Recipient

Birmingham and Solihull Integrated Care System

First report 8 Nov 2023•Latest report 22 Oct 2025

Recipient record

Reports, concerns and published responses

Health and care · Health-system partnership. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 3
Published responses: 100%
Concerns addressed: 3
Stated actions: 15

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

15stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

22 Oct2025
Birmingham and Solihull
Concerns raised4
1. Unprotected fire escapes providing easy access to roofs in rehabilitation settings
2. Lack of environmental risk assessment of fire escape and roof accessibility
3. Lack of guidelines specifying required fire escape protections in rehabilitation settings
1. Reliance on individual patient risk assessments instead of environmental access controls
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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
16 May2025
Birmingham and Solihull
Concerns raised1
1. Insufficient haematology department staffing and capacity for comprehensive reviews
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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
8 Nov2023
Birmingham and Solihull
Concerns raised3
1. Lack of GP awareness that referrals to secondary services may not be considered by secondary services
2. Failure to inform referring GPs when referrals to secondary services are rejected
3. Failure of secondary services to consider referrals requesting their review and assessment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

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

Reports, concerns and published responses

Reports over time

Concerns raised4

Unprotected fire escapes providing easy access to roofs in rehabilitation settings

Lack of environmental risk assessment of fire escape and roof accessibility

Lack of guidelines specifying required fire escape protections in rehabilitation settings

Reliance on individual patient risk assessments instead of environmental access controls

Concerns raised1

Insufficient haematology department staffing and capacity for comprehensive reviews

Concerns raised3

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

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

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