MONAHAN · 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

    Ricky James MONAHAN, a resident of a rehabilitation unit detained under section 37 of the Mental Health Act, died after falling from a height on 18 March 2025. The report identified an unprotected fire escape accessible from the garden and roof, no environmental risk assessment of this access, reliance on individual risk assessments, and a lack of guidelines for protecting fire escapes in rehabilitation settings.

    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. The report was sent to Birmingham and Solihull Integrated Care System; that does not assign responsibility.

    PFD Monitor interpretation

    Unprotected fire escapes providing easy access to roofs in rehabilitation settings

    Wider context from the report

    “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden. 2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham and Solihull Integrated Care System; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of environmental risk assessment of fire escape and roof accessibility

    Wider context from the report

    “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden. 2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham and Solihull Integrated Care System; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of guidelines specifying required fire escape protections in rehabilitation settings

    Wider context from the report

    “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden. 2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham and Solihull Integrated Care System; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on individual patient risk assessments instead of environmental access controls

    Wider context from the report

    “1. Mr Monahan was in a 10 bedded rehabilitation unit and was detained under S37 of the Mental Health Act. There was an unprotected fire escape at the rear of the building which could be easily accessed from the garden which in turn gave easy access to the roof. No environmental risk assessment had been completed regarding how accessible the fire escape was and how it easily provided access to the roof due to inadequate railings at the top of the staircase. The trust relied on individual risk assessments when considering what controls were required for individual patients when accessing the garden. 2. The inquest heard how there are no current guidelines setting out what protections are required for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths and in my view, action should be taken. ”
    Open source report

  2. Birmingham and Solihull

    AI-generated summary

    Tina Louise DOIG · 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

    Tina Louise Doig had myelodysplasia that progressed to acute myeloid leukaemia and underwent two stem cell transplants after the first failed. She developed sepsis, multiple organ failure and cardiac arrests, and died after becoming critically unwell. The report identified concern that an understaffed haematology department was working beyond capacity, and described failures in donor-recipient testing before the first transplant.

    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. The report was sent to Birmingham and Solihull Integrated Care System; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient haematology department staffing and capacity for comprehensive reviews

    Wider context from the report

    “1. The inquest heard evidence that the haematology department at the time of Mrs Doig’s stem cell transplant was understaffed and working beyond its capacity quite often leaving the team with very little time for comprehensive reviews. ████████ consultant haematologist at University Hospitals Birmingham NHS Foundation Trust confirmed at the inquest that the position remained the same today. This raises a concern that further deaths will occur and action is required. ”
    Open source report

  3. Birmingham and Solihull

    AI-generated summary

    Leva Amra ADRIS · 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

    Leva Amra Adris was pronounced deceased on 18 March 2023 after suffering a fitting episode, and post-mortem testing identified toxicity following an overdose of medication used for anxiety. The report raised concerns that a GP referral requesting secondary mental health assessment was not considered by secondary services, that the GP was not informed it had been rejected, and that the significance of worsening mental health symptoms may have been underestimated.

    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. The report was sent to Birmingham and Solihull Integrated Care System; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of GP awareness that referrals to secondary services may not be considered by secondary services

    Wider context from the report

    “6. I am equally concerned that not all GPs are aware that their referral to secondary services will not necessarily be considered by secondary services and that the GP making the referral was not informed that it had, in effect, been rejected. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham and Solihull Integrated Care System; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to inform referring GPs when referrals to secondary services are rejected

    Wider context from the report

    “6. I am equally concerned that not all GPs are aware that their referral to secondary services will not necessarily be considered by secondary services and that the GP making the referral was not informed that it had, in effect, been rejected. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham and Solihull Integrated Care System; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of secondary services to consider referrals requesting their review and assessment

    Wider context from the report

    “5. When a GP has referred a patient for review and assessment by secondary services I am concerned that it is not safe that there is no consideration of that referral by secondary services and the GP’s opinion that secondary services need to be involved is unilaterally over-ruled. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026