15 Apr 2026 Kiefer Kiam Bolangi Fraser-Phillips · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Lack of care plans addressing identified physical healthcare risks View source Failure to record therapeutic observations accurately and effectively View source
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Kiefer Kiam Bolangi Fraser-Phillips · Prevention of Future Deaths report
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Report summary
Kiefer Kiam Bolangi Fraser-Phillips, who had treatment-resistant paranoid schizophrenia and several physical health conditions including sleep apnoea, was found deceased in bed at a mental health unit on 18 September 2025. The post-mortem medical cause of death was recorded as sudden unexplained death in schizophrenia. Concerns included incomplete recording of therapeutic observations because of Wi-Fi problems and the absence of a care plan addressing physical health risks associated with his medication and sleep apnoea.
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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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of care plans addressing identified physical healthcare risks
Wider context from the report “2. Many patients with enduring mental health conditions on long term medication will have significant physical health conditions due to the side effects of the medication . These often include considerable weight gain, and in Mr Fraser-Phillips' case sleep apnoea and the associated risk of position asphyxia . There was no care plan in place to address these risks . Consideration needs to be given to ensuring patients with significant physical healthcare needs have adequate care plans in place to address any risks identified.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record therapeutic observations accurately and effectively
Wider context from the report “1. Staff had not been completing the comments section during therapeutic observations as the electronic device they used would drop Wi-Fi signal making it impossible to record the observations until they were back in the ward office . This creates a risk that observations are not being recorded accurately and effectively and creates a risk of future deaths.
” Open source 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 Strengthen ward-level Dialog+ audits, including checks that physical-health risks have documented action plans and follow-up, with feedback to clinical teams.
Verbatim wording from the response “Audit and Assurance Framework” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 ward desktops and laptops for observation recording and remind staff to document observations while Wi-Fi issues are addressed.
Verbatim wording from the response “2. Whilst a more permanent solution is finalised staff have access to desktops and laptops on the ward to input their observations. Staff have also been reminded of the importance of documenting their observations. Staff are being involved to ensure that the solution is sourced as a matter of urgency. I can assure you that the Trust will continue to review this matter until a satisfactory outcome is resolved.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and audit Inpatient MDT standards to support follow-up of actions identified in physical-health action plans.
Verbatim wording from the response “7. In response to the Coroner’s concerns, the Trust has strengthened its Audit and Assurance Framework for Dialog+ Care Planning at ward level. This framework includes:
- Routine ward-level audits of Dialog+ care plans
- Specific checks that relevant domains are being appropriately used, including the Physical Health domain
- Assurance that identified physical health risks are clearly reflected in the action plan, with proportionate and documented follow-up arrangements
- Feedback to clinical teams and incorporation of findings into local quality improvement activity” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Implement Dialog+ Care Planning across inpatient services to document physical-health risks, mitigation actions and review plans.
Verbatim wording from the response “Care Planning Improvements: Implementation of Dialog+ Care Planning” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Share learning from the case across inpatient teams on medication-related physical-health risks and documenting risks such as sleep apnoea, obesity and positional asphyxia.
Verbatim wording from the response “Learning and Prevention of Future Risk” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Conduct monthly audits of observation quality, address non-compliance, and report results to the Quality Assurance Group to identify and resolve systemic issues.
Verbatim wording from the response “During our investigations the Trust has also put into place actions to review the observations on the ward more closely, to ensure a high quality of observations. Monthly audits will now be taking place to review the quality of the observations. Actions will be taken where staff do not comply with policy and results of the audits will be taken to Quality Assurance Group for assurance, to ensure the Trust is providing the best care possible to our in-patients. This will also enable the Trust to monitor not just the quality of the observations but ensure if there are any systemic issues, these are raised and addressed immediately.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Survey ward Wi-Fi problems and explore and test clinically safe solutions for identified hotspots.
Verbatim wording from the response “1. A Survey has now been carried out on a number of the acute wards to understand the extent of the Wifi problems on the wards and ICT are exploring the best solution to resolve the issue where hot spots have been noted. Whilst this might seem like a straightforward problem to solve the ideal solution would be to move the receivers from above the ceilings but due to the nature of the clinical area that creates a ligature risk. Alternatives are currently being explored and the trust and will be tested to ensure efficacy for Wifi, as well as it being clinically safe to use with mitigations in place whilst this is completed.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Moving ward Wi-Fi receivers above ceilings is not currently feasible because it would create a ligature risk.
Verbatim wording from the response “1. A Survey has now been carried out on a number of the acute wards to understand the extent of the Wifi problems on the wards and ICT are exploring the best solution to resolve the issue where hot spots have been noted. Whilst this might seem like a straightforward problem to solve the ideal solution would be to move the receivers from above the ceilings but due to the nature of the clinical area that creates a ligature risk. Alternatives are currently being explored and the trust and will be tested to ensure efficacy for Wifi, as well as it being clinically safe to use with mitigations in place whilst this is completed.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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21 Nov 2025 Timothy Thomas Reading · Prevention of Future Deaths report Worcestershire
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Concerns raised 2 Lack of guidance defining the component elements and required depth of s.117 plans View source Absence of formal documented s.117 discharge plans agreed by all responsible care and treatment providers View source
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Timothy Thomas Reading · 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
Timothy Thomas Reading died on 9 January 2025. He had a history of mental illness and had been discharged from inpatient care into the community under a community treatment order. The report identified the absence of a formal documented section 117 support plan, slow and disjointed transition arrangements, and no handover between responsible clinicians; the inquest concluded that he died by suicide, with hanging recorded as the medical cause of death.
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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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance defining the component elements and required depth of s.117 plans
Wider context from the report “(2) I was informed by the Representative of BSMHFT that there is no national guidance from the NHS or other source that explains what a s.117 plan should address . If so, this represents a lacuna which gives rise to concern that mental health providers are unclear as to the component elements for a s.117 plan and the degree or depth of planning required for individual patients .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of formal documented s.117 discharge plans agreed by all responsible care and treatment providers
Wider context from the report “(1) The absence of a formal documented s.117 plan agreed by all those responsible for a patient’s care and treatment upon discharge into the Community from a lengthy inpatient stay creates a risk of disjointed, disorganized and inadequate support for vulnerable people suffering serious mental health conditions . This, in turn, may cause them to feel unsupported and helpless. BSMHFT did not provide a Plan despite requests to do so. S.117 is intended to ensure that patients receive planned and structured support tailored to their requirements. Such planning was absent in this case.
” Open source 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 Use a standardized Rio form covering all relevant s.117 meeting areas and remind acute-care staff to complete it.
Verbatim wording from the response “The Trust has now looked at the inpatient care and CMHT care around the s.117 plan on the back of your concerns. Section 117 of the Mental Health Act 1983 places a joint duty on the NHS Integrated Care Board and local authority to provide aftercare services for individuals detained under certain sections of the Act following discharge.” Source location Response from Birmingham and Solihull MH NHS Foundation Trust
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4 Mar 2025 Matthew John LYNCH · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 5 Failure of internal investigations to verify relevant witness information and clinical address records View source Insufficient interagency information sharing with landlords View source Failure of internal investigations to examine medication monitoring View source Barriers to accurate Mental Health Act section assessments View source Insufficient support worker training on enduring mental health conditions View source See 2 more concerns
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Matthew John LYNCH · Prevention of Future Deaths report
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Report summary
Matthew John Lynch was attacked in the garden of his supported living accommodation in Birmingham on 11 July 2023 and was killed by decapitation. The concerns included whether medication non-compliance and a change of address had been adequately followed up, the quality of mental health assessments, and information sharing and training between mental health services, the council, housing providers and support workers.
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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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to verify relevant witness information and clinical address records
Wider context from the report “1. Internal investigation: The internal investigation did not address how and whether the offender’s use of medication should have been monitored after the clinic visit on 12/05/23. This was important as non compliance with medication was a risk factor for relapse. In addition, during the inquest the trust confirmed they had not spoken to the CPN who attempted to visit the offender on 24/05/23 to verify whether they had attended the old or new address . This was a critical issue as the new address had not been updated on the clinical notes . This raises a concern about the quality of the investigation and whether the Trust is adequately learning from incidents.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient interagency information sharing with landlords
Wider context from the report “3. Information sharing between agencies and support worker training: The inquest heard evidence that Landlords have to rely on the information given to them by the residents and do not have access to other key information held by other agencies . This means the landlord is often not aware of key information about an individual . Given the potential for harm for residents and support workers consideration needs to be given to how best to share information to ensure residents are receiving the right care and landlords have sufficient information to be able to monitor residents and undertake risk assessments . The inquest heard evidence that support workers need more focussed training on mental health conditions and how to manage and help residents with enduring mental health conditions.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to examine medication monitoring
Wider context from the report “1. Internal investigation: The internal investigation did not address how and whether the offender’s use of medication should have been monitored after the clinic visit on 12/05/23 . This was important as non compliance with medication was a risk factor for relapse. In addition, during the inquest the trust confirmed they had not spoken to the CPN who attempted to visit the offender on 24/05/23 to verify whether they had attended the old or new address. This was a critical issue as the new address had not been updated on the clinical notes. This raises a concern about the quality of the investigation and whether the Trust is adequately learning from incidents.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Barriers to accurate Mental Health Act section assessments
Wider context from the report “2. Mental Health assessments: The inquest heard evidence that there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing . This raises a concern that incorrect MHA assessments are taking place and patients may be detained on an inappropriate section impacting patient care. A copy of a report prepared by ████████ is attached.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient support worker training on enduring mental health conditions
Wider context from the report “3. Information sharing between agencies and support worker training: The inquest heard evidence that Landlords have to rely on the information given to them by the residents and do not have access to other key information held by other agencies. This means the landlord is often not aware of key information about an individual. Given the potential for harm for residents and support workers consideration needs to be given to how best to share information to ensure residents are receiving the right care and landlords have sufficient information to be able to monitor residents and undertake risk assessments. The inquest heard evidence that support workers need more focussed training on mental health conditions and how to manage and help residents with enduring mental health conditions .
” Open source 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 Implement an actions tracker to monitor agreed multidisciplinary team plans and follow-up.
Verbatim wording from the response “The review acknowledged the risk of relapse identified in May 2023 on page 14, identifying that whilst plans were made within the Multi-disciplinary Team, there was no clear process to track these actions, leading to a lack of oversight. If there had been stronger oversight, the team would have been aware of the non-compliance with medication sooner, allowing for timely intervention. This would have included tracking the perpetrator’s prescription. To address this, the team has now implemented an actions tracker to ensure better oversight of agreed plans and follow up.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Train doctors and approved mental health professionals and incorporate the agreed joint guidance into Trust procedures.
Verbatim wording from the response “The Trust offers specific training to all trust section 12 approved doctors as part of their approved clinical reapproval training/ section 12 reapproval. This training is mandatory as part of the reapproval process and has been in place for the last 5 years. The Royal College of Psychiatrists offers this training to our Doctors. All doctors from the Trust on the section 12 rota and who participate in mental health act assessments for the Integrated Care Board are assured as section 12 approved. Once the joint guidance has been agreed, this will be used to train both doctors and AMHPs and be incorporated into our procedures.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Develop, approve and embed joint guidance for doctors and approved mental health professionals on appropriate Mental Health Act sections.
Verbatim wording from the response “Following the inquest our Associate Medical Director for Mental Health Legislation has been working with Birmingham City Council on a short joint guidance for the doctors and AMHPS which will be included in the Trust’s Mental Health Act Assessment policy. This is now a priority for the organisations and the aim is for this to be completed by the end of June. This guidance will progress through the relevant governance processes to ensure it is properly embedded in both organisations. The aim is that this will assist in ensuring that patients who are currently being admitted and need detention under the Mental Health Act are under a section that is most appropriate for them, in line with the code of practice. Assurance on appropriate use of the Mental Health Act is gained through the Trust Mental Health Act Committee and reported to Trust Board.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Remind clinical staff to record address and contact-number changes on the service-user demographic record in Rio.
Verbatim wording from the response “We have also written to all clinical staff to remind them that if they are notified of a change of address (or contact number) that this is recorded on the service user demographic information in Rio, the electronic patient record, which updates the “front page” and not just in the “progress notes”.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Meet and Greet workers in community mental health team receptions to verify demographic, contact and accommodation information.
Verbatim wording from the response “The review also found the process for updating and tracking address changes was not robust enough. To strengthen this process as referenced in the report, the team has implemented a “meet and greet” role to improve the accuracy of address updates and ensure better coordination. I will go into more detail around this point under point three.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue strengthening joint procedures, information sharing and collaborative working with Birmingham City Council and supported housing providers.
Verbatim wording from the response “We recognise the benefits of working in partnership with Birmingham City Council and Supported Housing Providers and will continue to commit to strengthening our joint procedures, relevant information sharing and enabling our professionals to work collectively at every opportunity.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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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 Record community mental health medication supplies on EPMA and monitor compliance through monthly medication audits and governance reporting.
Verbatim wording from the response “In relation to the prescription, where the Community Mental Health Team is supplying a service user with their medication, this is recorded on the Electronic Prescribing and Medicines Administration System (EPMA). The Trust outlined at the inquest how this system now has better functionality and this” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train doctors and approved mental health professionals through improved mental health assessment training delivered with Birmingham City Council.
Verbatim wording from the response “At Inquest our witness gave evidence following the survey which had been carried out which identified that there were two areas where practice should be improved. These included:” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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19 Aug 2024 Juliette Kirsty SEWELL · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure to schedule a specific review or audit date View source Failure to complete outstanding actions View source
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Juliette Kirsty SEWELL · Prevention of Future Deaths report
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Report summary
Juliette Kirsty SEWELL was discovered unresponsive on 16 February 2024 after being missing since 14 February, surrounded by empty medication packets, and was confirmed deceased following a fatal overdose. She had a history of mental health illness and had been awaiting a delayed follow-up appointment with the mental health team. Concerns included outstanding reviews of records for people not seen in over 12 months, ongoing clinical caseload stratification, and the lack of a scheduled review date, with a stated risk of future deaths occurring.
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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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to schedule a specific review or audit date
Wider context from the report “1. Following Juliette's death, a Structured Judgement Review ("SJR") was carried out which identified steps that have been taken. However, the SJR confirmed that a review of Rio records was being undertaken of those who have not been seen in over 12 months with actions to be identified, and that clinical stratification of current caseload is ongoing. I understand that a review or audit of this process is being scheduled to take place at some point in October 2024 (date unknown).
2. Upon conclusion of the inquest, I am Functus Officio meaning that my powers cease and I will have no way of checking if the recommended actions have been completed. In the circumstances, where action to be taken is outstanding and when a specific review date has not been scheduled , I am concerned that there is a risk of future deaths occurring.
3. The deadline for a response under this Report should coincide with the Trust's planned review/audit in October, therefore I am hopeful that the Trust will be able to respond swiftly thereafter, and hopefully will be able to confirm that positive action has been taken and whether any further work is necessary.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete outstanding actions
Wider context from the report “1. Following Juliette's death, a Structured Judgement Review ("SJR") was carried out which identified steps that have been taken. However, the SJR confirmed that a review of Rio records was being undertaken of those who have not been seen in over 12 months with actions to be identified, and that clinical stratification of current caseload is ongoing. I understand that a review or audit of this process is being scheduled to take place at some point in October 2024 (date unknown).
2. Upon conclusion of the inquest, I am Functus Officio meaning that my powers cease and I will have no way of checking if the recommended actions have been completed. In the circumstances, where action to be taken is outstanding and when a specific review date has not been scheduled, I am concerned that there is a risk of future deaths occurring.
3. The deadline for a response under this Report should coincide with the Trust's planned review/audit in October, therefore I am hopeful that the Trust will be able to respond swiftly thereafter, and hopefully will be able to confirm that positive action has been taken and whether any further work is necessary.
” Open source 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 Review EPR records for service users without clinician contact for over 12 months as part of ongoing monitoring.
Verbatim wording from the response “In relation to the outstanding action you have highlighted. I can confirm that in order to provide you with assurances by the date of your PFD response, we have brought forward the necessary steps to ensure the completion of the action earlier than anticipated. I can confirm that there continues to be an ongoing review of our Electronic Patient Record (EPR) RiO records for service users who have not been seen by any clinician within the team for over 12 months as part of ongoing monitoring.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue caseload stratification and provide monthly progress and outcome updates to the Clinical Services Manager.
Verbatim wording from the response “As of September 2024, there are 553 service users who have not had contact with Lyndon CMHT in over a year, which is 21.14% of the total caseload. Of the 553 service users, 36.99% (204) have been offered at least one appointment in the last year by the team but did not attend (DNA). The caseload stratification work described at the inquest continues to develop, to date, 1028 desktop reviews have been completed. Of this number, 436 have since had contact with the CMHT and a further 110 have an appointment booked on the system. Lyndon CMHT books appointments up to five weeks ahead, so the remaining 482 service users will be booked in when new appointment slots become available. The 482 patients are existing patients of the CMHT, they have had appointments with the CMHT and have Care Support Plans in place.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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1 Aug 2024 Kieran Lavin · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 3 Insufficiently specific guidance for informal patient transport risk assessments View source Failure to record transport risk formulations View source Failure to record critical suicide risk information completely and promptly View source
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Kieran Lavin · 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
Kieran Lavin, who had experienced worsening depression and suicidal thoughts, died after leaving a mental health unit with his wife for transport to another facility. Shortly afterwards, on the M5 motorway, he exited the vehicle and was struck by vehicles. The principal concerns were that critical suicide-risk information was not recorded or recorded promptly, and that the transport risk assessment and guidance for family transport were inadequate.
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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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently specific guidance for informal patient transport risk assessments
Wider context from the report “2. Post-death trust learning led to new guidance for when an informal patient requests family, carer, or friend transport them from PDU. For ease of reference it states:
“Where appropriate, it is reasonable for the option of an informal patient to be transported by family/carer/friends. In all such cases, decision needs to be based on the risk/benefit ratio and this also needs to be clearly discussed with the person transporting to make sure there is understanding and agreement. This needs to be clearly documented within the patient’s notes. If there is any concern or disagreement expressed by the person, family/carer/friends, then alternative arrangements need to be made by us.”
I am not persuaded this is sufficient to remove the risk of an inadequate risk assessment in the future. By way of contrast, trust guidance C52 ‘Mental Health Act Transport of Patients’ - which applies when a patient has been assessed under the Act and ambulance service transport is to be used - at paragraph 12 includes 15 specific questions that the risk assessor should ask as part of the transport risk formulation, including: How far does the patient have to travel? What is the patients age and gender? What is their current state of mind? Is there a risk to the driver/accompanying individuals? The updated guidance cited above is absent any equivalent specific questions or assistance on when it is or is not appropriate. For example, in Kieran’s case clinicians were aware his sex, age, and background of relationship breakdown statistically recognised him as being at a higher risk of suicide, PDU is only intended for a brief stay whereas Kieran was there for nearly 48 hours and his state of mind was not assessed in the hours before the risk formulation (even thought it was known to fluctuate), the journey if considered would have been noted to take him away from local roads onto a high speed motorway, and his wife/the driver was known to be a trigger for his low mood. Further, there was no consideration of what his wife had to be told to ensure she was safe, providing genuine informed consent given the interplay of patient confidentiality. In Kieran’s case the transport risk formulation did not consider whether his risk of suicide included road traffic collision as an unrelated mechanism. My concern is the above cited guidance in simply stating the decision should be based on ‘appropriateness’ and ‘the risk/benefit ratio’ does not sufficiently prompt clinicians to consider the full range of key issues and is inconsistent with the more expansive guidance in C52 for when an ambulance is to be used.
For completeness, (1) there was discussion during the inquest about why there cannot be a blanket ban on informal patients with recent suicidal ideation via road traffic collision being transported by family etc given they represent a very small cohort of patients. If no such ban is considered appropriate, in my view, the need for more expansive and specific guidance for clinicians equivalent to C52 is increased, and (2) there was discussion at the inquest of a transport risk formulation based on a points system with a written draft suggestion from the Family’s counsel; I attach a copy which may be of assistance for the trust when deciding what if any action to take.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record transport risk formulations
Wider context from the report “1. Critical suicide risk information was not recorded at all or not recorded in a timely manner. On 10/12/23, the experienced nurse did not record at all in the 'suicide' box on the 'level 1 – risk screening' the first report of suicidal ideation via road traffic collision. She described this omission as an error and the likely explanation was that she was the only nurse working on a very busy shift. On 11/12/23, the experienced nurse did not in a timely manner record in the ‘suicide’ box on the ‘level 1 – risk screening’ the second report of suicidal ideation via road traffic collision received by 11am. She said the likely explanation for not updating the ‘suicide’ box until 8:51pm (and after the nurse-in-charge made his transport risk formulation) was that she was the only nurse working on a very busy shift. The experienced Nurse-in-Charge did not record at all the transport risk formulation saying that was not his usual practice. The Patient Safety Manager said long standing trust policy required clinicians to record key information as soon as possible. I am not persuaded this long standing policy is sufficient by itself to remove the risk in the future of critical suicide risk information not being recorded at all or in a timely manner given three experienced nurses within 24 hours failed to follow the policy.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record critical suicide risk information completely and promptly
Wider context from the report “1. Critical suicide risk information was not recorded at all or not recorded in a timely manner. On 10/12/23, the experienced nurse did not record at all in the 'suicide' box on the 'level 1 – risk screening' the first report of suicidal ideation via road traffic collision. She described this omission as an error and the likely explanation was that she was the only nurse working on a very busy shift. On 11/12/23, the experienced nurse did not in a timely manner record in the ‘suicide’ box on the ‘level 1 – risk screening’ the second report of suicidal ideation via road traffic collision received by 11am. She said the likely explanation for not updating the ‘suicide’ box until 8:51pm (and after the nurse-in-charge made his transport risk formulation) was that she was the only nurse working on a very busy shift. The experienced Nurse-in-Charge did not record at all the transport risk formulation saying that was not his usual practice. The Patient Safety Manager said long standing trust policy required clinicians to record key information as soon as possible. I am not persuaded this long standing policy is sufficient by itself to remove the risk in the future of critical suicide risk information not being recorded at all or in a timely manner given three experienced nurses within 24 hours failed to follow the policy.
” 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 Review and revise Psychiatric Decisions Unit handover standards to require urgent information to be documented and communicated before transport, discharge and other significant decisions.
Verbatim wording from the response “The quality and standards of the handover process in the PDU will be reviewed, with particular attention to ensuring that critical information is documented and communicated before key decisions, such as patient transport, are made. The handover process will also be revised to establish clear standards that require the documentation and communication of urgent information prior to any significant decisions, including patient discharge.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Transport Policy to require open, thorough discussions with family members, friends or carers before agreeing patient transport by them.
Verbatim wording from the response “As already conveyed to you, we have updated our Transport Policy to emphasise that an open and thorough discussion needs to be had with any family member/friend/carer prior to agreeing the transport of the patient by them. The option for patients to be transferred in this manner will remain, as that upholds the dignity and autonomy of the patient, and is in the spirit” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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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 Scoring the proposed transport-risk checklist cannot be undertaken because it would be arbitrary, unsupported by evidence, and could omit relevant risks.
Verbatim wording from the response “I would like to begin by thanking the family for their suggested checklist for this risk assessment. We are grateful for this offer. The factors identified in the checklist submitted by the family barrister includes risk factors that would and should be considered in a risk assessment and management conversation. However, it would not be possible to score these as this would be an arbitrary process, with no grounding in research or evidence based clinical practice. Given the areas of risk that need to be considered, having such a prescriptive list could potentially result in staff members omitting to review key areas of risk that may not be indicated on the list, thereby inadvertently replacing comprehensive clinical risk assessment and management processes, which would have serious negative impact on the quality and safety of patient assessment and management.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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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 Family-member transport will remain available where appropriate because retaining patient dignity, autonomy, choice and least restrictive practice is considered necessary.
Verbatim wording from the response “As already conveyed to you, we have updated our Transport Policy to emphasise that an open and thorough discussion needs to be had with any family member/friend/carer prior to agreeing the transport of the patient by them. The option for patients to be transferred in this manner will remain, as that upholds the dignity and autonomy of the patient, and is in the spirit” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
20 Jun 2024 Shelemiah Pedajah PETERKIN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure to establish and disseminate clear clinical standards for early warning signs View source Failure to complete early warning signs to the required standard View source Inadequate staffing levels in community mental health services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Shelemiah Pedajah PETERKIN · 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
Shelemiah Pedajah PETERKIN was reported missing on 2 October 2023 and was found deceased at home after police forced entry. The inquest concluded suicide following intentional poisoning. Concerns included staffing shortages and delays in mental-health referrals, as well as incomplete early-warning-sign documentation and delayed action to address clinical standards, creating risks of missed assessment, intervention and treatment opportunities.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish and disseminate clear clinical standards for early warning signs
Wider context from the report “Matter 2
1. I heard evidence from the Structured Judgment Review that a learning point was identified that early warning signs were not completed to the required expectation or standard.
2. As such, an Action Plan was prepared and a task was agreed that this would be discussed at the Trust Risk and Task Finishing Group to establish clear clinical standards, with the same then being disseminated within the Trust . This was allocated to the Clinical Service Manager for ICCR and was due to be completed by May 2024.
3. In evidence, it was confirmed that target had been missed due to a meeting being cancelled , but assurance was offered that it would take place in July - after the inquest has concluded.
4. I am concerned that if this target is pushed back and/or is not met , for whatever reason, there is a risk that future deaths will occur. Upon conclusion of the inquest, I am Functus Officio, with no power to request updates from the Trust to check and ensure that targets have been met and changes have been made. Whilst I am grateful for the efforts of reassurance provided by representatives of the Trust at the inquest, I am reluctant to dismiss my concerns, particularly where actions remain outstanding, and I have opportunity to take action now to ensure that the risk of future deaths is reduced.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete early warning signs to the required standard
Wider context from the report “Matter 2
1. I heard evidence from the Structured Judgment Review that a learning point was identified that early warning signs were not completed to the required expectation or standard .
2. As such, an Action Plan was prepared and a task was agreed that this would be discussed at the Trust Risk and Task Finishing Group to establish clear clinical standards, with the same then being disseminated within the Trust. This was allocated to the Clinical Service Manager for ICCR and was due to be completed by May 2024.
3. In evidence, it was confirmed that target had been missed due to a meeting being cancelled, but assurance was offered that it would take place in July - after the inquest has concluded.
4. I am concerned that if this target is pushed back and/or is not met, for whatever reason, there is a risk that future deaths will occur. Upon conclusion of the inquest, I am Functus Officio, with no power to request updates from the Trust to check and ensure that targets have been met and changes have been made. Whilst I am grateful for the efforts of reassurance provided by representatives of the Trust at the inquest, I am reluctant to dismiss my concerns, particularly where actions remain outstanding, and I have opportunity to take action now to ensure that the risk of future deaths is reduced.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing levels in community mental health services
Wider context from the report “Matter 1
1. I heard evidence that there was a 6-day delay in the Community Mental Health Team team making a referral to the Home Treatment Team which was put down "clinical pressures". Upon discussion, these "clinical pressures" related to staffing levels and the evidence was that at the time the team was meant to have 7 clinical members of staff but only had 3. I was told that matters have improved somewhat and that now there is sufficient staffing levels.
2. However, it was confirmed that gaps in staffing levels do occur which can have a knock-on effect of causing issues with service delivery and care for patients .
3. It is not difficult to foresee that inadequate staffing levels will give rise to missed opportunities for patients to be assessed; for interventions to take place; and for treatments to be given - particularly where patients may choose to disengage with services but who do not demonstrate any "red flags" or early warnings, as was the case with Shelley.
4. As such, I am concerned about the risk of future deaths occurring if staffing issues arise in the future .
” 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 Recruit staff into vacant and newly funded community mental health posts to increase team workforce capacity.
Verbatim wording from the response “Matter 1- Relating to staffing
Since this time, Lyndon CMHT has successfully recruited into all vacant posts. Additional investment into the team has also taken place as a result of Community Mental Health Transformation, this has increased the workforce capacity within the team, these roles have also been recruited into. With the additional funding and successful recruitment into all vacant posts, it is unlikely that the team will face inadequate levels of staffing in in the immediate future. If however this was to occur, there is a clear escalation process in place that would ensure a timely review of any gaps and would support the development of a clear plan to mitigate the identified risks.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate further Early Warning Signs support into DIALOG+ care-planning and safety-planning training for staff.
Verbatim wording from the response “Matter 2- Early Warning Signs
This was discussed at the Clinical Risk Processes Group on 13th June 2024, with a further meeting chaired by the Deputy Medical Director and Head of Patient Safety on 21st June 2024. It was agreed that Early Warning Signs is a core skill of those who have undertaken clinical training, and that further support for this will be incorporated into the DIALOG+ (care planning and safety planning) training for staff which is currently underway. Additionally, the current CPA Part B Care Plan and the new Dialog+ Safety Plan have been reviewed and there are information and descriptor sentences already built into these forms to indicate the expected standard for the description of an Early Warning Sign. There are processes in place for teams to review the completion and quality of Care Plans through audits and clinical supervision.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include information and descriptor sentences defining the expected Early Warning Sign standard in CPA Part B and DIALOG+ safety plans.
Verbatim wording from the response “Matter 2- Early Warning Signs
This was discussed at the Clinical Risk Processes Group on 13th June 2024, with a further meeting chaired by the Deputy Medical Director and Head of Patient Safety on 21st June 2024. It was agreed that Early Warning Signs is a core skill of those who have undertaken clinical training, and that further support for this will be incorporated into the DIALOG+ (care planning and safety planning) training for staff which is currently underway. Additionally, the current CPA Part B Care Plan and the new Dialog+ Safety Plan have been reviewed and there are information and descriptor sentences already built into these forms to indicate the expected standard for the description of an Early Warning Sign. There are processes in place for teams to review the completion and quality of Care Plans through audits and clinical supervision.” Source location Response from BSMHFT
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 Audit and supervise care-plan completion and quality across teams.
Verbatim wording from the response “Matter 2- Early Warning Signs
This was discussed at the Clinical Risk Processes Group on 13th June 2024, with a further meeting chaired by the Deputy Medical Director and Head of Patient Safety on 21st June 2024. It was agreed that Early Warning Signs is a core skill of those who have undertaken clinical training, and that further support for this will be incorporated into the DIALOG+ (care planning and safety planning) training for staff which is currently underway. Additionally, the current CPA Part B Care Plan and the new Dialog+ Safety Plan have been reviewed and there are information and descriptor sentences already built into these forms to indicate the expected standard for the description of an Early Warning Sign. There are processes in place for teams to review the completion and quality of Care Plans through audits and clinical supervision.” Source location Response from BSMHFT
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 Recruitment and an established escalation process are considered sufficient to address the risk of inadequate staffing in the immediate future.
Verbatim wording from the response “Matter 1- Relating to staffing
Since this time, Lyndon CMHT has successfully recruited into all vacant posts. Additional investment into the team has also taken place as a result of Community Mental Health Transformation, this has increased the workforce capacity within the team, these roles have also been recruited into. With the additional funding and successful recruitment into all vacant posts, it is unlikely that the team will face inadequate levels of staffing in in the immediate future. If however this was to occur, there is a clear escalation process in place that would ensure a timely review of any gaps and would support the development of a clear plan to mitigate the identified risks.” Source location Response from BSMHFT
Open published response
3 Jun 2024 Tcherno Bari · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 12 Failure to ensure police access to the written risk assessment View source Failure to provide attending police officers with the written risk rating View source Failure to maintain an accurate and up-to-date missing person policy View source Lack of police officer awareness of the required risk rating View source Failure to communicate the RCRP challenge process to BSMHFT View source Delays in communicating police disagreement with the reported risk category View source Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise View source Lack of formal notification of police disagreement about risk category View source Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients View source Failure to inform BSMHFT when missing patient investigations are closed View source Failure to invite police representatives to daily appraisal meetings View source Failure of routine monitoring to ensure completion of the risk rating View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tcherno Bari · 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
Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure police access to the written risk assessment
Wider context from the report “(7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment , or require attending constables, or later the Locate team, to request a copy of the risk assessment . In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide attending police officers with the written risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy . I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’ , and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an accurate and up-to-date missing person policy
Wider context from the report “(5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP . I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of police officer awareness of the required risk rating
Wider context from the report “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’ . Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’ .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the RCRP challenge process to BSMHFT
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT . Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it . However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process . Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in communicating police disagreement with the reported risk category
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later , and WMP often close missing patient investigations without informing BSMHFT.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise
Wider context from the report “(8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. RCRP and APP appear to regard reports from mental health clinicians no differently to those from members of the public, and family and friends of the missing person . Context: police witnesses agreed that BSMHFT clinicians were the experts on mental health diagnosis, including identifying those conditions that carry an increased risk of suicide, and assessing the risk of suicide generally. However, this case demonstrates how in the heat of the moment an (inexperienced) attending constable can overlook that expertise and quickly dismiss it .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal notification of police disagreement about risk category
Wider context from the report “(6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category . BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Clinical Service Managers to coordinate attempts to locate high-risk missing patients
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients , and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case, and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform BSMHFT when missing patient investigations are closed
Wider context from the report “(4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to invite police representatives to daily appraisal meetings
Wider context from the report “(3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case , and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’ .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of routine monitoring to ensure completion of the risk rating
Wider context from the report “(2) A ‘monitoring tool’ in the BSMHFT Missing Patient Policy requires routine monitoring to ensure nurses are completing ‘appendix A’ and ‘appendix B’, but not ‘appendix C – risk rating’ . Context: I was told this is under review, however I was concerned this is still outstanding 9 months following the death .
” 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 Assign accountability for the missing persons policy to the new Executive Director of Quality and Safety/Chief Nursing Officer.
Verbatim wording from the response “At the time of the inquest the Missing Persons Policy was being updated, in line with changes from Right Care Right Person (RCRP). Since this time the update has been completed and there have been a number of changes made. In addition the Trust have a new Executive Director of Quality and Safety/Chief Nursing officer who will be accountable for the policy. The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out ‘why is the risk is considered to be present’. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver missing-person training and provide flash cards reminding managers of coordination, police liaison and daily appraisal responsibilities.
Verbatim wording from the response “On 25 June 2024 there was a training session put together which was attended by Clinical Service Managers, Nurse Managers, Matrons, Ward Managers for the in-patient wards and the Home Treatment Team Managers. During the session this inquest was used as a training tool and staff were reminded of their professional responsibilities, particularly around the co-ordination with police and daily meetings. Flash cards were provided to ensure that CSM’s are reminded of what they should be doing when patients go missing.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require police to notify the Trust in writing of decisions and reasoning when not deploying immediately after critical concern is communicated.
Verbatim wording from the response “Under the updated policy the police will formally notify BSMHFT in writing, with their decision and reasoning if they have decided not to deploy immediately, when critical concern is communicated to them by a mental health nurse in regard to a inpatient who is missing. This would enable the escalation process to be taken forward by senior clinicians as set out in Appendix K, if necessary.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue updating and circulating the escalation process when contact details change.
Verbatim wording from the response “The updated policy sets out clearly the RCRP escalation process (challenge process) under Appendix K. This has been circulated to responsible clinicians and senior nurses within BSMHFT. As the escalation procedure contact details alter in the future, the process will continue to be updated and circulated to all senior clinicians in BSMHFT and will continue to be part of the missing persons policy.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the RCRP escalation process to responsible clinicians, senior nurses and clinical staff, including its incorporation in the updated policy.
Verbatim wording from the response “The updated policy sets out clearly the RCRP escalation process (challenge process) under Appendix K. This has been circulated to responsible clinicians and senior nurses within BSMHFT. As the escalation procedure contact details alter in the future, the process will continue to be updated and circulated to all senior clinicians in BSMHFT and will continue to be part of the missing persons policy.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and approve the missing persons policy to incorporate RCRP, national guidance, partnership requirements and inquest feedback.
Verbatim wording from the response “At the time of the inquest the Missing Persons Policy was being updated, in line with changes from Right Care Right Person (RCRP). Since this time the update has been completed and there have been a number of changes made. In addition the Trust have a new Executive Director of Quality and Safety/Chief Nursing officer who will be accountable for the policy. The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out ‘why is the risk is considered to be present’. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.” Source location Response from BSMHFT
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 Introduce quarterly and annual audits of Appendix C completion and present them to the clinical governance committee.
Verbatim wording from the response “The updated policy, which has now been approved by both the Trust and our colleagues in the West Midlands Police has an updated Audit and Monitoring tool which requires quarterly and annual audits to be presented to the clinical governance committee for assurance, lead by the Matron for each inpatient area. Whilst this previously did not include Appendix C, it has now been updated to include this.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace Appendix C with a decision-recording form documenting the reasons for critical concern and provide it to attending police officers.
Verbatim wording from the response “At the time of the inquest the Missing Persons Policy was being updated, in line with changes from Right Care Right Person (RCRP). Since this time the update has been completed and there have been a number of changes made. In addition the Trust have a new Executive Director of Quality and Safety/Chief Nursing officer who will be accountable for the policy. The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out ‘why is the risk is considered to be present’. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.” Source location Response from BSMHFT
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 West Midlands Police is responsible for responding to whether attending constables should consider mental health clinicians’ risk assessments.
Verbatim wording from the response “8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate to be extra vigilant before rejecting their opinion on risk category.” Source location Response from BSMHFT
Open published response
13 Mar 2024 Jacob Michael Nicholas BILLINGTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to record prisoners’ GP and CMHT details in an easily accessible format View source Failure to establish effective information sharing for prison discharge coordination View source Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties View source Unclear responsibilities and case remit for the prison discharge coordinator role View source Failure to coordinate interagency release management and share critical information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jacob Michael Nicholas BILLINGTON · 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
Jacob Michael Nicholas Billington was unlawfully killed when he was stabbed in the neck during a night out in Birmingham on 6 September 2020. The concerns included inadequate coordination and information-sharing between agencies during the release of a high-risk prisoner with serious mental health difficulties, and a lack of clear cross-agency guidance and understanding of responsibilities.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record prisoners’ GP and CMHT details in an easily accessible format
Wider context from the report “2. Sysmone Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Sysmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish effective information sharing for prison discharge coordination
Wider context from the report “4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of cross-agency provisions and guidance for release planning of high-risk prisoners with mental health difficulties
Wider context from the report “3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibilities and case remit for the prison discharge coordinator role
Wider context from the report “4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate interagency release management and share critical information
Wider context from the report “1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include the resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning any are not traced and treated assertively in the community.
” 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 Include the BSMHFT MAPPA Clinical Lead in developing a sustainable MAPPA engagement strategy and identifying alternative arrangements for gaps.
Verbatim wording from the response “The Deputy Medical Director chaired an initial scoping meeting in response to these issues identified by the PFD on 10th April 2024, culminating in agreement on 3 primary areas of focus:” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an improved referral and discharge procedure through the updated standard operating protocol.
Verbatim wording from the response “In the meantime we can offer you assurances that since the events that culminated in Mr Billington’s death the Trust has improved the structure and supervision surrounding the prison discharge coordinator roles, such that the practitioners have weekly supervision with opportunity to escalate cases of concern, and an improved system of referrals and discharge procedures, reflected in the updated standard operating protocol. This means that in the event of a similar situation occurring again, there would be sufficient structure to ensure and support the flexibility in service provision to prevent such an individual falling between services, even where they had been discharged from active multiagency management by MAPPA.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Prison Discharge Coordinator job description, role scope and potential additional resource requirements.
Verbatim wording from the response “2. Role of the Prison Discharge Coordinator. The Standard Operating Procedure has been revised. In addition to this there is an intention to review the Job Description of this role and understand in more depth the scope of what this role can achieve currently or will need to achieve in the future including any potential additional resource requirements. This review is aimed at aligning the role’s” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Prison In-reach and CMHT interaction process, complete a gap analysis and develop a plan to strengthen continuity of care.
Verbatim wording from the response “3. Interface between Prison In-reach and the CMHT- A comprehensive review of the current interaction process between the Prison In-reach team and the CMHT is planned. This will involve a detailed gap analysis to determine areas needing strengthening. We aim to develop a clear plan to enhance this interface, thereby improving continuity of care and ensuring that individuals receive the necessary support as they transition from prison to community-based services.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish dedicated cross-organisational, multidisciplinary Task and Finish workstreams to review processes and policies and identify further action.
Verbatim wording from the response “To ensure effective progress in addressing these areas, we will establish dedicated workstreams that will operate as part of a Task and Finish group. The stakeholders for each workstream will be responsible for reviewing existing processes and relevant policies to determine if further action is required. The initially identified stakeholders have been both cross-organisational and multi-professional including Secure Care Services, the In Reach Team, Community Mental Health Services (BSMHFT and FTB) and HMP Birmingham. As this work progresses, if additional key stakeholders are identified, they will be included.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Approach SystemOne to discuss the feasibility of adding a local field for community mental health team information.
Verbatim wording from the response “Systemone
Whilst this point is an issue which will need to be addressed at a more national level by other Interested Parties, the Trust has also looked at its own Systemone interface in HMP Birmingham to see if this can be amended locally.” Source location Response from BSMHFT
Open published response
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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 National Systemone interface issues must be addressed by other Interested Parties, although the Trust is exploring a local amendment.
Verbatim wording from the response “Systemone
Whilst this point is an issue which will need to be addressed at a more national level by other Interested Parties, the Trust has also looked at its own Systemone interface in HMP Birmingham to see if this can be amended locally.” Source location Response from BSMHFT
Open published response
23 Nov 2023 Philip Laurence Justin MALONE · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients View source Inadequate psychiatric bed capacity in Birmingham and Solihull View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Philip Laurence Justin MALONE · 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
Philip Laurence Justin Malone, who had treatment-resistant schizophrenia and had deteriorated significantly in late June 2023, was found deceased in his supported accommodation on 3 July 2023. The inquest concluded that his death was the consequence of suicide. The principal concern was inadequate psychiatric bed capacity in Birmingham and Solihull, after clinicians sought to admit him but no inpatient bed was available, creating an ongoing 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. The report was sent to Birmingham and Solihull Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients
Wider context from the report “1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action.
2. The Patient Safety Manager ████████ gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved, and there is a genuine risk of the same problem with another patient in the future.
3. ████████ added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged . In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged , and amplifies the chronic shortage of beds.
4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board.
The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding.
My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate. Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate psychiatric bed capacity in Birmingham and Solihull
Wider context from the report “1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action.
2. The Patient Safety Manager ████████ gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved , and there is a genuine risk of the same problem with another patient in the future.
3. ████████ added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged. In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged, and amplifies the chronic shortage of beds.
4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board.
The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding.
My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate . Whilst some action may have been taken it is insufficient to resolve the problem . It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.
” 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 Operate a clinical oversight group with acute wards to support appropriate discharges and escalate delays caused by non-clinical issues.
Verbatim wording from the response “A clinical oversight group (COG) now meets regularly with all acute wards to support clinically appropriate discharges and enable escalation of discharge delays that occur as a result of non-clinical issues (appendix 2).” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lead a business case to secure funding for new Highcroft acute capacity, with submissions scheduled for early spring 2024.
Verbatim wording from the response “Additional workstreams
Highcroft redevelopment project: The Trust is currently leading on a business case to secure funding to build new acute hospital capacity on the Highcroft hospital site in North Birmingham. The long term plan is to replace all of the ageing bed stock on the site. The medium term plan is to realise two new additional wards. Based on our acute bed case for need, these are currently proposed to be an 18-bedded acute ward and a 12-bedded acute intensive care ward (PICU). Business case submissions are scheduled to be submitted in early Spring 2024. However, even if the case is approved, this is only the first step and it would be at least a few years before it is likely to be completed.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate with the ICB in a steering group examining additional contracted beds closer to Birmingham as an interim measure.
Verbatim wording from the response “Strategic bed procurement steering group: This group is led by ICB with BSMHFT and FTB input. It is looking at how additional contracted beds can be contracted closer to Birmingham as an interim measure while the Highcroft programme is in development.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and lead a locality model linking local hospital beds with home treatment teams, community teams and local communities to prioritise admissions by clinical risk and need.
Verbatim wording from the response “3. Increasing bed base capacity locally.
The programme concluded in the summer of 2023 with the recommendation that two core workstreams are developed and delivered to improve bed capacity, namely:” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with local authorities to improve inpatient social-care support and enable faster, safer discharges.
Verbatim wording from the response “The Trust is working with our local authorities to improve the social care support to patients on our inpatient wards with an aim to provide speedier and safer discharges and thus create more capacity within our bed stock (See appendix 1)” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission and complete a 12-month consultancy project addressing local mental health bed shortages and out-of-area placements.
Verbatim wording from the response “Birmingham and Solihull NHS Foundation Trust commissioned the services of Grant Thornton Consultancy to work with us on a specific 12-month project to address the issue of local bed shortages” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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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 Addressing mental health bed availability relies substantially on system partners, so the Trust cannot resolve the issue alone.
Verbatim wording from the response “I would like to take this opportunity to explain that whilst many steps are being taken to address the matter of bed availability, the solution is very much reliant on our system partners as well. We are continuing to work closely with them. As you state within your PFD Report; this is a national problem. The Trust is therefore taking all available steps, within its power, in order to minimise and reduce the risks associated with this issue. I understand that in making the decision around the PFD at and request you expressed that you took into account that multiple PFD reports have already been issued, but in your view the volume of reports and repetition of issuing further reports is tangible and the fact that another report is being issued may contribute.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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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 Trust can develop capacity and pathways only within the resources, scope and abilities available to it.
Verbatim wording from the response “I would like to express that the issuing of PFDs has not directly influenced the ongoing work the Trust has been undertaking for some time on this matter and we remain committed to do all we can to develop capacity and pathways that enable us to meet the needs of our population within the resources we have available to us.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
8 Nov 2023 Leva Amra ADRIS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Lack of GP awareness that referrals to secondary services may not be considered by secondary services View source Failure to inform referring GPs when referrals to secondary services are rejected View source Failure of secondary services to consider referrals requesting their review and assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 Mental Health NHS Foundation Trust; 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 Mental Health NHS Foundation Trust; 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 Mental Health NHS Foundation Trust; 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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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 Amend the GP referral form to clarify that the service will assess referrals and determine where patients’ needs are best met, removing confusing secondary-care terminology.
Verbatim wording from the response “We have made alterations to our referral form for those GPs who continue to refer using the attached referral form. We have made it explicitly clear that the Community Mental Health and Wellbeing Service will review the referral and determine where the patients’ needs can be best met. We have also removed reference to referral to ‘secondary care services’ to avoid confusion.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue disseminating the referral and service-model information through GP communications, engagement sessions, meetings and healthcare partnership forums.
Verbatim wording from the response “We have now liaised with the staff involved in order to be able to respond to your concerns in relation to the GP referral system to secondary mental health services and communication to GPs in respect of the same. Community Mental Health Services have been undergoing significant transformation since April 2021. In line with the attached national programme of work the government committed significant investment in Community Mental Health Services to integrate the ‘front door’ of Mental Health Services with Primary Care Networks (PCNs), improving access to services, providing a multi-agency approach and reducing unnecessary waits. There has been significant communication around the programme and the changes with our PCN Clinical Directors, leads and GPs.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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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 Established local triage of Community Mental Health and Wellbeing Service referrals is considered sufficient.
Verbatim wording from the response “All referrals coming into our Community Mental Health and Wellbeing Service, will be triaged locally, this has been the process in place for many years and is an already established process. BSMHFT central SPOA function is primarily an administrative function and referrals are sent by SPOA (Single Point of Access) to local services to triage (with the exception of older persons services).” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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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 referral showed no need for medical input or urgent intervention and was handled within the suggested timeframe.
Verbatim wording from the response “This particular referral was managed by an experienced registered psychiatric nurse with secondary care expertise. Having reviewed the referral form there was no indication of a request specifically for a medical colleague review, neither was there an assessed need for medical input. Should the assessing psychiatric nurse have felt a medically trained colleague needed to review the patient, they would have brought the case to one of the regular Multi-Disciplinary Meetings (MDTs) or would have immediately spoken with a medically trained colleague for support. As stated, this was not indicated in this case.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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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 Specialist mental health services, including PCN mental health professionals, should assess need and determine appropriate service placement rather than individual GPs.
Verbatim wording from the response “The assessment of mental health need should be retained within the specialist community mental health and wellbeing service and should not be for individual GPs to determine. As mentioned above PCNs now have access to experienced Mental Health professionals who are best placed to review need and determine where in the service individuals needs can be met.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
31 Oct 2023 Andrew BOWLES · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Lack of access to essential patient records before mental health liaison assessment and treatment View source
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.
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AI-generated summary
Andrew BOWLES · 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
Andrew BOWLES was found face down in a canal on 16 May 2023 after leaving Birmingham City Hospital, where he had been assessed following concerns about his mental health. The medical cause of death was drowning. The principal concern was that the mental health liaison nurse did not have direct access to City Hospital records containing information about command hallucinations and thoughts of self-harm, which may have affected the assessment and potential referral for psychiatric admission.
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× 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to essential patient records before mental health liaison assessment and treatment
Wider context from the report “3. The mental health liaison nurse from Birmingham and Solihull mental health NHS foundation trust did not have a log in to be able to directly access City Hospital records , but rather relied on a colleague to access any notes and provide a verbal handover. Further, she stated in evidence that her assessment may have taken place prior to the A&E notes being put onto the system , as she was unaware that Mr Bowles had been experiencing command hallucinations and had thoughts of self-harm, the same being denied when she saw him less than an hour later. Her evidence was clear, that had she been privy to this information, it would have put a different angle on the assessment and would have led down the route of psychiatric review for potential admission.
4. I am concerned that the mental health liaison nurse undertook her assessment without having access to City Hospital records, which contained essential information that would have impacted on her assessment . I am concerned that there may still be a risk to the life of some patients if the mental health liaison team and Birmingham City Hospital are not ensuring that essential patient records are being appropriately shared and read prior to diagnosis and treatment . The situation may well be the same at University Hospitals Birmingham, given that Birmingham and Solihull Mental Health NHS foundation Trust also run a mental health liaison service in the A&E department.
” Open source report
2 Oct 2023 Paula LENIHAN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to complete or update risk assessments adequately View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Paula LENIHAN · 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
Paula Lenihan was found deceased at her home on 6 March 2023. The medical cause of death was ischaemic and hypertensive heart disease, with combined toxicity from drugs in her system. The principal concern was that risk assessments within the Birmingham & Solihull Mental Health NHS Foundation Trust were not being completed or updated satisfactorily, creating a risk from insufficient recording of risk information.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or update risk assessments adequately
Wider context from the report “1. The evidence given on behalf of the Birmingham & Solihull Mental Health NHS Foundation Trust was that in addition to this present case, where the deceased's risk assessment was not updated between November 2021 and her death in March 2023 despite circumstances which I was told ought to have triggered an update, there were a further number of cases within the Trust in which Root Cause Analysis reports had been produced, where it had also been found that risk assessments were not being completed in line with expectations ; further, that it was not clear why this was happening.
2. If risk assessments are not being properly completed or updated , then there is an obvious risk of deaths occurring in the future, as a result of insufficient recording of risk . The fact that risk-relevant information may be recorded in the body of clinical notes is not reassuring, because a risk assessment or risk summary ought to capture the most salient risk information so that a professional looking quickly can absorb it; this is all the more important where professionals are under time pressure.
3. The evidence given to me was that a 'task and finish group' has been set up to address the issue, which expects to have concluded by early next year, i.e. 2024, and that this group will be addressing matters as they are found rather than waiting until the final stage of its existence early next year. The evidence was that this group is at an early stage, with meetings considering the terms of reference and also, recently, the most appropriate persons to contribute to the group.
4. In the circumstances I am concerned that currently there is an extant issue within the Trust about the completion of risk assessments being, on a number of occasions, unsatisfactory . The task and finish group is at an early stage and I do not know what it is going to do, or when. I therefore cannot be reassured that the issues around risk recording which that group is going to examine have, at this point in time, been addressed . It seems to me that they continue to exist , because there has been no evidence to tell me otherwise.
” 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 Monitor risk-assessment completion through monthly local clinical governance committees and the trust-wide performance delivery group.
Verbatim wording from the response “To ensure we continue to support staff in maintaining these levels of completion we will be monitoring via our monthly local CMHT clinical governance committee and trust wide performance delivery group.” Source location Response from Birmingham and Solihull Mental Health
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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 Complete the review of the risk management policy.
Verbatim wording from the response “The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .” Source location Response from Birmingham and Solihull Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a project group reviewing the risk assessment process, outpatient clinics and documentation for care support patients.
Verbatim wording from the response “The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .” Source location Response from Birmingham and Solihull Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ratify the revised risk management policy.
Verbatim wording from the response “The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .” Source location Response from Birmingham and Solihull Mental Health
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 protected dedicated staff time to update risk assessment documentation.
Verbatim wording from the response “The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .” Source location Response from Birmingham and Solihull Mental Health
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 Trust disputes that failing to update risk assessment information already recorded would create a risk of death or meet the PFD threshold.
Verbatim wording from the response “I understand that during evidence presented at the inquest you concluded that the failure to update the risk assessment did not contribute to the death and accepted that the information was recorded within the records for staff to access. Your report sets out your belief that the risk assessment should be updated ‘so that a professional looking quickly can absorb it; this is all the more important where professionals are under time pressure.’ This aspect of your report is not based on evidence heard at the inquest and the Trust does not accept that failing to update the Risk Assessment section of the medical notes, when the information is already within the records, would result in death. Even in times of pressure, clinicians would review all the necessary pertinent information prior to reviewing a patient.” Source location Response from Birmingham and Solihull Mental Health
Open published response
14 Jul 2023 PETER MARTIN AARON FLEMING · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure of medication-management processes to identify proposed carbamazepine treatment View source Lack of care-coordinators for seriously mentally ill patients View source Lack of GP resources for proactively checking collection of prescribed medication View source Delays in primary care organisations providing important patient updates to GPs View source Unavailability of approved mental health practitioners within 24 hours View source Unavailability of mental health places of safety View source Failure of digital systems used by different health organisations to communicate View source Unavailability of mental health inpatient beds View source Ineffective communication between specialist mental health teams View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
PETER MARTIN AARON FLEMING · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of medication-management processes to identify proposed carbamazepine treatment
Wider context from the report “3. Carbamazepine management was proposed in 2012 to manage the deceased’s mental health however this was not picked up by his GP and was only noted by a BSMHFT consultant in August 2022 . Therefore, the deceased went 10 years without this medication. BSMHFT could not explain at the inquest why this omission had not been identified sooner . BSMHFT’s RCA action plan does not have any action to avoid a repeat occurrence. My concern is this RCA indicates a problem with process and systems and further consideration is required to avoid a repeat occurrence.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of care-coordinators for seriously mentally ill patients
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull . In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators , mental health inpatient beds, ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of GP resources for proactively checking collection of prescribed medication
Wider context from the report “5. The deceased’s GP raised concerns that current resources do not allow GPs to pro-actively check patients are collecting prescribed medication due to excessive patient lists . My concern is that this is a consequence of lack of resources at a national level .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in primary care organisations providing important patient updates to GPs
Wider context from the report “4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other. Further, GPs often do not get important patient updates from primary care organisations for many days or weeks . (See examples above: the GP did not pick up the carbamazepine prescription, and could not prescribe the medication in October 2022). My concern is communication between different health organisations is not as effective as it could be and important information is being missed , and consequently a material delay in treatment is occurring .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of approved mental health practitioners within 24 hours
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period . When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’, and AMHPs , presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health places of safety
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’ , and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of digital systems used by different health organisations to communicate
Wider context from the report “4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other . Further, GPs often do not get important patient updates from primary care organisations for many days or weeks. (See examples above: the GP did not pick up the carbamazepine prescription, and could not prescribe the medication in October 2022). My concern is communication between different health organisations is not as effective as it could be and important information is being missed, and consequently a material delay in treatment is occurring.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health inpatient beds
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available , and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds , ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication between specialist mental health teams
Wider context from the report “2. BSMHFT utilizes self-contained specialist teams. The deceased was treated by (a) crisis team/home treatment team, (b) community mental health team, and (b) psychiatric liaison team. The evidence demonstrated communication between the specialist teams was not effective and this caused delays. For example, the psychiatric liaison team nurse that reviewed the deceased updated the community mental health team. However, the GP could not prescribe the deceased’s medication in October 2022 because it had not been approved by the community mental health team consultant via an ESCA and the deceased went without his medication. The deceased’s GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse’s involvement. The deceased cited this delay as making his mental health worse shortly before his death. My concern is communication between the specialist teams is not effective enough . BSMHFT’s RCA action plan is to seek assurance from the CCG/ICB that communication between the specialist teams is being strengthened. My concern is that this does not go far enough and there should be consideration of a formal process or policy.
” 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 police to streamline the section 136 process for access to Places of Safety.
Verbatim wording from the response “Whilst it is best practice that a service user presenting with a mental health concerns is taken to a mental health Place of Safety, this could not be achieved on the particular day in question as all the mental health Places of Safety within the Trust were taken. However, Mr Fleming was conveyed to the Accident & Emergency Department at Heartlands Hospital which is an appropriate Place of Safety and indeed there are a number of A&E departments across the Birmingham and Solihull area where their services can be taken too as Places of Safety. In terms of its own provision the Trust has three Places of Safety available across the organisation. The pressure on these facilities is multi-factorial. Work is ongoing in this area with the Police to streamline the s.136 process.” Source location Response from Birmingham and Solihull Mental Health Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the Shared Care Platform to enable participating organisations to access clinical information and improve information exchange.
Verbatim wording from the response “Following the introduction of the shared electronic system across Birmingham, Sandwell and Solihull areas through Your Care Connected some years ago, the Trust could access some clinical information from primary care services. However, in the last 12 months this has been enhanced, and is now known as the Shared Care Platform. This allows a number of different organisations to access different clinical information across the system, including investigation results, thus improving the exchange of clinical information and thus improving patient care.” Source location Response from Birmingham and Solihull Mental Health Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Dialog Plus care-planning tool across the transition to the Community Mental Health Framework.
Verbatim wording from the response “The use of a Dialog Plus Care Planning tool will be the foundational component of the framework to ensure the holistic identification of needs with allocation of the appropriate clinician within teams to support those needs to be met, to liaise with other professionals who need to input into care and to ensure the Action Plan is reviewed in a timely manner.” Source location Response from Birmingham and Solihull Mental Health Foundation Trust
Open published response
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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 Carbamazepine does not require a shared care agreement; clinical correspondence is considered sufficient to communicate prescribing advice.
Verbatim wording from the response “Carbamazepine is on the Birmingham and Solihull IMOC formulary as an AMBER medicine, meaning that once a specialist has advised initiation of this medicine, any prescriber can prescribe it. There is no requirement for a shared care agreement for carbamazepine and there has never been a template for one. Communication is evidenced via clinical correspondence.” Source location Response from Birmingham and Solihull Mental Health Foundation Trust
Open published response
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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 Trust will not respond to concerns about GPs proactively checking medication collection, leaving the matter to others.
Verbatim wording from the response “The Trust cannot respond to this point and will leave this to others to respond to. If a patient is open to BSMHFT, our staff will regularly speak to the patient about all aspects of their care, including medication.” Source location Response from Birmingham and Solihull Mental Health Foundation Trust
Open published response
12 Jul 2023 Mohammed Khalid HUSSAIN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 8 Failure to safely effect medication changes View source Failure to safely communicate high clozapine levels View source Ineffective pharmacy processes due to lack of resources View source Failure of the internal investigation process to identify central issues View source Lack of understanding of clozapine level monitoring, interpretation and response View source Failure to learn from a previous Regulation 28 report View source Failure to highlight high clozapine results in routinely used clinical notes View source Failure to monitor clozapine and norclozapine levels View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mohammed Khalid HUSSAIN · 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
Mohammed Khalid HUSSAIN was found collapsed on the bathroom floor at his home on 28 November 2022 and was confirmed deceased shortly afterwards. The medical cause of death was determined to be sudden cardiac death in schizophrenia. Concerns included inadequate systems for monitoring, communicating and acting on high clozapine levels and medication changes, as well as deficiencies in internal investigation, understanding of clozapine and pharmacy resourcing.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to safely effect medication changes
Wider context from the report “2. Medication changes: After a review on 14/10/22, when a high level of clozapine was noted from a blood test on 03/05/22, the consultant indicated that medication should reduce on the next prescription. This was communicated by email to the care coordinator however this was not read or acted upon. The inquest heard how there was no safe system to effect medication changes .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to safely communicate high clozapine levels
Wider context from the report “1. Monitoring clozapine levels: The inquest heard evidence that there was a clear system to monitor monthly blood test results looking for low white cell count, however there was no clear system for monitoring the actual clozapine and nor clozapine levels. In addition the inquest heard how there was no safe system to communicate high levels of clozapine .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective pharmacy processes due to lack of resources
Wider context from the report “7. Pharmacy resourcing: The inquest heard evidence that processes within the pharmacy were not effective due to a lack of resources .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the internal investigation process to identify central issues
Wider context from the report “6. Quality of the internal investigation process: The initial investigation report did not raise significant issues regarding the monitoring of clozapine and importantly whether Mr Hussain did in fact have toxicity. It was only when ████████ wrote a report on 26/03/23 (7months after the death) that this issue was highlighted and addressed. This raises a concern about the quality of the internal investigation process and whether it is able to identify central issues in a particular case .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of clozapine level monitoring, interpretation and response
Wider context from the report “4. Understanding of clozapine: I heard evidence that there was a lack of understanding of when to measure clozapine levels, how to interpret high clozapine levels and then how to respond to a high level .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from a previous Regulation 28 report
Wider context from the report “5. August 2020 Regulation 28 report: I sent a Regulation 28 report in August 2020 (case of Ian Allen) which identified that there was no system in place to ensure abnormal clozapine levels were escalated and acted upon and that there was a lack of understanding of the importance of clozapine monitoring and how frequently levels should be monitored. Given this report there is a concern that the Trust has not learnt from the previous Regulation 28 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. The report was sent to Birmingham and Solihull Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to highlight high clozapine results in routinely used clinical notes
Wider context from the report “3. How to record high clozapine levels: The clozapine and nor clozapine levels are recorded in the pharmacy section of the records. There was no system for highlighting high clozapine results in the rio notes which are routinely used by all clinicians.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor clozapine and norclozapine levels
Wider context from the report “1. Monitoring clozapine levels: The inquest heard evidence that there was a clear system to monitor monthly blood test results looking for low white cell count, however there was no clear system for monitoring the actual clozapine and nor clozapine levels . In addition the inquest heard how there was no safe system to communicate high levels of clozapine.
” 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 Put support processes in place to guide clinicians who are new to the Trust when clozapine prescribing advice is needed.
Verbatim wording from the response “Where a clinician may be new to the Trust there will be clear instructions to ask for support at the time of need and the line manager, team managers and clinical director will have processes in place to guide them to ensure they have the right advice.” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise pharmacy review of clozapine assay levels and communication of results to consultants as an interim mitigation.
Verbatim wording from the response “• For there to be a review of the governance processes for the management of clozapine using the safety summit approach. In the short term as a mitigator the pharmacy team have prioritised the reviewing of the assay levels and the communication to consultants” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an urgent clozapine learning session and provide future training and development to refresh staff knowledge.
Verbatim wording from the response “Following the last PFD in August 2020 the Trust made significant changes to the processes and procedures surrounding clozapine and its use. However this case has highlighted areas of learning. Consequently, the Trust has now put into place an urgent learning session along with future planned training and development to ensure staff keep up to date with this and learning is refreshed, alongside other additional support systems that have previously been introduced.” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement significant changes to clozapine processes and procedures following the August 2020 report.
Verbatim wording from the response “5. August 2020 Regulation 28 Report” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop clozapine e-learning modules and take them to the Learning and Development team for approval.
Verbatim wording from the response “2. Development of a series of e-learning modules on the trust e-learning platform form the Learn It Online resource www.learnitonline.co.uk. Clinical staff will be able to access these as part of their on-going training to improve knowledge around clozapine. This is anticipated that the team will be able to take this to the Learning and Development team by September 2023.” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a specialist Pharmacy Clozapine Team to support assay follow-up, staff training and clozapine prescribing practice.
Verbatim wording from the response “3. The Trust has multidisciplinary experts on the subject of clozapine. There is also expertise in the Pharmacy Clozapine Team; to support follow up of raised clozapine plasma assays but more importantly to support all teams involved with the use of clozapine with training in the handling of clozapine and promotion of the trust clozapine prescribing guidelines and procedures. This team is expected to be established by September 2023. All these colleagues will be made known to staff for any advice that is needed. Staff can also ask for help through their manager, who can signpost them accordingly. This will help improve the skills and experience in responding to results on clozapine levels appropriately with the care of the patient at the centre of all decisions.” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review governance processes for clozapine management using a safety summit approach.
Verbatim wording from the response “On this occasion the following actions were identified and carried out:” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Email prescribers about documenting care decisions and clinical review following out-of-range clozapine results.
Verbatim wording from the response “The Training is aimed to be in place to ensure that staff are confident in the use of clozapine and its monitoring in the future. We have sent an email to all prescribers about the need to record about decisions of care following a clozapine result that may be out of range, the need to ensure there is clinical review and this is documented.” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and record a clozapine training webinar for clinical staff, with intranet access for those unable to attend.
Verbatim wording from the response “A number of training elements are being planned:” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide electronic prescribing guidance and communicate procedures for implementing clozapine dose changes.
Verbatim wording from the response “As part of the learning there will be clear guidance on prescribing on the electronic system and communication of how best to do this when a dose change is required.” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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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 Existing ICE access, abnormal-result indicators and pharmacy reporting provide the strongest safeguards for recording and responding to high clozapine levels.
Verbatim wording from the response “All blood test results are made available to staff in the ICE system, which is provided to us by our pathology service provider. This system is used both for ordering tests and reviewing results. It is accessed from within Rio and in patient context, so all staff have ready access to results. In common with most other systems, abnormal results are indicated within the system along with the normal reference range.” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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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 Existing governance processes provide oversight of serious incident investigation quality and learning-based recommendations.
Verbatim wording from the response “Serious Incident investigations are carried out under the Serious Incident Framework (2015) and are conducted for the purposes of learning to prevent recurrence. As part of this investigation expert opinion was sought from our Specialist Clozapine Pharmacist; ████████
████████, which were included within the body of the RCA and reflect a number of the issues you have raised.” Source location Response Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
15 Mar 2023 Jai SINGH · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 11 Failure to meaningfully engage with families and consider family concerns View source Poor record keeping within and between teams View source Failure to recognise the significance of reported psychotic symptoms and provide adequate assessment and treatment View source Absence of a rolling risk assessment facility in SystemOne View source Absence of ongoing risk assessment documentation for patients with mental illness in SystemOne View source Failings in use of the ACCT system View source Failure to identify the need for inpatient admission and assessment for secure transfer View source Delays in taking patients onto the mental health caseload and providing allocated CPN and MDT oversight View source Failure to use interpreters View source Absence of a psychiatrist from the mental health MDT View source Poor communication within and between teams View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jai SINGH · 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
Jai Singh died at City Hospital on 28 January 2022 after being found in cardiac arrest in his cell at HMP Birmingham, having asphyxiated after placing a bag over his head. The report identifies repeated failures to communicate and record family and clinical concerns, use interpreters, assess risk, operate the ACCT process, and provide appropriate mental-health admission and transfer. It also identifies ongoing risks from the absence of a psychiatrist in the prison mental-health MDT and the lack of ongoing risk-assessment documentation in SystemOne.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to meaningfully engage with families and consider family concerns
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family , insufficient consideration of family concerns and failings in the use of the ACCT system.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor record keeping within and between teams
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams , the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT system.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the significance of reported psychotic symptoms and provide adequate assessment and treatment
Wider context from the report “4. In Mr. Singh's case it is my conclusion that it is likely that if a psychiatrist had been at a mental health MDT meeting held on the 19th January 2022 they would have identified that he needed to be admitted to ward 2 without further delay. At the very least the need for urgent review by a psychiatrist and CPN would have been recognised and facilitated which would in turn have lead to admission. CPNs in Mr. Singh's case continually failed to identify the significance of repeatedly and consistently reported psychotic symptoms and consequently he did not receive adequate assessment and treatment which increased his risk of self harm and suicide which in turn was not sufficiently identified. The absence of a psychiatrist at the MDT creates a risk that the significance of some symptoms and presentations will not be recognised and further deaths could occur due to lack of appropriate assessment and treatment.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a rolling risk assessment facility in SystemOne
Wider context from the report “5. Other electronic health care records systems used in mental health settings have a rolling risk assessment document that clinicians are required to review and update at certain points in a patient's management. The risk assessment document provides a prompt to clinicians to formally consider risk and come to a reasoned, documented conclusion that then feeds into decision making. The record also provides a reliable, easily accessible source of risk history. No such facility is in use on SystemOne at HMP Birmingham . Further, the evidence given was that once a system is not being used routinely across mental health care within the prison estate and is not provided as standard on SystemOne. This creates an ongoing risk to life arising from under-estimation of risk as a result of clinicians not formally considering and assessing current risk levels, and salient risk history not being easily accessible . It is understood by Birmingham and Solihull Mental Health Trust that it should be possible to create a specific risk assessment record within SystemOne and this is being considered locally. However, the evidence given was that this issue should be highlighted nationally and that the developers and distributors of SystemOne should be involved so as to ensure the best available solution is identified.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of ongoing risk assessment documentation for patients with mental illness in SystemOne
Wider context from the report “3. However, there are two features of the mental health care provided to Mr. Singh that create a risk to the lives of others that have not yet been rectified:
i. the fact that the mental health team multi-disciplinary team (MDT) does not include a psychiatrist; and
ii. the absence of any ongoing risk assessment documentation for patients with mental illness within the SystemOne records at HMP Birmingham .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failings in use of the ACCT system
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT system .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the need for inpatient admission and assessment for secure transfer
Wider context from the report “2. Much of the evidence at the inquest focused on the central issue of repeated missed opportunities to identify that Mr. Singh required admission to the prison's inpatient ward, ward 2, and assessment for section 48 transfer to a medium secure unit (which would have been likely to result in transfer to a medium secure unit). The consequences of the failure to transfer Mr. Singh to an inpatient setting were compounded by the fact that he was not taken onto the mental health team's caseload promptly and therefore did not have the benefit of an allocated CPN and the oversight and input of a mental health multi-disciplinary team. Many steps have been undertaken by Birmingham and Solihull Mental Health Trust (who provide mental health services within the prison) to minimise the risk of such a situation occurring again.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in taking patients onto the mental health caseload and providing allocated CPN and MDT oversight
Wider context from the report “2. Much of the evidence at the inquest focused on the central issue of repeated missed opportunities to identify that Mr. Singh required admission to the prison's inpatient ward, ward 2, and assessment for section 48 transfer to a medium secure unit (which would have been likely to result in transfer to a medium secure unit). The consequences of the failure to transfer Mr. Singh to an inpatient setting were compounded by the fact that he was not taken onto the mental health team's caseload promptly and therefore did not have the benefit of an allocated CPN and the oversight and input of a mental health multi-disciplinary team . Many steps have been undertaken by Birmingham and Solihull Mental Health Trust (who provide mental health services within the prison) to minimise the risk of such a situation occurring again.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use interpreters
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters , poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT system.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a psychiatrist from the mental health MDT
Wider context from the report “3. However, there are two features of the mental health care provided to Mr. Singh that create a risk to the lives of others that have not yet been rectified:
i. the fact that the mental health team multi-disciplinary team (MDT) does not include a psychiatrist ; and
ii. the absence of any ongoing risk assessment documentation for patients with mental illness within the SystemOne records at HMP Birmingham.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication within and between teams
Wider context from the report “1. A multitude of factors contributed to Mr. Singh's death across the custodial and healthcare teams within HMP Birmingham. Many steps have been taken by all organisations with responsibility for Mr. Singh's safety and health during his time at HMP Birmingham to rectify failings that have been identified such as the consistent failure to use interpreters, poor communication and record keeping within and between teams, the absence of meaningful engagement with Mr. Singh's family, insufficient consideration of family concerns and failings in the use of the ACCT system.
” 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 Review the clinical outcomes of the Consultant Psychiatrist MDT attendance pilot after three months.
Verbatim wording from the response “The Trust has begun a 3 month pilot which will ensure a Consultant Psychiatrist attends the MDT meetings at the Prison each week. The Secure Care and Offender Health Clinical Governance Committee (CGC) will review the outcomes for the pilot after 3 months, to ascertain if this is clinically beneficial to patients. Our primary aim is to ensure that our patients receive the best care at the right time and this pilot will ensure that this review takes place.” Source location Response from Birmingham and Solihull Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add an accessible risk-assessment document to SystemOne for Trust staff.
Verbatim wording from the response “The Trust is restricted to what it can change on SystemOne due to it being the national software used in prisons. We are however meeting with the software company on 27 April 2023 to discuss the concerns raised within the PFD. Any changes to be made at a national level by SystemOne may take some time. Consequently the Trust has looked to how it will be able introduce risk assessment documentation into the system and ensure that Trust staff complete this in the interim.” Source location Response from Birmingham and Solihull Mental Health
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 Roll out the SystemOne risk-assessment process to clinical staff using a practice alert and Standard Operating Procedure.
Verbatim wording from the response “A risk assessment has been added to the System One software that is accessible for the Trust staff only. This will be rolled out to staff with a dissemination plan, which is attached. The plan includes a practice alert and a Standard Operating Procedure to be sent to all clinical staff. This has now taken place. This will set out the requirements for the risk assessments to be completed. This will ensure that going forward all patients will receive a risk assessment when one is necessary. The roll out of this will be complete by 20 May 2023.” Source location Response from Birmingham and Solihull Mental Health
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 Run a three-month pilot providing weekly Consultant Psychiatrist attendance at prison MDT meetings.
Verbatim wording from the response “The Trust has begun a 3 month pilot which will ensure a Consultant Psychiatrist attends the MDT meetings at the Prison each week. The Secure Care and Offender Health Clinical Governance Committee (CGC) will review the outcomes for the pilot after 3 months, to ascertain if this is clinically beneficial to patients. Our primary aim is to ensure that our patients receive the best care at the right time and this pilot will ensure that this review takes place.” Source location Response from Birmingham and Solihull Mental Health
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 Trust is restricted in changing the national prison software, and national SystemOne changes may take time.
Verbatim wording from the response “The Trust is restricted to what it can change on SystemOne due to it being the national software used in prisons. We are however meeting with the software company on 27 April 2023 to discuss the concerns raised within the PFD. Any changes to be made at a national level by SystemOne may take some time. Consequently the Trust has looked to how it will be able introduce risk assessment documentation into the system and ensure that Trust staff complete this in the interim.” Source location Response from Birmingham and Solihull Mental Health
Open published response
11 Jan 2023 Leroy Patrick HAMILTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of inpatient mental health beds View source Lack of an agreed multi-agency protocol for informal patients absconding from emergency departments View source Failure to undertake and appropriately classify risk assessments for missing persons View source Failure to classify reported people as missing persons View source Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed View source Lack of Psychiatric decisions unit spaces View source See 3 more concerns
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
Leroy Patrick HAMILTON · 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
Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient mental health beds
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU. Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed multi-agency protocol for informal patients absconding from emergency departments
Wider context from the report “3. Multi agency protocol for informal missing patients: The inquest heard how there is no agreed protocol to deal with informal patients who abscond from emergency departments . Consideration should be given to setting up an agreed protocol so that all agencies involved understand their respective roles and responsibilities.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and appropriately classify risk assessments for missing persons
Wider context from the report “5. WMP risk assessments for missing persons: When Mr Hamilton was first reported as missing no risk assessment was undertaken about his level of risk to himself . The call had confirmed he was at risk of harming himself . The leads to a concern that staff do not understand when and how to risk assesses incidents and when to identify high risk incidents .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to classify reported people as missing persons
Wider context from the report “4. WMP Missing person investigations: The inquest heard how on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr Hamilton as a missing person when he was reported as missing . On both occasions he should have been treated as a high risk missing person. This raises a serious concern that staff do not understand when people should be classified as missing . Consideration should be given to ensuring staff properly understand how to assess if someone should be treated as a missing person and WMP should consider whether further training is required.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed
Wider context from the report “2. Safe space: The inquest heard how it is often the case that due to the lack of inpatient beds and PDU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed . This means that acutely ill mental health patients are often left for long periods without any specialist care, support or observation . Consideration should be given to setting up a safe space where patients can wait for a bed or PDU space which is able to cater for their special needs and keep them safe.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Psychiatric decisions unit spaces
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces : The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU . Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
” Open source report
23 Jun 2022 Khalid Seneen Yousef · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Insufficient understanding of the L&D police custody suite model’s role and limitations View source Inadequate training of L&D practitioners View source Lack of clarity about responsibility for mentally unwell persons in custody View source Failure to learn sufficient lessons from the incident View source Inadequate experience of L&D practitioners View source Lack of commissioned psychiatrists within the L&D police custody suite model View source Inadequate supervision of L&D practitioners View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Khalid Seneen Yousef · 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
Khalid Seneen Yousef was decapitated during a sustained knife assault at a premises in Birmingham on 4 January 2018. The report identifies concerns that a Liaison and Diversion clinician failed to recognise the perpetrator’s psychosis and refer him for mental health assessment, and that the custody-suite model lacked commissioned psychiatrists, with wider concerns about responsibility, training and supervision.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient understanding of the L&D police custody suite model’s role and limitations
Wider context from the report “3. West Midlands Police officers and BSMHFT staff do not sufficiently understand the role and limitations of the L&D police custody suite model .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate training of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for mentally unwell persons in custody
Wider context from the report “2. Liaison and clarity is needed between Chief Constables and the Trusts providing L&D services on who has responsibility for mentally unwell persons in custody .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn sufficient lessons from the incident
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate experience of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience , training and supervision of L&D practitioners .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of commissioned psychiatrists within the L&D police custody suite model
Wider context from the report “1. The L&D police custody suite model has not commissioned psychiatrists .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of L&D practitioners
Wider context from the report “4. BSMHFT have not learnt sufficient lessons from the incident and need to review experience, training and supervision of L&D practitioners .
” 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 Discuss interagency responsibility and information-sharing for mentally unwell people in custody at the next JSOG meeting.
Verbatim wording from the response “The Trust has placed the matter onto the agenda at the next JSOG (Joint Strategic Operational Group), where the Trust meet with the Police and other stakeholders on a regular basis. The next meeting is due to take place on 18th August 2022. The meeting will discuss how to share this information between agencies to ensure that the message is shared clearly and clarity is gained around what the Liaison and Diversion Service are responsible for.” Source location Response form Birmingham and Solihul Mental Health Trust
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 Review and update the induction programme, including role-specific induction packs, shadowing and training for new staff and students.
Verbatim wording from the response “The Team Manager is now working on a project which will be completed by the end of October 2022 to review the current induction programme and produce an up to date induction programme which is suited to different team roles and areas of work. This will include an induction pack, shadowing and training package for all new staff and students. As part of the new tender process which is also currently taking place, the Trust have also planned to have psychologists join the L&D for reflective practice groups which are to take place. Through this work there will be assurance that training, supervision and experience are a priority and changes are made where necessary.” Source location Response form Birmingham and Solihul Mental Health Trust
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 Introduce psychologists into Liaison and Diversion reflective-practice groups through the new tender process.
Verbatim wording from the response “The Team Manager is now working on a project which will be completed by the end of October 2022 to review the current induction programme and produce an up to date induction programme which is suited to different team roles and areas of work. This will include an induction pack, shadowing and training package for all new staff and students. As part of the new tender process which is also currently taking place, the Trust have also planned to have psychologists join the L&D for reflective practice groups which are to take place. Through this work there will be assurance that training, supervision and experience are a priority and changes are made where necessary.” Source location Response form Birmingham and Solihul Mental Health Trust
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 Develop and publish a weekly bulletin explaining the Liaison and Diversion Service’s role and limitations.
Verbatim wording from the response “As stated in point 2 above the Trust intends to discuss this in more detail at the JSOG meeting in August. This meeting will address your concerns around cross-agency information. However, in order to address the internal issue around understanding the role of the Liaison and Diversion Service, the Manager of the team will be carrying out internal work with the Trust Communications Team to put a piece together as part of the weekly bulletin outlining what the team do. This will be completed in line with the outcome of the current tender for the new integrated offender health service, which will incorporate liaison and diversion in custody. This will ensure the greatest visibility, clarity and impact with the communication. We expect to be in a position to complete this in September 2022.” Source location Response form Birmingham and Solihul Mental Health Trust
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 Publish a weekly bulletin explaining the Liaison and Diversion Service’s role and limitations to improve internal understanding.
Verbatim wording from the response “As stated in point 2 above the Trust intends to discuss this in more detail at the JSOG meeting in August. This meeting will address your concerns around cross-agency information. However, in order to address the internal issue around understanding the role of the Liaison and Diversion Service, the Manager of the team will be carrying out internal work with the Trust Communications Team to put a piece together as part of the weekly bulletin outlining what the team do. This will be completed in line with the outcome of the current tender for the new integrated offender health service, which will incorporate liaison and diversion in custody. This will ensure the greatest visibility, clarity and impact with the communication. We expect to be in a position to complete this in September 2022.” Source location Response from Birmingham and Solihull Mental Health
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 Introduce psychologist participation in Liaison and Diversion reflective practice groups through the new tender process.
Verbatim wording from the response “The Team Manager is now working on a project which will be completed by the end of October 2022 to review the current induction programme and produce an up to date induction programme which is suited to different team roles and areas of work. This will include an induction pack, shadowing and training package for all new staff and students. As part of the new tender process which is also currently taking place, the Trust have also planned to have psychologists join the L&D for reflective practice groups which are to take place. Through this work there will be assurance that training, supervision and experience are a priority and changes are made where necessary.” Source location Response from Birmingham and Solihull Mental Health
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 Discuss cross-agency information sharing and clarify Liaison and Diversion Service responsibilities at the Joint Strategic Operational Group meeting.
Verbatim wording from the response “The Trust has placed the matter onto the agenda at the next JSOG (Joint Strategic Operational Group), where the Trust meet with the Police and other stakeholders on a regular basis. The next meeting is due to take place on 18th August 2022. The meeting will discuss how to share this information between agencies to ensure that the message is shared clearly and clarity is gained around what the Liaison and Diversion Service are responsible for.” Source location Response from Birmingham and Solihull Mental Health
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 Review the induction programme and produce an updated role-specific programme, including induction materials, shadowing and training for new staff and students.
Verbatim wording from the response “The Team Manager is now working on a project which will be completed by the end of October 2022 to review the current induction programme and produce an up to date induction programme which is suited to different team roles and areas of work. This will include an induction pack, shadowing and training package for all new staff and students. As part of the new tender process which is also currently taking place, the Trust have also planned to have psychologists join the L&D for reflective practice groups which are to take place. Through this work there will be assurance that training, supervision and experience are a priority and changes are made where necessary.” Source location Response from Birmingham and Solihull Mental Health
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 Trust cannot respond to commissioning psychiatrists within the Liaison and Diversion model because it follows the national model.
Verbatim wording from the response “The Birmingham and Solihull Mental Health NHS Foundation Trust gave evidence in court during the inquest that the Liaison and Diversion Service follow the national model. The Trust is therefore unable to respond to the point around commissioning of psychiatrists within the model. We note that NHS England was also sent a copy of the Prevention of Future Deaths Report and we hope that they will be able to provide more information to you in due course.” Source location Response form Birmingham and Solihul Mental Health Trust
Open published response
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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 Trust cannot respond to commissioning psychiatrists within the Liaison and Diversion model because it follows the national model.
Verbatim wording from the response “The Birmingham and Solihull Mental Health NHS Foundation Trust gave evidence in court during the inquest that the Liaison and Diversion Service follow the national model. The Trust is therefore unable to respond to the point around commissioning of psychiatrists within the model. We note that NHS England was also sent a copy of the Prevention of Future Deaths Report and we hope that they will be able to provide more information to you in due course.” Source location Response from Birmingham and Solihull Mental Health
Open published response
26 May 2022 SAIFUR RAHMAN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Lack of a reliable central record of cell fabric history View source Lack of a formal process for communicating and acting on prison cell risk assessment results View source Lack of a formal process for complete visual inspection of ward cells View source Delays in calling code blue emergencies View source Failure of daily and weekly cell fabric checks to identify risks View source See 2 more concerns
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AI-generated summary
SAIFUR RAHMAN · 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
Saifur Rahman was found in cardiac arrest in his cell at HMP Birmingham on 20 January 2021, was taken to hospital after resuscitation, and died on 23 January 2021. The post-mortem recorded hypoxic/ischaemic encephalopathy associated with external neck compression, and the jury found that his intention was to commit suicide. The report raised concerns about delayed emergency calls, inadequate records of cell history, insufficient cell risk assessments, and the lack of a formal process for prison and mental health staff to inspect and act on cell risks.
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× 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable central record of cell fabric history
Wider context from the report “2. Cell history: the evidence revealed that cell fabric history - including fabric changes, damage and repairs - is safety critical information. Information about the history of cell H3-15 was lost or unclear as it transversed control of the prison changing from G4S to national control in 2018-2019 and there was no prison master/central record . My ongoing concern is that HMP Birmingham does not currently have a master/central record of cell history and there are many Ayes who have a national contract for cell fabric changes and repairs. The evidence was unclear on whether the prison would have access to this safety critical information if the third party contractor changed .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal process for communicating and acting on prison cell risk assessment results
Wider context from the report “4. Prison ████████ risk assessment: the evidence revealed that dynamic daily and weekly prison officer cell fabric checks did not identify the risks within cell H3-15. The evidence from the mental health trust was that as their risk assessment is annual and the environment on ward 2 and ward 3 is dynamic and can quickly change, the prison needs to undertake its own ████████ risk assessment. I was provided with a verbal undertaking that the head of safer custody will undertake the first annual prison cell ████████ risk assessment visually inspecting all 15 x 2 cells 6 months after the NHS risk assessment, and delegate twenty monthly thereafter, resulting in alternating 6 monthly risk assessments. My ongoing concern is that there is no formalised process and consideration needs to be given to how results of the prison ████████ risk assessment is communicated to, and acted upon, by the mental health trust .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal process for complete visual inspection of ward cells
Wider context from the report “3. NHS annual ████████ risk assessment: the evidence revealed that the mental health trust assessors had historically only dip-sampled a selection of the 15 x 2 cells on health care ward 2 (physical health) and ward 3 (mental health). They did not record which cells had been visually checked and relied in part on second-hand information from the prison about cell fabric and design. There had not been effective communication between the prison and health care staff. Generally, the trust had 140+ buildings across its entire estate to assess, this was done by two members of the health and safety team, and the assessment of the health care unit at HMP Birmingham was expected to be completed over several hours on one day. I was provided with a verbal undertaking that the trust would now visually inspect all 15 x 2 cells annually. However, this relies exclusively on the co-operation of the prison who have competing tensions given the operationally dynamic and challenging environment, especially if cells are occupied during the assessment. My ongoing concern is that there is no formalised process between the prison and mental health trust to visually inspect each cell . It is recognised prisoners housed on ward 2 and 3 are at a much greater risk of suicide than the general prison population, and general public as a whole, and will spend a great deal of time unobserved in the 15 x 2 cells. Therefore, in my view, visually inspecting 30 cells is not disproportionate to the level of risk and is not comparable to assessing an outpatient building in the community. The dynamic and challenging environment means it is likely all cells cannot be inspected on one visit. Visually inspecting each cell therefore needs to be properly planned and resourced by both the prison and mental health trust and consideration needs to be given to a formal process.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in calling code blue emergencies
Wider context from the report “1. Calling a “code blue”: the evidence revealed that the safety critical code blue call – automatically triggering an emergency response - was delayed by up to 2 minutes. The evidence was inconsistent on whether the cell entry briefing included the identification of an extra officer with a radio, and why therefore an officer in full person protective equipment ran out of the cell and across the ward to where she had left her radio to call the code blue. Delayed code blue calls have been a repeated problem at HMP Birmingham despite it being raised by the Prison and Probation Ombudsman and coroners in earlier regulation 28 reports. My ongoing concern is that delayed code blue calls will continue , and consideration should be given to the effectiveness of training in light of the evidence given by the prison officers at the inquest.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of daily and weekly cell fabric checks to identify risks
Wider context from the report “4. Prison ████████ risk assessment: the evidence revealed that dynamic daily and weekly prison officer cell fabric checks did not identify the risks within cell H3-15 . The evidence from the mental health trust was that as their risk assessment is annual and the environment on ward 2 and ward 3 is dynamic and can quickly change, the prison needs to undertake its own ████████ risk assessment. I was provided with a verbal undertaking that the head of safer custody will undertake the first annual prison cell ████████ risk assessment visually inspecting all 15 x 2 cells 6 months after the NHS risk assessment, and delegate twenty monthly thereafter, resulting in alternating 6 monthly risk assessments. My ongoing concern is that there is no formalised process and consideration needs to be given to how results of the prison ████████ risk assessment is communicated to, and acted upon, by the mental health trust.
” 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 Formalise the risk-assessment process with the prison by placing it on the Local Delivery Board meeting agenda.
Verbatim wording from the response “In order for this reassurance to be given, the Trust did consider future planning and resourcing to ensure that this would be completed. This takes place each year and the risk assessments for the prison are part of the Audit schedule for the Trust. In respect of formalising the process with the prison, the Trust’s Head of Healthcare at HMP Birmingham has emailed the Local delivery Board to ask that this matter is placed on the agenda for the meeting on 16th June 2022. This will ensure that the process is formalised. Commissioners will also be present at this meeting.” Source location Response from BSMHFT
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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 Update the ligature risk assessment model to cover more cells over time and maintain an audit trail of previously viewed cells.
Verbatim wording from the response “NHS Annual Risk Assessment
The Trust had already identified the sampling of cells under the Ligature Risk Assessment as an area for improvement and prior to the inquest had provided evidence that the assessment model had already been updated to enable greater coverage of cells from year to year and to generate an audit trail for those cells which had been viewed in previous years.” Source location Response from BSMHFT
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation View every prison cell during the annual ligature risk assessment, subject to the prison providing assessor access.
Verbatim wording from the response “on accessing any particular cell. Having received this assurance the Trust were able to reconsider the proportionality of the assessment and confirm to you that in future years the Ligature Risk Assessment would view all cells provided that the prison provided access.” Source location Response from BSMHFT
Open published 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 prison, not the Trust, is responsible for implementing actions from prison risk assessments, including repairs and fabric upgrades.
Verbatim wording from the response “This gives us some concern as the wording suggests that the Trust has some element of control or can take action on any Risk Assessment carried out by the Prison. It was agreed in evidence at the inquest that any actions developed within Risk Assessments carried out by either BSMHFT or the Prison, would need to be taken by the Prison and not BSMHFT, as the Trust has no control to make any repairs or fabric upgrades within the prison. The prison are ultimately responsible for any actions, although we also monitor these through regular meetings with the prison. I would be grateful if you can make any necessary amendments to this point as we consider it is misleading.” Source location Response from BSMHFT
Open published response
27 Apr 2022 Natasha Mary ADAMS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to follow the Care Management & CPA/Care Support Policy 2019 when downgrading levels of care View source Delays in auditing other patients' compliance with the Care Management & CPA/Care Support Policy 2019 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Natasha Mary ADAMS · 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
Natasha Mary ADAMS died by suicide at home on 12 August 2021 after presenting to hospital with recent fleeting suicidal thoughts and being assessed as in crisis. The report identified concerns that her level of mental health care had been downgraded without clinicians following the relevant policy, and that an audit of other patients had not been undertaken four months after it was identified as an action.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the Care Management & CPA/Care Support Policy 2019 when downgrading levels of care
Wider context from the report “BSMHFT's Root Cause Analysis Report identified that in July 2021 Natasha's level of care level was downgraded from CPA to Care Support without clinicians following the trust's Care Management & CPA/Care Support Policy 2019 . I heard evidence from Natasha's family this had a dramatic impact on Natasha's mental health. The RCA action plan identified the need to conduct an audit of other patients to check the trust's compliance with the Care Management & CPA/Care Support Policy 2019. The RCA Report was released in December 2021. The evidence was that 4 months later no action has been taken and other patients have not yet had their cases audited. The delay is the trust's Clinical Governance Committee needs to approve the audit process, which is unlikely to happen until the summer of 2022, and possibly not until as late as September 2022 because of staff holidays. In my view until such a delay is of serious concern and action should be taken to bring forward the audit.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in auditing other patients' compliance with the Care Management & CPA/Care Support Policy 2019
Wider context from the report “BSMHFT's Root Cause Analysis Report identified that in July 2021 Natasha's level of care level was downgraded from CPA to Care Support without clinicians following the trust's Care Management & CPA/Care Support Policy 2019. I heard evidence from Natasha's family this had a dramatic impact on Natasha's mental health. The RCA action plan identified the need to conduct an audit of other patients to check the trust's compliance with the Care Management & CPA/Care Support Policy 2019. The RCA Report was released in December 2021. The evidence was that 4 months later no action has been taken and other patients have not yet had their cases audited. The delay is the trust's Clinical Governance Committee needs to approve the audit process , which is unlikely to happen until the summer of 2022, and possibly not until as late as September 2022 because of staff holidays. In my view until such a delay is of serious concern and action should be taken to bring forward the audit.
” 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 an audit of compliance with the Care Management and CPA/Care Support Policy 2019 across other patients.
Verbatim wording from the response “I understand that the report was given due to the lack of actions taken around the recommendation for the need to conduct an audit of other patients to check the trust's compliance with the Care Management & CPA/Care Support Policy 2019. Firstly I am very sorry that this action has not taken place. As a Trust we are taking our action plans very seriously and are working to improve patient care for the future, where lessons are identified within our Serious Incident reviews.” Source location 2022-0124-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust_Published
Open published response
25 Mar 2021 Azra Parveen HUSSAIN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Failure to provide families with direct remote participation in MDT meetings View source Failure to raise incident reports for significant suicide-related information View source Failure to record significant family concerns and patient accounts View source Failure to update risk screens after significant changes in presentation View source Failure to remove or mitigate ligature risks from bedroom-area doors View source Failure to communicate significant risk information in handovers and MDTs View source Continuing ligature risk from en-suite and other doors in unobserved areas of mental health units View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Azra Parveen HUSSAIN · 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
Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with direct remote participation in MDT meetings
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to raise incident reports for significant suicide-related information
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised , and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant family concerns and patient accounts
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra . Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update risk screens after significant changes in presentation
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated , an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to remove or mitigate ligature risks from bedroom-area doors
Wider context from the report “2. BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk : the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufactures for 10 years. BSMHT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in-patient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate significant risk information in handovers and MDTs
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020 . Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Continuing ligature risk from en-suite and other doors in unobserved areas of mental health units
Wider context from the report “2. BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk: the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufactures for 10 years. BSMHT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in-patient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country .
” 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 Establish an expert group to determine prioritisation of bedroom-door pressure alarm installations.
Verbatim wording from the response “As part of this review we are recommending that we develop a work programme to apply continuous door pressure alarm systems to the bedroom doors on a number of our wards. This is a significant piece of work and we are prioritising the wards to which we will initially apply these systems based on acuity of patients and ligature history prevalence. We have established an expert group to assist us in determining the prioritisation process which includes a mental health expert from the Quality Team at NHS England and our Mental Health Quality Lead from Birmingham and Solihull Clinical Commissioning Group. We will have reached a decision on prioritisation and the associated timeline by the end of May 2021. There are a number of factors that will contribute to the timeline for delivery including:-” Source location 2021-0082-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and prioritise a work programme for continuous pressure alarms on bedroom doors, with a delivery timeline decision by the end of May 2021.
Verbatim wording from the response “As part of this review we are recommending that we develop a work programme to apply continuous door pressure alarm systems to the bedroom doors on a number of our wards. This is a significant piece of work and we are prioritising the wards to which we will initially apply these systems based on acuity of patients and ligature history prevalence. We have established an expert group to assist us in determining the prioritisation process which includes a mental health expert from the Quality Team at NHS England and our Mental Health Quality Lead from Birmingham and Solihull Clinical Commissioning Group. We will have reached a decision on prioritisation and the associated timeline by the end of May 2021. There are a number of factors that will contribute to the timeline for delivery including:-” Source location 2021-0082-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust-Redacted
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 Review physical, relational and procedural controls to strengthen safety across acute inpatient wards and present recommendations for approval.
Verbatim wording from the response “When considering the safety of our inpatient environment, we approach this using a framework that incorporates the triad of physical, relational and procedural security and controls. We have commenced a full review of all of these controls to strengthen the safety of our acute inpatient wards. The results of the review and the associated recommendations will be presented to our Integrated Quality Committee for approval, who in turn report directly to our Trust Board of Directors.” Source location 2021-0082-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust-Redacted
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 Establish a rolling capital programme supporting ongoing ligature-safety works across the estate.
Verbatim wording from the response “We are also establishing a rolling capital programme to support ongoing ligature works to all of our Estate.” Source location 2021-0082-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust-Redacted
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 Offer families participation in formal MDT meetings where clinically appropriate, subject to consent, confidentiality, relationship, risk and safeguarding considerations.
Verbatim wording from the response “With regard to involvement of families in formal MDT meetings we will involve families within the MDT meeting itself where there is clinically appropriate. It will not always be appropriate as such decisions will be influenced by a number of things such as:-” Source location 2021-0082-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust-Redacted
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 Family attendance at formal MDT meetings cannot always be offered because of consent, confidentiality, safeguarding, and risks to patients or others.
Verbatim wording from the response “With regard to involvement of families in formal MDT meetings we will involve families within the MDT meeting itself where there is clinically appropriate. It will not always be appropriate as such decisions will be influenced by a number of things such as:-” Source location 2021-0082-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust-Redacted
Open published response
17 Aug 2020 Ian Allen · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of clear national guidance on clozapine monitoring frequency and blood test type View source Lack of a system for escalating blood test results to the consultant View source Lack of understanding of the importance and frequency of clozapine level monitoring View source Failure to act on high clozapine blood test results through repeat testing and dose adjustment View source Insufficient education of Mental Health practitioners on clozapine monitoring and level adjustment View source Lack of understanding of clozapine monitoring, blood test selection and drug effects View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ian Allen · 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
Ian Allen collapsed suddenly at the nursing home where he resided on 31 December 2019 and died soon after arriving at hospital. The medical cause of death was clozapine toxicity. Concerns included a high clozapine blood level not being acted upon, inadequate monitoring and dose adjustment after smoking cessation, and the absence of a system to escalate blood test results to the consultant.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear national guidance on clozapine monitoring frequency and blood test type
Wider context from the report “4. I heard evidence at the inquest that there was a general lack of understanding about clozapine monitoring, which blood test to undertake and the general effect this drug can have on patients. I heard evidence that national guidance was required to clearly set out how frequently clozapine levels should be monitored and what type of blood test should be undertaken.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for escalating blood test results to the consultant
Wider context from the report “2. There was no system in place at the time to ensure blood test results were escalated to the consultant to ensure action was 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the importance and frequency of clozapine level monitoring
Wider context from the report “3. There was a general lack of understanding at the inquest about the importance of monitoring clozapine levels and how frequently these levels should be monitored.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on high clozapine blood test results through repeat testing and dose adjustment
Wider context from the report “1. In February 2019 a blood test result confirmed that Mr Allen had a high level of clozapine in his blood. This was not acted upon and no further blood test was taken. The clozapine dose was not adjusted as it should have been.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient education of Mental Health practitioners on clozapine monitoring and level adjustment
Wider context from the report “5. Further education is required of Mental Health practitioners on the importance of clozapine monitoring and level adjustment.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of clozapine monitoring, blood test selection and drug effects
Wider context from the report “4. I heard evidence at the inquest that there was a general lack of understanding about clozapine monitoring, which blood test to undertake and the general effect this drug can have on patients. I heard evidence that national guidance was required to clearly set out how frequently clozapine levels should be monitored and what type of blood test should be undertaken.
” 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 Audit all patients prescribed clozapine on the identified doctor’s caseload for unconsidered anomalous results.
Verbatim wording from the response “We have commenced an audit of all patients prescribed Clozapine on Dr ████████’s caseload to ensure that there are no other patients for whom anomalous results have not been considered. In addition, we are in the process of issuing a practice alert to all of our Doctors reminding them of the importance of review when anomalous results are evident.” Source location 2020-0161-Response-from-Birmingham-and-Solihull-Mental-Health-Trust_Redacted.pdf
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 Strengthen multidisciplinary meeting focus on physical health and include clozapine in quality-improvement checks of testing and abnormal-result actions.
Verbatim wording from the response “We have existing Multi-Disciplinary team meetings in place across our organisation and are now specifically strengthening the focus on physical health within these meetings utilising a quality improvement approach. This will provide an additional system for checking that periodic tests have taken place, ensuring that they are routinely acted upon when they are abnormal. Clozapine has now been added to this project to increase awareness.” Source location 2020-0161-Response-from-Birmingham-and-Solihull-Mental-Health-Trust_Redacted.pdf
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 Send pharmacy reports of clozapine results above 600 to the Clozapine Lead for direct escalation to the Consultant and Divisional Pharmacist.
Verbatim wording from the response “There is a system in place whereby anomalous results received are escalated to the Consultant, for example, via the Multi-Disciplinary Team meeting, the administrative staff in receipt of paper results or by junior medical staff who have checked electronic investigations; however on this occasion it appears that this failed. We have therefore put in place an additional control whereby our Information Team will send a report to the pharmacy Clozapine Lead of any results >600 so that these can be escalated directly to the Consultant and the Divisional Pharmacist so that appropriate action can be taken. This will include discussion and action where appropriate at the Multi-Disciplinary Team meeting.” Source location 2020-0161-Response-from-Birmingham-and-Solihull-Mental-Health-Trust_Redacted.pdf
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 Deliver clozapine education for junior doctors through the postgraduate medical education programme, using learning from the regulation 28 report.
Verbatim wording from the response “In addition, we are working with our Post Graduate Medical Education training programme to utilise the learning from the regulation 28 report in the training of junior doctors on the use of clozapine and the importance of acting upon abnormal results where it is deemed necessary.” Source location 2020-0161-Response-from-Birmingham-and-Solihull-Mental-Health-Trust_Redacted.pdf
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 clozapine training to pharmacists to promote consistent advice and rapid responses.
Verbatim wording from the response “This guidance will be approved in November 2020 and once this has been completed, this will be disseminated round the Trust as a reminder to other staff to ensure that they are complying with the updated guidance. We have already provided all pharmacists with some additional training on Clozapine so we have more consistent advice and can respond quickly where necessary.” Source location 2020-0161-Response-from-Birmingham-and-Solihull-Mental-Health-Trust_Redacted.pdf
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 Review and update the Trust clozapine guidelines following the investigation into Mr Allen’s death.
Verbatim wording from the response “As you may be aware from the Mr ████████s evidence at inquest; the Trust is currently in the process of reviewing and updating the Trust Clozapine guidelines following the investigation carried out into Mr Allen’s death. We understand that on 26 August 2020, in response to the Prevention of Future death reports from the Coroner there has now been an update in the MHRA guidance in relation to clozapine.” Source location 2020-0161-Response-from-Birmingham-and-Solihull-Mental-Health-Trust_Redacted.pdf
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 Issue a practice alert to doctors reminding them to review anomalous clozapine results.
Verbatim wording from the response “We have commenced an audit of all patients prescribed Clozapine on Dr ████████’s caseload to ensure that there are no other patients for whom anomalous results have not been considered. In addition, we are in the process of issuing a practice alert to all of our Doctors reminding them of the importance of review when anomalous results are evident.” Source location 2020-0161-Response-from-Birmingham-and-Solihull-Mental-Health-Trust_Redacted.pdf
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 Draft and send a clozapine safety alert to clinicians to support immediate action where necessary.
Verbatim wording from the response “In addition, as we set out in response to your first point, further education will be built into the Post Graduate Medical Education programme to address any gaps in knowledge on clozapine. A safety alert is also being drafted and sent to all clinicians so that immediate action can be taken where necessary.” Source location 2020-0161-Response-from-Birmingham-and-Solihull-Mental-Health-Trust_Redacted.pdf
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 Disseminate the approved updated clozapine guidance across the Trust as a staff reminder.
Verbatim wording from the response “This guidance will be approved in November 2020 and once this has been completed, this will be disseminated round the Trust as a reminder to other staff to ensure that they are complying with the updated guidance. We have already provided all pharmacists with some additional training on Clozapine so we have more consistent advice and can respond quickly where necessary.” Source location 2020-0161-Response-from-Birmingham-and-Solihull-Mental-Health-Trust_Redacted.pdf
Open published response
22 Oct 2019 Nigel Byron Abbott · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 10 Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community View source Failure to learn and correct identified unsafe beliefs about section 135 warrants View source Mental health professionals operating caseloads well in excess of recommended levels View source Failure of agencies to work together effectively View source Failure to use section 4 for urgent cases View source Failure to provide section 140 beds View source Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments View source Chronic shortage of psychiatric beds View source Failure of agencies to work together effectively on mental health detention processes View source Misunderstanding between agencies about urgent section 135 warrant requirements View source See 7 more concerns
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
Nigel Byron Abbott · 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
On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn and correct identified unsafe beliefs about section 135 warrants
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected .
My on-going concern is that the agencies involved in this area are not working together effectively. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Mental health professionals operating caseloads well in excess of recommended levels
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to work together effectively
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use section 4 for urgent cases
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used .
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide section 140 beds
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT .
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments .
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Chronic shortage of psychiatric beds
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds .
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to work together effectively on mental health detention processes
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process , reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected.
My on-going concern is that the agencies involved in this area are not working together effectively . The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding between agencies about urgent section 135 warrant requirements
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation . This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available . All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected.
My on-going concern is that the agencies involved in this area are not working together effectively. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report
27 Sep 2019 Anthony Joseph McCormack · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Unavailability of inpatient beds for people assessed and fit for detention View source Failure of home treatment team capacity and resources to support adequate patient assessment and monitoring View source
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.
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AI-generated summary
Anthony Joseph McCormack · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Joseph McCormack was found dead at home on 7 May 2019 after concerns about his wellbeing. He had been identified as in crisis and assessed as fit for detention, but no inpatient bed was available; concerns included inadequate assessment and monitoring by overstretched community mental health services. The inquest concluded that the death was suicide due to the unavailability of an inpatient mental health bed.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of inpatient beds for people assessed and fit for detention
Wider context from the report “1. Between the 16th March 2019 and the 25th April 2019, a bed could not be found for the Deceased even though he had been assessed and fit for detention . The absence of a bed meant that Mr. McCormack was not adequately assessed and appropriate treatment could not be given. With inpatient admission it is unlikely Mr. McCormack would have taken his life. The evidence from witnesses from BSMHT was that there continues to be a shortage of beds .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of home treatment team capacity and resources to support adequate patient assessment and monitoring
Wider context from the report “2. Evidence was given that the case load of the home treatment team to whom Mr. McCormack was referred is carrying 5 times the number of patients it was originally intended for and does not have the resources to provide adequate assessment and monitoring to patients thereby putting lives at risk.
” Open source report
6 Sep 2019 Ms Shannon Quinn · Prevention of Future Deaths report Black Country
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Concerns raised 7 Failure to adhere to the five-minute patient observation level View source Inconsistent and minimal training for care staff in managing complex patient needs View source Minimal training for care staff in performing patient resuscitation View source Lack of a joint multidisciplinary care plan View source Inconsistent sharing of clinical documentation and care plans between statutory agencies and private-sector care providers View source Insufficient contact with the care coordinator View source Failure to provide a ligature-free environment despite escalating ligature and self-harm risk View source See 4 more concerns
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
Ms Shannon Quinn · 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
Ms Shannon Quinn, a 24-year-old woman with a complex mental health history and repeated self-harm, was found hanging in her room at Oak House on 9 January 2019 and was pronounced deceased shortly afterwards. The report identified concerns including inadequate information sharing and joint care planning, insufficient staff training, escalating ligature risk without sufficient environmental measures, and failure to adhere to five-minute observations.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to the five-minute patient observation level
Wider context from the report “5. The patient observation level of 5 minutes was introduced to minimise risk of self-harm but not adhered to .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent and minimal training for care staff in managing complex patient needs
Wider context from the report “2. There was inconsistent and minimal training provided to Oak House staff in respect of managing SQ’s complex needs by the Mental Health Trust.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Minimal training for care staff in performing patient resuscitation
Wider context from the report “6. Evidence emerged during the inquest that there had been minimal training for Oak House staff in performing resuscitation on patients . The training received included general first aid training by e-learning .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a joint multidisciplinary care plan
Wider context from the report “3. There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent sharing of clinical documentation and care plans between statutory agencies and private-sector care providers
Wider context from the report “1. Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the statutory agencies and private sector . In particular, there was no sharing of medical notes/care plans between the Birmingham and Solihull and Mental Health Trust and Oak House .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient contact with the care coordinator
Wider context from the report “3. There was a lack of a joint multi-disciplinary/Trust care plan and insufficient contact with the care coordinator due to difficulties in travelling to meet the patient outside the normal Trust area and staff sickness absence.
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a ligature-free environment despite escalating ligature and self-harm risk
Wider context from the report “4. There was an escalating risk of use of ligatures and incidents of self-harm and little if any measures were introduced to try and provide a ligature free environment .
” Open source report
22 Jul 2019 Richard Patrick Carlon · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Unavailability of approved Mental Health practitioners for Mental Health Act assessments View source Failure to advise BSMHT when a person is found safe and well at home View source
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
Richard Patrick Carlon · 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
Richard Patrick Carlon, who had paranoid schizophrenia and a history of relapsing after taking illicit substances, was detained under the Mental Health Act after stating that he would kill himself. He later left care, was found at his father’s home, and subsequently stepped in front of a lorry; he died in hospital from polytrauma following the road traffic collision. The concerns included the lack of an approved Mental Health practitioner to conduct an assessment and failures in communication between the police and mental health services after he was found safe and well.
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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of approved Mental Health practitioners for Mental Health Act assessments
Wider context from the report “1. No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr Carlon on 14/11/18. I was told this was an ongoing problem and was delaying assessments .
” 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 Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise BSMHT when a person is found safe and well at home
Wider context from the report “2. When Mr Carlon was found safe and well at home WMP did not advise BSMHT . This was a missed opportunity for Mental health to re-engage with Mr Carlon and make a further assessment of his condition. Consideration need to be given to how agencies can improve communication.
” 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