12 Jul 2019 David Jonathon Jukes · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure to follow through plans made to discuss and assess patients View source Failure to maintain accurate records of contacts, decisions and risk assessments View source Failure of the system to carry out necessary psychiatric assessments in police custody View source Failure to use all available means to locate patients requiring assessment View source Failure to ensure staff compliance with record-keeping duties is detected View source Failure to provide material arrest information for mental health assessments in custody View source Failure to attempt timely assessment after a high-risk patient re-establishes contact View source Failure to pass reliable information between mental health services View source Insufficient HTT capacity to maintain progress notes and risk assessments View source See 6 more concerns
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AI-generated summary
David Jonathon Jukes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.
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 through plans made to discuss and assess patients
Wider context from the report “5. It was planned that Mr. Jukes would be discussed at a team meeting on the 3rd October 2018 after the psychologist raised concerns on the 2nd. There is no credible evidence he was discussed or a plan made to locate and assess him . No explanation was provided in evidence for why evidence given of a strategy to guard against this occurring in future. Therefore there continues to be a risk that plans to discuss patients in meetings will not be followed through which puts lives at risk.
” 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 accurate records of contacts, decisions and risk assessments
Wider context from the report “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes . Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment . There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited. Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected.
” 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 system to carry out necessary psychiatric assessments in police custody
Wider context from the report “3. Despite not being informed by the BCPFT liaison and diversion nurse that Mr Jukes was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018. She also gave some information about the circumstances of his arrest, further information about the incident and police involvement had been reported to Street Triage during the night and was noted in the RIO notes. Despite this, no psychiatrist visited or attempted to visit Mr. Jukes in custody which it was stated in evidence was the usual practice of the team. It is not known why this was. Not having a robust and effective system to carry out necessary assessments whilst a patient is detained in police custody puts lives at risk.
” 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 all available means to locate patients requiring assessment
Wider context from the report “4. Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was treating suicide and harm to others, on the 2nd October 2018 the HTT’s only recorded attempt to contact Mr. Jukes before the 9th October 2018 was a single call (which probably mistakenly went to his wife’s phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication to Mr. Jukes (although he had communicated this way with the team before and provided them with his email address) nor a call to his wife to ask her for assistance . There was evidence at inquest from the RCA Author that there should have been more effort to contact him at least from the 4th onwards if not before. Failure to utilise all means of locating a patient whereabouts are unknown, who requires assessment and who is not making contact with the team puts lives at risk.
” 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 ensure staff compliance with record-keeping duties is detected
Wider context from the report “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes. Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment. There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited . Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected.
” 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 material arrest information for mental health assessments in custody
Wider context from the report “1. The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr. Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody . She was provided with a print out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft, threatened suicide and harm to others and not come out in response to police negotiators. This information was not included in a verbal handover according to the nurse’s evidence and there is no record of it being handed over to her. She stated in evidence that if she had been aware of the extent of the events overnight on the 27th into the 28th she would have arranged a Mental Health Act assessment when he did not engage with her. There is a risk to life if assessments of mental health in custody are not informed by material information about circumstances connected with arrest.
” 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 attempt timely assessment after a high-risk patient re-establishes contact
Wider context from the report “6. On the 9th October 2018 an HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018 . By this time he was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances, had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week. This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact . The staff involved maintained in evidence that they acted appropriately, evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk . No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues.
” 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 pass reliable information between mental health services
Wider context from the report “2. The above psychiatric liaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based at Perry Barr custody suite and was informed that Mr. Jukes was not known to the service. She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of his previous evening. It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred . Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn’t explain why the nurse was left with the impression that he was not known to services. It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise . If reliable information is not being passed there is a risk to life from ill-informed decision making.
” 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 HTT capacity to maintain progress notes and risk assessments
Wider context from the report “8. Evidence was given at the inquest that the reason HTT may not be maintaining good record keeping was due to insufficient capacity arising from a combination of too few staff arising from under-funding of the service and unnecessary referrals being made to the team . Evidence was given that there is work underway to introduce a systems to prevent inappropriate referrals and that funding has been granted for a further two CPNS for HTTs within BSMHT. However the evidence was that this will not be enough to enable staff to have the time to comply with their obligations to update progress notes and risk assessments . If funding is not sufficient to enable staff to fulfil their professional obligations to their patients, lives are at risk.
” 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 Develop and pilot mandatory clinical risk assessment and management training covering cumulative risk factors, suicide prevention and risk documentation.
Verbatim wording from the response “In direct response to this matter of concern we are now reviewing our Home Treatment Team Operating Protocol to strengthen the requirement for nurse led triage and assessment screening and appropriate clinical escalation to a Consultant Psychiatrist. Consultant Psychiatrist overview and scrutiny of each case would either be through direct clinical assessment or review or through input and direction within the multi-disciplinary team or through formal or informal supervision of doctors and other home treatment staff. We note the view of the team that they felt they acted appropriately and are therefore also using this very sad incident as a Case Study in our new Clinical Risk Assessment and Management Training so that staff are fully alert to accumulative risk factors. This training is mandatory for all clinical staff in the Trust irrelevant of clinical profession or team.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-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 Review the Home Treatment Team operating protocol to strengthen nurse-led triage, assessment screening and escalation to consultant psychiatrists.
Verbatim wording from the response “In direct response to this matter of concern we are now reviewing our Home Treatment Team Operating Protocol to strengthen the requirement for nurse led triage and assessment screening and appropriate clinical escalation to a Consultant Psychiatrist. Consultant Psychiatrist overview and scrutiny of each case would either be through direct clinical assessment or review or through input and direction within the multi-disciplinary team or through formal or informal supervision of doctors and other home treatment staff. We note the view of the team that they felt they acted appropriately and are therefore also using this very sad incident as a Case Study in our new Clinical Risk Assessment and Management Training so that staff are fully alert to accumulative risk factors. This training is mandatory for all clinical staff in the Trust irrelevant of clinical profession or team.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-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 clear multidisciplinary-team standards and recording requirements through a quality-improvement project.
Verbatim wording from the response “As you state, it is vitally important that clinical records are documented to evidence the care and treatment plans for patients that are discussed between clinicians. We have identified that when our Multi-Disciplinary Team meetings take place there is evidence of some inconsistency in the recording of discussions and outcomes in some areas. In direct response to this finding we have increased administrative resources within our Home Treatment Teams to enable consistent administrative support to our Multi-Disciplinary Team meetings which in turn will ensure that outcomes are clearly recorded. In addition, we have commenced a Quality Improvement Project to develop clear standards for Multi-Disciplinary Team meetings and recording requirements. We apologise sincerely for this failing in our clinical record keeping for Mr Jukes.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-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 a joint operating protocol with the Sandwell Liaison and Diversion Service for custody-based patient assessment.
Verbatim wording from the response “We are grateful to you for raising this matter with us as it has identified the need for a joint operating protocol to be developed between BSMHT and the Liaison and Diversion Service in Sandwell. We have been in liaison with this team and are scheduled to meet and develop this protocol in late September 2019.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase Home Treatment Team workforce capacity through additional managers, practitioners, medical staff, psychologists and administrative staff.
Verbatim wording from the response “We are conscious that our Home Treatment Teams have been operating within an environment of high demand and acuity and that may at times compromise their ability to consistently meet the important standards that we expect of staff. We are investing a significant amount of new financial resource into our Home Treatment Team to increase workforce capacity. This includes:” Source location 2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase administrative support for Home Treatment Team multidisciplinary meetings so discussions and outcomes are recorded consistently.
Verbatim wording from the response “As you state, it is vitally important that clinical records are documented to evidence the care and treatment plans for patients that are discussed between clinicians. We have identified that when our Multi-Disciplinary Team meetings take place there is evidence of some inconsistency in the recording of discussions and outcomes in some areas. In direct response to this finding we have increased administrative resources within our Home Treatment Teams to enable consistent administrative support to our Multi-Disciplinary Team meetings which in turn will ensure that outcomes are clearly recorded. In addition, we have commenced a Quality Improvement Project to develop clear standards for Multi-Disciplinary Team meetings and recording requirements. We apologise sincerely for this failing in our clinical record keeping for Mr Jukes.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve care-planning and clinical-risk-assessment processes through a quality-improvement project.
Verbatim wording from the response “In addition to this, we have launched two critical Quality Improvement Projects – one is to develop and implement core MDT minimum standards for recording of clinical documentation; the second is to improve our care planning and clinical risk assessment processes.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-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 Use a clinical-record communication-preference field to support contact with patients through appropriate channels.
Verbatim wording from the response “We sincerely apologise for this matter. The matter of communication preferences is being addressed by the Trust in that we now have a communication preference field within the clinical record RIO.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Open published response
25 Mar 2019 Nora Theresa Bruton · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure to maintain robust communication of crisis calls across care-delivery teams View source Failure to disseminate revised Clinical Risk Assessment training to treating clinicians View source Delays in completing the Home Treatment Team model review and overhaul 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
Nora Theresa Bruton · 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
Nora Theresa Bruton was found face down in a pond on 15 November 2018 and was declared deceased at the scene. Post-mortem and toxicological evidence indicated death by drowning while under the influence of alcohol. The report identified concerns about insufficient assessment of the impact of increased alcohol on suicidal thinking and self-risk, lack of referral to Addiction Services, and gaps in communication and recording of crisis calls between mental health teams.
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 maintain robust communication of crisis calls across care-delivery teams
Wider context from the report “2. A review of the protocol for communicating crisis calls to all teams involved in care delivery to ensure a robust system of communication has not been acted upon . I heard evidence that prior to Nora’s death there had been two separate incidents which led to significant patient harm and/or death which involved gaps in crisis call communication . Consideration should be given to ensuring this review takes place and the protocol appropriately modified as a matter of urgency;
” 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 disseminate revised Clinical Risk Assessment training to treating clinicians
Wider context from the report “1. A recommendation contained within the RCA report to carry out a review of the Clinical Risk Assessment training to incorporate clear risk formulation and management around harmful substance abuse, had been carried out, but this has had not been adequately disseminated to clinicians on the ground . Consideration therefore should be given to ensuring proper dissemination of this revised training to all treating clinicians as a matter of urgency;
” 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 completing the Home Treatment Team model review and overhaul
Wider context from the report “3. I heard evidence that the Home Treatment Team model was undergoing a process of review and overhaul, and that this process had taken approximately 18 months to date but there was no estimate of when this would be completed by . Consideration should therefore be given as to ensuring that this review is concluded as a matter of urgency and any changes to the Home Treatment Team model are implemented with similar urgency.
” 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 Implement a dedicated crisis email system with weekday support and roll it out to Community Mental Health Teams.
Verbatim wording from the response “We have taken the opportunity to strengthen our internal arrangements for communicating crisis messages through the development of a dedicated crisis email address within our Home Treatment Teams. During the hours of Monday to Friday 0900 to 1700 hours, there is dedicated support to manage this system and to allocate calls. This system has been evaluated positively and is now being rolled out to our Community Mental Health Teams.” Source location 2019-0099-Response-by-Birmingham-and-Solihull-mental-Health-NHS-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 Increase out-of-hours service capacity by assigning a senior clinician each evening to manage and triage Home Treatment Team activity.
Verbatim wording from the response “We have also increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm – 2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by administrative staff and handed over with a signature to qualified staff to action.” Source location 2019-0099-Response-by-Birmingham-and-Solihull-mental-Health-NHS-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 Reorganise administrative call handling and signed handover to qualified staff for action.
Verbatim wording from the response “We have also increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm – 2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by administrative staff and handed over with a signature to qualified staff to action.” Source location 2019-0099-Response-by-Birmingham-and-Solihull-mental-Health-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and operate a working group to devise a pilot of revised clinical risk training.
Verbatim wording from the response “I am able to confirm that a working group has now been established to devise a pilot of reviewed clinical risk training both in terms of content and the way it is delivered. We are in the final editorial stages of a new Dual diagnosis policy which will be launched across the organisation by the end of July 2019 which also confirms the guidance, policy and practice to be adhered to when treating patients with dual diagnosis. Referral processes from acute care to alcohol and substance misuse providers have now been formalised and the Trust is now formally referring patients to these providers rather than relying on self referral by service users.” Source location 2019-0099-Response-by-Birmingham-and-Solihull-mental-Health-NHS-Trust
Open published response
7 Feb 2019 Stephen Anthony Kennedy · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Unavailability of acute inpatient beds View source Unavailability of timely psychological services due to internal service structures and waiting lists 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
Stephen Anthony Kennedy · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Anthony Kennedy had a history of emotional unstable personality disorder, depression and frequent self-harm, and his condition deteriorated during 2018. He was found hanging at his home on 08/10/18 and was declared deceased. Concerns included that psychological therapy was unavailable because of service structures and long waiting lists, and that a lack of acute inpatient beds contributed to further episodes of self-harm and suicide attempts.
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 acute inpatient beds
Wider context from the report “2. In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts. The availability of acute beds is a serious concern .
” 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 timely psychological services due to internal service structures and waiting lists
Wider context from the report “1. The deceased suffered from emotional unstable personality disorder and was in crisis for most of 2018. The recommended treatment for his condition was psychological therapy. He had not had any psychological input since 2010. The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services . He had to be under the community mental health team to be able to access psychological services . There were periods when he was under the care of the community mental health team but at this time he remained on a long waiting list for psychological services . Throughout 2018 he never received any psychological services . I am concerned that the main treatment option for the deceased was not available to him due to internal structures and long waiting lists .
” 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 clinical psychology capacity within every Home Treatment Team.
Verbatim wording from the response “With regard to the matter of Psychological Therapy, I am able to confirm that we now have a plan for investing in clinical psychology capacity within our Home Treatment Team services. From September 2019, subject to recruitment, we anticipate to be in a position whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist within their team. Approval has been given to advertise these posts and this will help us to ensure compliance with NICE guidance and to deliver clinically effective care as per recommended guidelines. The Clinical Psychologist will also contribute to multi disciplinary team assessments, discussions and decisions relating to care planning and treatment options for patients, as well as providing supervision to other members of the team. We are also increasing nursing capacity to ensure that community caseloads are more manageable.” Source location 2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-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 Reduce delayed discharges to improve acute bed availability.
Verbatim wording from the response “On the matter of bed availability, it is recognised that at times patients are unable to access a bed at the point of clinical decision making and that this can lead to increased risk, despite best efforts to manage patients safely in an alternative environment. We are undertaking a number of initiatives to try to mitigate this risk including:-” Source location 2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint patient flow coordinators to mitigate inpatient bed availability risks.
Verbatim wording from the response “On the matter of bed availability, it is recognised that at times patients are unable to access a bed at the point of clinical decision making and that this can lead to increased risk, despite best efforts to manage patients safely in an alternative environment. We are undertaking a number of initiatives to try to mitigate this risk including:-” Source location 2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review patient flow to mitigate risks associated with unavailable inpatient beds.
Verbatim wording from the response “On the matter of bed availability, it is recognised that at times patients are unable to access a bed at the point of clinical decision making and that this can lead to increased risk, despite best efforts to manage patients safely in an alternative environment. We are undertaking a number of initiatives to try to mitigate this risk including:-” Source location 2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Open published response
21 Jan 2019 Neil Antony Black · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to examine injection sites and DVT sites View source Lack of joint handovers between drug detoxification and primary care nurses View source Failure to maintain an effective working relationship between IDTS and primary care nurses View source Unclear allocation of responsibility for prisoner observations View source See 1 more concern
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
Neil Antony Black · 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
Neil Antony Black was remanded into HMP Birmingham on 8 March 2018 after disclosing extensive alcohol and intravenous drug use and a DVT in his right leg. He became increasingly unwell in prison, was admitted to hospital on 12 March with suspected sepsis, and was diagnosed with infective endocarditis and lung abscesses before deteriorating to multi-organ failure and dying on 31 March 2018. The report identified concerns about inconsistent physical observations, inadequate interaction between prison healthcare teams, unclear responsibilities, and the lack of examination of his leg and injection sites.
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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 Failure to examine injection sites and DVT sites
Wider context from the report “3. Neil Black came into prison with a DVT in his right leg which was caused by IV drug use injecting into his groins. His groins sites and leg were not examined during his time at the prison . Consideration needs to be given to ensure there is a clear protocol for the examination of injection sites and DVT sites.
” 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 joint handovers between drug detoxification and primary care nurses
Wider context from the report “1. BWing is the drug detoxification wing at Birmingham prison. Prisoners undergoing drug detoxification see IDTS nurses for drug needs and primary care nurses for health care needs. Prisoners on B wing often have complex mixed needs . The evidence at the inquest confirmed there were no joint handovers despite the nurses being located very close to each other. Consideration needs to be given to joint handovers to ensure those prisoners with joint needs have a coordinated approach.
” 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 effective working relationship between IDTS and primary care nurses
Wider context from the report “2. Evidence at the inquest confirmed that there was some animosity between IDTS and primary care nurses . In addition witnesses were unclear who should undertake what observations on prisoners and for what reason. Consideration needs to be given to improving the relationship and making it clearer who is responsible for what observations.
” 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 allocation of responsibility for prisoner observations
Wider context from the report “2. Evidence at the inquest confirmed that there was some animosity between IDTS and primary care nurses. In addition witnesses were unclear who should undertake what observations on prisoners and for what reason . Consideration needs to be given to improving the relationship and making it clearer who is responsible for what observations.
” 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 Deliver planned informal inter-team events, including case-busting sessions and team briefings.
Verbatim wording from the response “Whilst we acknowledge there are challenges in the teams working relationships we can also cite a number of good practices and interim team working that we have initiated over the last year. We hold a Management/Leaders meeting every Monday morning where any issues are aired and can be immediately resolved to ensure problems are rapidly discussed and solutions implemented. To further improve the teams working together we have established a Band 7 (Team Manager) meeting for all healthcare teams on a monthly basis. This meeting will provide an opportunity where any issues between the healthcare teams can be openly discussed and resolutions agreed at an appropriately senior level. We have also planned a series of more informal events to support inter team working – these include “case busting” and team briefings.” Source location 2019-0024-Response-by-Birmingham-Community-Healthcare-NHS-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 Implement the physical-observation protocol defining IDTS and B3 responsibilities, NEWS scoring, referral, escalation, and required full observations.
Verbatim wording from the response “In relation to the physical observations there is a new protocol which clarifies the process for physical observations on prisoners. IDTS nurses complete observations for people at risk of withdrawal which ensures people are experiencing a safe detoxification.” Source location 2019-0024-Response-by-Birmingham-Community-Healthcare-NHS-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 Implement joint midday handovers for patients requiring physical healthcare and substance misuse treatment, amend handover records, and audit the process.
Verbatim wording from the response “We commenced a process on 11 February 2019 whereby the Nurse in Charge for both the “B3” team (the primary, or physical, healthcare team employed by BCHC) and the “IDTS” team (the Integrated Drug Treatment Service team employed by BSMH) have a verbal handover at the midday handover for any patients who are presenting as requiring joint care for both physical care and substance misuse treatment. The handover documents for both IDTS and B3 will be amended to ensure these patients discussed are recorded. This will be audited after one month to ensure the process is effective and any amendments to this process will be made.” Source location 2019-0024-Response-by-Birmingham-Community-Healthcare-NHS-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 national guidance and local protocols for DVT management and examination of intravenous injection sites.
Verbatim wording from the response “We have carefully reviewed the national guidelines and our current protocols in relation to both the management of deep vein thrombosis (DVT) and the physical examination of intravenous (IV) injection sites. We are content that our local protocols reflect national guidelines. Unfortunately in this particular case our local protocols were not followed and a reminder went out to all healthcare staff on 13 February 2019 to ensure that all appropriate observations at any physical examination are carried out.” Source location 2019-0024-Response-by-Birmingham-Community-Healthcare-NHS-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 Establish monthly Band 7 meetings for healthcare teams to discuss inter-team issues and agree resolutions.
Verbatim wording from the response “Whilst we acknowledge there are challenges in the teams working relationships we can also cite a number of good practices and interim team working that we have initiated over the last year. We hold a Management/Leaders meeting every Monday morning where any issues are aired and can be immediately resolved to ensure problems are rapidly discussed and solutions implemented. To further improve the teams working together we have established a Band 7 (Team Manager) meeting for all healthcare teams on a monthly basis. This meeting will provide an opportunity where any issues between the healthcare teams can be openly discussed and resolutions agreed at an appropriately senior level. We have also planned a series of more informal events to support inter team working – these include “case busting” and team briefings.” Source location 2019-0024-Response-by-Birmingham-Community-Healthcare-NHS-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 Remind all healthcare staff to complete appropriate observations during physical examinations of injection and DVT sites.
Verbatim wording from the response “We have carefully reviewed the national guidelines and our current protocols in relation to both the management of deep vein thrombosis (DVT) and the physical examination of intravenous (IV) injection sites. We are content that our local protocols reflect national guidelines. Unfortunately in this particular case our local protocols were not followed and a reminder went out to all healthcare staff on 13 February 2019 to ensure that all appropriate observations at any physical examination are carried out.” Source location 2019-0024-Response-by-Birmingham-Community-Healthcare-NHS-Trust
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 Existing local protocols for examining injection and DVT sites reflect national guidelines, so no new examination protocol is required.
Verbatim wording from the response “We have carefully reviewed the national guidelines and our current protocols in relation to both the management of deep vein thrombosis (DVT) and the physical examination of intravenous (IV) injection sites. We are content that our local protocols reflect national guidelines. Unfortunately in this particular case our local protocols were not followed and a reminder went out to all healthcare staff on 13 February 2019 to ensure that all appropriate observations at any physical examination are carried out.” Source location 2019-0024-Response-by-Birmingham-Community-Healthcare-NHS-Trust
Open published response
18 Dec 2018 John Anthony Delahaye · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to conduct a welfare check on cell unlock View source Failure to ensure healthcare attendance at ACCT reviews View source Unreliable recording of relevant past and current medical conditions View source Lack of clarity in the in possession medication risk assessment question View source Failure to use the in possession medication risk assessment View source See 2 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
John Anthony Delahaye · 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
John Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.
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 conduct a welfare check on cell unlock
Wider context from the report “4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not 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 ensure healthcare attendance at ACCT reviews
Wider context from the report “3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
” 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 Unreliable recording of relevant past and current medical conditions
Wider context from the report “2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’ . Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
” 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 in the in possession medication risk assessment question
Wider context from the report “1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate : “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not 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 use the in possession medication risk assessment
Wider context from the report “1. There is confusion surrounding the meaning of the following question from NHS England’s national clinical template for in possession Risk Assessments in the Secure Estate: “Have you had problems in the last 6 months with not taking, or not remembering to take your medicines as prescribed?” The Risk Assessment had not been used in the assessment for Mr. Delahaye’s in possession modification on the 29th January 2018 when it ought to have been. However, during the course of considering what the outcome would have been if the risk assessment had been undertaken, more than one clinician interpreted the question as pertaining only to consideration of incidents where medication had not been taken. It was the Coroner’s view that the question is also asking about incidents where medication may have been taken but not “as prescribed” thus encompassing an overdose (accidental or deliberate). The question is not clear and this creates a risk that the score generated may be incorrect and in possession medication may be authorised where it ought not to be, putting lives at risk.
2. During the inquest it emerged that the mental health nurse who assessed Mr. Delahaye on the 2nd January 2018 and the GP who assessed him for in possession medication on the 29th January 2018, had not identified from his notes all relevant past medical conditions. It emerged that whilst the System One records (a case management system used across the prison estate) has the facility to provide a summary of significant past and current medical conditions, it is not reliable at HMP Birmingham because conditions are not consistently given the correct ‘read code’. Evidence from the NHS England clinical reviewer, ████████, was that this problem is not unique to HMP Birmingham and is found in other prison healthcare teams and requires a change of culture and practice to bring the system for read coding into line with that in the community. The absence of a reliable source for quickly identifying relevant past and current medical conditions puts lives at risk from misinformed decision making.
3. No member of the healthcare team was present at any of Mr. Delahaye’s ACCT reviews. It was identified during the inquest that a member of either the mental health team, primary care or the drug/alcohol service ought to have been present at the first review at least. It was the evidence of a first line manager who had involvement in the ACCT that a member of the custodial team had contacted healthcare and asked them to attend but this was not documented and the healthcare team maintained they were unaware of the date of the first review. Whilst the ACCT book provides a checklist of actions to be undertaken at various times it does not include making healthcare aware of the first review. As this is a national Ministry of Justice form, HMP Birmingham can’t change it but a failure to inform healthcare of an ACCT review could result in useful knowledge or expertise not being available to the ACCT team and could put lives at risk.
4. On the morning of the 5th March 2018 Mr. Delahaye’s cell had been unlocked at approximately 07:50. It is likely that he was already dead at this time (and had been so for some hours) but he was not found because the prison custody officer who unlocked his cell did not look into the cell or seek any kind of acknowledgement from Mr. Delahaye. It was acknowledged by the relevant PCO and by the Safer Custody Manager that unlock ought to have involved a welfare check. The Safer Custody Manager’s evidence is that the need for a welfare check on unlock has been emphasised to senior managers and leads through a bilateral document covered at formal briefings. However, it was not clear how this is then communicated down to the individual custody officers and how they are being audited to make sure they are conducting a welfare check on unlock. The absence of a welfare check creates a risk that a prisoner in need of life saving assistance at the time of unlock is not identified.
” Open source report
18 Sep 2018 Paul Price · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure to accurately record mental health information View source Delays in transferring critical mental health information between mental health services and GPs View source Failure to arrange follow-up after mental health concerns are raised View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Price · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Price had a history of depression and anxiety, and was found outside his room on 04/06/18 after falling from a window; he was pronounced deceased at hospital, with the medical cause of death recorded as multiple injuries. Concerns included delays in communicating mental-health assessment information to his GP, incompatible IT systems, and a failure to return a call about concerns for his wellbeing.
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 accurately record mental health information
Wider context from the report “2. A call was made to the Mental Health team on 01/06/18 raising a concern about Paul’s mental health. The caller was told that the computer systems were down and the mental health team would call back – they did not call back. There is concern that staff are not accurately recording information and arranging follow-up.
” 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 transferring critical mental health information between mental health services and GPs
Wider context from the report “1. Paul was seen for a full assessment on 04/05/18. The summary of that attendance in a letter was not received by the GP until 29/05/18 . In the meantime Paul had attended his GP with ongoing concerns about his mental health and requesting further medication. The delay in receiving critical information about vulnerable patients could put them a risk and result in over prescribing medication . In addition I was told that the IT systems for Birmingham and Solihull Mental Health Trust and the GPs are incompatible meaning that letters have to be faxed or posted causing further delay .
” 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 arrange follow-up after mental health concerns are raised
Wider context from the report “2. A call was made to the Mental Health team on 01/06/18 raising a concern about Paul’s mental health. The caller was told that the computer systems were down and the mental health team would call back – they did not call back. There is concern that staff are not accurately recording information and arranging follow-up .
” 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 Invest in electronic recording, listening devices, and hybrid mail to support timely GP correspondence.
Verbatim wording from the response “1. In relation to the delay in Paul’s GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devices and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.” Source location Paul-Price-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish Trustwide timescales and targets for completing GP letters.
Verbatim wording from the response “1. In relation to the delay in Paul’s GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devices and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.” Source location Paul-Price-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement system changes, including an automated phone system, to record and audit internal and external calls and support message forwarding.
Verbatim wording from the response “3. On the matter of computer systems, staff recording information and following up, we have checked our IT systems and there is no record of unplanned downtime for the 1st June 2018. Any planned downtime tends to be very late into the day and before the start of the morning shift. The failure to pass on the message was a staff error but we are also looking to implement system changes which will support the recording and forwarding of messages. This includes an automated phone call system which will log and audit all phone calls made internally and externally to the Trust. Again I would like to be able to write to you in three months to advise you of our progress in making this system available and implemented across all our hundred plus teams.” Source location Paul-Price-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in developing and implementing Docman electronic mail links with local GP surgeries.
Verbatim wording from the response “We are also in the process of developing an electronic mail system linking to GP surgeries via Hybrid Mail. This system is called Docman and currently there is a project working group being led by Birmingham Women and Children’s NHS Foundation Trust which we have joined. This group is working to implement Docman across all GP surgeries locally and then to develop it as a national system.” Source location Paul-Price-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit additional Home Treatment service staff, proceeding ahead of funding confirmation after submitting a business case to Commissioners.
Verbatim wording from the response “To immediately address this issue we have increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm-2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by our administrative staff and handed over with a signature to qualified staff to action. In the longer term we are seeking to recruit additional staff to our Home Treatment service and have submitted a business case to our Commissioners in this regard. Given the urgency of this issue, we have decided to proceed with recruitment to this team ahead of funding confirmation. Recruitment is about to go live.” Source location Paul-Price-Response2
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 Implement monthly monitoring to ensure GP letters are issued within the nationally required two-week timescale.
Verbatim wording from the response “In addition to this we have implemented a monthly monitoring process to ensure that letters are provided within the nationally required 2 week timescale.” Source location Paul-Price-Response2
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 Increase out-of-hours capacity by assigning a Band 7 senior clinician each evening to manage, triage and assess Home Treatment Team calls.
Verbatim wording from the response “To immediately address this issue we have increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm-2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by our administrative staff and handed over with a signature to qualified staff to action. In the longer term we are seeking to recruit additional staff to our Home Treatment service and have submitted a business case to our Commissioners in this regard. Given the urgency of this issue, we have decided to proceed with recruitment to this team ahead of funding confirmation. Recruitment is about to go live.” Source location Paul-Price-Response2
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 Reorganise administrative call handling and signed handover to qualified staff for action.
Verbatim wording from the response “To immediately address this issue we have increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm-2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by our administrative staff and handed over with a signature to qualified staff to action. In the longer term we are seeking to recruit additional staff to our Home Treatment service and have submitted a business case to our Commissioners in this regard. Given the urgency of this issue, we have decided to proceed with recruitment to this team ahead of funding confirmation. Recruitment is about to go live.” Source location Paul-Price-Response2
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 an out-of-hours switchboard safeguard requiring advice from a 24/7 bed-management clinician when clinical staff cannot respond.
Verbatim wording from the response “In addition, we have placed an additional safeguard in place via our out of hours main switchboard, whereby in the event of failure to secure a response from clinical” Source location Paul-Price-Response2
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 Implement electronic GP correspondence through the Trust-wide Hybrid Mail rollout and Docman, supported by GP-practice IT infrastructure.
Verbatim wording from the response “I am pleased to be able to advise you that since issuing this Prevention of Future Deaths report, we have implemented significant improvements in relation to both the quality and timeliness of communication with GPs. This includes the full roll out of a hybrid mail system across the Trust. On 5 March 2019, we enabled a new feature within Hybrid Mail called Docman. This feature dramatically reduces the time it takes for GPs to receive letters from the Trust. Instead of letters being posted, they are sent electronically and we have worked in partnership with our Local Clinical Commissioning Group to ensure that GP practices have the necessary IT infrastructure to receive such communication. Letters sent to GPs via Docman will normally arrive at their destination on the same working day and are released from Hybrid mail every 15 minutes.” Source location Paul-Price-Response2
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 its computer systems were down on 1 June 2018; it attributes the missed message to staff error.
Verbatim wording from the response “3. On the matter of computer systems, staff recording information and following up, we have checked our IT systems and there is no record of unplanned downtime for the 1st June 2018. Any planned downtime tends to be very late into the day and before the start of the morning shift. The failure to pass on the message was a staff error but we are also looking to implement system changes which will support the recording and forwarding of messages. This includes an automated phone call system which will log and audit all phone calls made internally and externally to the Trust. Again I would like to be able to write to you in three months to advise you of our progress in making this system available and implemented across all our hundred plus teams.” Source location Paul-Price-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trustwide timescales, electronic recording, hybrid mail and management oversight are considered sufficient to address delays in completing GP letters.
Verbatim wording from the response “1. In relation to the delay in Paul’s GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devices and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.” Source location Paul-Price-Response
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Rapid information sharing across NHS providers requires a national solution beyond the Trust’s local systems and arrangements.
Verbatim wording from the response “2. With respect to the incompatibility of BSMHFT and GP systems, this is a local issue that is reflected nationally and we have previously written to you about this more general topic. We are, and continue to be of the view that there does need to be a national solution to rapid information sharing between NHS care providers. We have previously written to NHS England (NHSE) about this need, however there is no solution at present, which means that risk remains in our systems. We have worked collaboratively with our local MERIT mental health partners (Birmingham Childrens, D&W, BCP and CWP) to find a local solution to this; we do now have a single system in place that allows us to access each other’s information electronically.” Source location Paul-Price-Response
Open published response
12 Sep 2018 Greg HUTCHINS · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 6 Failure to retain staff recollection of telephone triage View source Lack of contemporaneous records of telephone triage View source Failure to update the RIO system with telephone triage information View source Lack of subsequent notes of telephone triage View source Lack of clarity about the purpose and scope of telephone triage View source Absence of a national system for rapid information sharing 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
Greg HUTCHINS · 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
Greg HUTCHINS committed suicide on 28 August 2017 in a hotel room after suffocating himself with a plastic bag and helium. Concerns included the lack of recollection and contemporaneous or subsequent records of a telephone triage, no update in the RIO system, uncertainty about the triage’s purpose, and limited rapid information sharing for people from outside the Birmingham area.
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 retain staff recollection of telephone triage
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” 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 contemporaneous records of telephone triage
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” 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 the RIO system with telephone triage information
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” 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 subsequent notes of telephone triage
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” 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 the purpose and scope of telephone triage
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” 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 national system for rapid information sharing
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” Open source report
15 Mar 2017 Leah Abby Ratheram · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Lack of early approved social worker involvement in Mental Health Act assessments View source Unclear responsibility for patients during transfer between mental health services View source Failure to share and access mental health records effectively between organisations View source Lack of coordinated mental health care during crisis and transfer View source See 1 more concern
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
Leah Abby Ratheram · 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
Leah Abby Ratheram, who had autism, foetal alcohol syndrome and a history of self-harm, died after being found hanging from a tree on 7 October 2016. The report raised concerns about the lack of coordinated care and unclear responsibility between mental health organisations, ineffective sharing of records and risk information, and uncertainty about the Mental Health Act assessment process.
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 early approved social worker involvement in Mental Health Act assessments
Wider context from the report “3. The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed. There is a concern that lack of involvement of this specialty at any early stage will affect the quality of mental health act assessments and the safety of 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 Unclear responsibility for patients during transfer between mental health services
Wider context from the report “1. Adults aged between 18 – 25 now have mental health services provided by two organisations – Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust. If a patient presents in crisis to A&E they will be seen by someone from the RAID team who work for Birmingham and Solihull Mental Health Trust. If they require ongoing treatment they will be referred to forward Thinking Birmingham. There is a concern that patients will have no coordinated approach to their care at a time of crisis. It is also unclear who will ultimately be responsible for the patient, particularly during the period of transfer.
” 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 share and access mental health records effectively between organisations
Wider context from the report “2. Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process. It was unclear how staff from each organisation would access each other’s records when patients present to one or other of the services.
” 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 coordinated mental health care during crisis and transfer
Wider context from the report “1. Adults aged between 18 – 25 now have mental health services provided by two organisations – Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust. If a patient presents in crisis to A&E they will be seen by someone from the RAID team who work for Birmingham and Solihull Mental Health Trust. If they require ongoing treatment they will be referred to forward Thinking Birmingham. There is a concern that patients will have no coordinated approach to their care at a time of crisis. It is also unclear who will ultimately be responsible for the patient, particularly during the period of transfer.
” Open source report
25 Jul 2016 Patricia Ann Cleghorn · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Unavailability of acute mental health inpatient beds View source Limited resources and care for vulnerable people in the community View source Failure to control access to available medication for a person at risk of overdose View source Failure to undertake a formal suicide and overdose risk assessment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Patricia Ann Cleghorn · 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
Patricia Ann Cleghorn, who had suicidal ideation and was awaiting an inpatient mental health bed, was found collapsed at home after receiving diazepam and was declared dead by paramedics on 14 December 2015. The concerns were the lack of an available inpatient bed, allowing her to self-medicate with potentially dangerous drugs despite repeated statements that she intended to overdose, and the absence of a formal risk assessment.
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 acute mental health inpatient beds
Wider context from the report “(1) The deceased could not be admitted to hospital as there were no inpatient beds available . I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care.
” 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 Limited resources and care for vulnerable people in the community
Wider context from the report “(1) The deceased could not be admitted to hospital as there were no inpatient beds available. I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care .
” 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 control access to available medication for a person at risk of overdose
Wider context from the report “(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oromorph . No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her .
” 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 a formal suicide and overdose risk assessment
Wider context from the report “(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oromorph. No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.
” 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 Issue a formal practice alert reinforcing suicide-risk, medicines-management and safe-medication-administration requirements, with staff acknowledgement.
Verbatim wording from the response “2. The Senior Nurse for Professional Standards issued a formal practice alert on 12th September 2016 to registered and unregistered clinicians in our crisis and community teams to reinforce the requirements for:” Source location 2016-0270-Response-by-Birmingham-and-Solihull-NHS-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 Add a consultant psychiatrist to each home treatment team for daily medical review or opinion of high-risk patients.
Verbatim wording from the response “• One consultant psychiatrist will form part of each home treatment team to ensure that all patients who are presenting high levels of risk have daily access to medical review or medical opinion. This will be in place across all of our home treatment teams by the end of October 2016” Source location 2016-0270-Response-by-Birmingham-and-Solihull-NHS-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 Implement a standard enhanced-care pathway for patients awaiting beds, including updated assessments, care plans, daily reviews and crisis plans.
Verbatim wording from the response “All of these patients have received:” Source location 2016-0270-Response-by-Birmingham-and-Solihull-NHS-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 Establish a Clinical Risk Management Group addressing risk-management training, suicide prevention and crisis-care-plan implementation.
Verbatim wording from the response “3. We have established a Clinical Risk Management Group which is addressing:” Source location 2016-0270-Response-by-Birmingham-and-Solihull-NHS-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 bed-management and community processes to enhance care for patients awaiting inpatient admission.
Verbatim wording from the response “As a result of the unfortunate death of Mrs Cleghorn we have taken immediate action to review our bed management processes and community processes, so that we can ensure that any patient awaiting access to an inpatient bed receives enhanced care from our community staff.” Source location 2016-0270-Response-by-Birmingham-and-Solihull-NHS-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 the Medicines Code and supporting staff guidance to address medication-administration and risk-assessment issues, and report through internal governance.
Verbatim wording from the response “Proposed Action Plan – All of the actions are in place with the exception of item 4 which will be delivered by the end of November 2016” Source location 2016-0270-Response-by-Birmingham-and-Solihull-NHS-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 Take action to manage the medicines-policy breach.
Verbatim wording from the response “Proposed Action Plan – All of the actions are in place with the exception of item 4 which will be delivered by the end of November 2016” Source location 2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
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 Medication checks and removal of excessive medicines are limited by service users’ capacity and willingness to disclose information and permit searches.
Verbatim wording from the response “Where risks are identified then medicines supply should be tightly controlled and overall medicines possession checked regularly as far as possible. If indicated, following appropriate risk assessment we will work with service users and carers to remove excessive medication in the interests of safety. It has to be recognised that we have to work within reasonable limits which are determined by the services user’s capacity and preparedness to fully disclose information and allow checks/searches. If our staff are in any way unsure that it is safe to supply medication, the team will need to consider whether to withhold supply and explain why.” Source location 2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Open published response
15 Apr 2016 Luke Christie AYRES · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure to provide an escort for paramedics from reception to the Ward View source Failure to provide the Ambulance Service with accurate current patient-status information View source Failure of ward staff to call 999 directly View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke Christie AYRES · 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
Luke Christie AYRES, aged 24, died on 27 September 2015 while serving a custodial sentence as an inpatient at Raeside Clinic. He was found hanging by a ligature in his bedroom and could not be resuscitated. Concerns included delays and communication risks in contacting the ambulance service, and the absence of staff to escort paramedics from reception to the ward.
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 an escort for paramedics from reception to the Ward
Wider context from the report “2. The evidence was that when the Paramedics arrived in reception no-one was present to escort them to the Ward and only once they had arrived did a member of staff go to meet them . This is a source of obvious and dangerous delay .
” 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 the Ambulance Service with accurate current patient-status information
Wider context from the report “1. The 999 call to the ambulance service made by Raeside reception after the issuing of a 2222 medical emergency call was cut off when they attempted to transfer the Ambulance Service to Ward Severn. The ambulance Service therefore had to get the number from the operator and called back a minute later. When they were put through to the Ward the person they were speaking with was not at Luke’s side and did not know his current status because she was in an office some distance away from him and the staff with him. There is no evidence that this actually had an impact on Luke’s death but there are risks for the future arising from the fact that:
a) the Ward staff do not call 999 themselves necessitating a delay and a risk of the call being cut off when the call is transferred to the Ward; and
b) the person providing information to the Ambulance Service may not know the patient’s current status and could therefore give incorrect 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 ward staff to call 999 directly
Wider context from the report “1. The 999 call to the ambulance service made by Raeside reception after the issuing of a 2222 medical emergency call was cut off when they attempted to transfer the Ambulance Service to Ward Severn. The ambulance Service therefore had to get the number from the operator and called back a minute later. When they were put through to the Ward the person they were speaking with was not at Luke’s side and did not know his current status because she was in an office some distance away from him and the staff with him. There is no evidence that this actually had an impact on Luke’s death but there are risks for the future arising from the fact that:
a) the Ward staff do not call 999 themselves necessitating a delay and a risk of the call being cut off when the call is transferred to the Ward ; and
b) the person providing information to the Ambulance Service may not know the patient’s current status and could therefore give incorrect information.
” 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 Extend ward medical-emergency simulations to test ambulance-call connection and availability of patient information and observations.
Verbatim wording from the response “We have therefore decided to extend the simulation of medical emergencies on our wards at Reaside to include the connection of the call to the ambulance service and to also ensure that the individual nominated to make the call has all of the relevant medical information and observations of the patient to hand. We currently deliver quarterly medical emergency simulation exercises at Reaside Clinic (the most recent being just 2 weeks ago) and will explore the possibility of increasing the frequency.” Source location 2016-0148-Response-by-Birmingham-and-Solihull-NHS-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 Amend the local protocol to nominate and identify a staff member to receive arriving paramedics.
Verbatim wording from the response “On the matter of receiving the Paramedics at the Clinic, we have amended our local protocol to ensure that the nurse in charge nominates an individual to await arrival of the Paramedics. This individual will also wear a high visibility vest so that they are immediately identifiable upon arrival of the paramedic team.
We believe that the improvements identified above will enhance our current arrangements for medical emergencies at Reaside Clinic and would like to thank you once again for bringing these matters to our attention.” Source location 2016-0148-Response-by-Birmingham-and-Solihull-NHS-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 Replace Reaside Clinic’s telephony system with the Trust’s standard system.
Verbatim wording from the response “During the inquest, evidence gave rise to concern about the procedures associated with the handling of medical emergency calls at Reaside Clinic, together with a lack of assurance that Paramedics would always be greeted in reception by a member of ward staff who could immediately escort them to the scene of the incident.” Source location 2016-0148-Response-by-Birmingham-and-Solihull-NHS-Trust
Open published response
23 Jul 2015 Doreen England · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Lack of staff knowledge about pressure sore formation and prevention View source Lack of clear ward leadership View source Inadequate on-site medical cover View source Failure to provide staff training on pressure sore formation and prevention View source Failure to prepare care plans for patients at high risk of pressure sore formation View source Inadequate RMN training on pressure sores View source Failure to act on identified clinical risks 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
Doreen England · 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
Doreen England, an 81-year-old woman with vascular dementia, developed a severe pressure sore during her admission to Rosemary Suite from 20 July 2014 and died on 30 September 2014. The principal concerns were the failure to prepare and implement a care plan despite her high risk, inadequate staff knowledge and training about pressure sore prevention, and insufficient ward leadership and medical cover.
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 staff knowledge about pressure sore formation and prevention
Wider context from the report “(1) Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared. Staff at the inquest confirmed they had a lack of knowledge about pressure sore formation and how to prevent pressure sores occurring. Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.
” 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 clear ward leadership
Wider context from the report “(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover.
” 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 on-site medical cover
Wider context from the report “(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover.
” 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 staff training on pressure sore formation and prevention
Wider context from the report “(2) Since these events staff confirmed at the inquest that they had still not had training on pressure sore formation and prevention.
” 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 prepare care plans for patients at high risk of pressure sore formation
Wider context from the report “(1) Despite a waterlow score on admission confirming she was at high risk of pressure sore formation no care plan was prepared. Staff at the inquest confirmed they had a lack of knowledge about pressure sore formation and how to prevent pressure sores occurring. Staff working on mental health wards dealing with elderly patients must have a clear understanding of basic medical care in particular how pressure sores occur and what steps are required to address those at high risk.
” 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 RMN training on pressure sores
Wider context from the report “(4) Registered Mental Health Nurses at the inquest confirmed their RMN training had not covered the subject of pressure sores in any detail and they felt they had inadequate awareness and knowledge . This is a subject that should be covered in the RMN curriculum.
” 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 identified clinical risks
Wider context from the report “(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover.
” Open source report
3 Sep 2014 Yohannes Kidane · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Lack of sufficient staffing for effective ACCT observations View source Insufficient night staffing to enable staff comfort breaks View source Insufficient night staffing to provide healthcare and other prisoner needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Yohannes Kidane · 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
Yohannes Kidane was remanded into custody at Birmingham Prison and was found in his cell with a noose around his neck after previous self-harm incidents. CPR was provided, but he was declared dead on 19 December 2013. The concerns included insufficient night staffing in the healthcare wards, compromised ACCT observations, and the impact of staff not taking breaks on prisoner care and staff wellbeing.
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 sufficient staffing for effective ACCT observations
Wider context from the report “(2) I am concerned that the ability to undertake effective ACCT observations is compromised by the lack of sufficient staff .
” 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 night staffing to enable staff comfort breaks
Wider context from the report “(3) When I asked how staff took breaks at night I was told staff did not take breaks during the night . I am concerned about the impact this would have on the care and wellbeing of prisoners and on the staff. Staff must need to take comfort breaks throughout the night which would add an additional burden on the already stretched staffing levels .
” 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 night staffing to provide healthcare and other prisoner needs
Wider context from the report “(1) The healthcare department has 2 wards with 15 patients on each ward. The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards. Evidence confirmed there were a number of prisoners on ward 2 who required ACCT observation plus other prisoners requiring attention. At the time only 1 nurse was present as the Prison officer was on the other ward.
I am concerned the wards have insufficient staff at night to provide for all the healthcare and other needs of prisoners.
” 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 Meet with G4S and National Offender Management Service representatives to address non-clinical night duties, including cell-bell responses and ACCT observations.
Verbatim wording from the response “We have met with G4S and representatives from the National Offenders Management Service as the evidence at the inquest identified that a significant part of the duties during the night are non-clinical, for example responding to cell bells, general enquiries and undertaking ACCT observations. I understand that they will be providing a separate response to you.” Source location 2014-0392-Response-by-Birmingham-Solihull-NHS
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 Liaise with Birmingham Community Healthcare Trust and G4S regarding night staffing levels and additional overnight support.
Verbatim wording from the response “In order to respond to the concerns that you have raised, the Trust has liaised with Birmingham Community Healthcare Trust (who provide physical healthcare on Ward 1 of the healthcare centre) and G4S who provide healthcare prison officers in the” Source location 2014-0392-Response-by-Birmingham-Solihull-NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue pursuing Commissioner funding for an additional Ward 2 staff member.
Verbatim wording from the response “I am disappointed to report that we asked our Commissioner to attend two meetings regarding funding of an extra staff member for Ward 2. They declined to attend” Source location 2014-0392-Response-by-Birmingham-Solihull-NHS
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 G4S and the National Offender Management Service will provide a separate response concerning non-clinical night duties and ACCT observations.
Verbatim wording from the response “We have met with G4S and representatives from the National Offenders Management Service as the evidence at the inquest identified that a significant part of the duties during the night are non-clinical, for example responding to cell bells, general enquiries and undertaking ACCT observations. I understand that they will be providing a separate response to you.” Source location 2014-0392-Response-by-Birmingham-Solihull-NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Funding approval for an extra Ward 2 staff member has not progressed because the Commissioner declined meetings; the matter will continue to be pursued.
Verbatim wording from the response “I am disappointed to report that we asked our Commissioner to attend two meetings regarding funding of an extra staff member for Ward 2. They declined to attend” Source location 2014-0392-Response-by-Birmingham-Solihull-NHS
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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 Healthcare Commissioners are responsible for funding additional prison healthcare staff and are invited to address the staffing concern.
Verbatim wording from the response “healthcare centre. The Trust has also forwarded a copy of your letter to the Commissioner responsible for funding healthcare services within the prison.” Source location 2014-0392-Response-by-Birmingham-Solihull-NHS
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations