16 Jun 2026 Trevor John Ridd · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 7 Lack of regular testing and maintenance of the sprinkler system View source Failure to ensure operators distinguish fault and fire notifications and escalate appropriately View source Failure to provide operators with relevant property risk information alerts View source Failure to provide staff with a clear process for verifying secondary signal wording View source Lack of a clear procedure for handling fault and fire signals received in quick succession View source Failure to ensure correct ordering of sprinkler fault and fire signals View source Lack of training and briefing for operators on handling notification signals received in quick succession View source See 4 more concerns
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AI-generated summary
Trevor John Ridd · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 04 January 2026, Trevor John Ridd’s bedding caught fire while he was unable to leave his bed because of mobility issues. The sprinkler system activated, but its fault and fire signals were treated as one incident and no 999 call was raised by the Alarm Receiving Centre operator; Mr Ridd was later found with burns and died after suffering cardiac arrest. Concerns included the handling and wording of the two signals, operator training and briefing, and the testing and maintenance of the sprinkler system.
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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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of regular testing and maintenance of the sprinkler system
Wider context from the report “3. It is not clear what training or instruction individual operators receive in relation to how they are to deal with situations where two notification signals are received in quick succession. It is also unclear what information alerts (if any) are communicated to individual operators in respect of the property from which the signals are received i.e. was it noted that the signals came from Mr Ridd’s property who was bed-bound and a known smoker with severe COPD where there had been a previous incident where he had singed his blanket from smoking in his bed?
4. The evidence at Inquest suggested that the two signals received were the wrong way around however it was not clear why this was and whether this has since been rectified.
5. There is no evidence of regular testing and maintenance of the sprinkler system .
6. It is not clear what individual operators have been ‘briefed’ on post-incident with regards to situations where two notification signals are received in quick succession from the same property.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure operators distinguish fault and fire notifications and escalate appropriately
Wider context from the report “2. It remains unclear as to why the individual operator treated both signals as being part of the same incident and failed to raise a 999 call ; it is not clear how a fault notification works alongside a fire notification .
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide operators with relevant property risk information alerts
Wider context from the report “3. It is not clear what training or instruction individual operators receive in relation to how they are to deal with situations where two notification signals are received in quick succession. It is also unclear what information alerts (if any) are communicated to individual operators in respect of the property from which the signals are received i.e. was it noted that the signals came from Mr Ridd’s property who was bed-bound and a known smoker with severe COPD where there had been a previous incident where he had singed his blanket from smoking in his bed?
4. The evidence at Inquest suggested that the two signals received were the wrong way around however it was not clear why this was and whether this has since been rectified.
5. There is no evidence of regular testing and maintenance of the sprinkler system.
6. It is not clear what individual operators have been ‘briefed’ on post-incident with regards to situations where two notification signals are received in quick succession from the same property.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide staff with a clear process for verifying secondary signal wording
Wider context from the report “7. It is not clear what communications have been issued to staff to reinforce the requirement to verify wording of any secondary signals , nor is it clear how staff are to verify the wording of secondary signals .
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear procedure for handling fault and fire signals received in quick succession
Wider context from the report “1. It is not clear why the sprinkler system generated two signals (one ‘fault’ and one ‘fire’) within seconds of one another and what the procedure was for handling this .
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure correct ordering of sprinkler fault and fire signals
Wider context from the report “3. It is not clear what training or instruction individual operators receive in relation to how they are to deal with situations where two notification signals are received in quick succession. It is also unclear what information alerts (if any) are communicated to individual operators in respect of the property from which the signals are received i.e. was it noted that the signals came from Mr Ridd’s property who was bed-bound and a known smoker with severe COPD where there had been a previous incident where he had singed his blanket from smoking in his bed?
4. The evidence at Inquest suggested that the two signals received were the wrong way around however it was not clear why this was and whether this has since been rectified .
5. There is no evidence of regular testing and maintenance of the sprinkler system.
6. It is not clear what individual operators have been ‘briefed’ on post-incident with regards to situations where two notification signals are received in quick succession from the same property.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of training and briefing for operators on handling notification signals received in quick succession
Wider context from the report “3. It is not clear what training or instruction individual operators receive in relation to how they are to deal with situations where two notification signals are received in quick succession . It is also unclear what information alerts (if any) are communicated to individual operators in respect of the property from which the signals are received i.e. was it noted that the signals came from Mr Ridd’s property who was bed-bound and a known smoker with severe COPD where there had been a previous incident where he had singed his blanket from smoking in his bed?
4. The evidence at Inquest suggested that the two signals received were the wrong way around however it was not clear why this was and whether this has since been rectified.
5. There is no evidence of regular testing and maintenance of the sprinkler system.
6. It is not clear what individual operators have been ‘briefed’ on post-incident with regards to situations where two notification signals are received in quick succession from the same property .
” 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 Continue reviewing training requirements and operator competency arrangements through continuous improvement and TSA accreditation processes.
Verbatim wording from the response “3. Training requirements and operator competency arrangements will continue to be reviewed as part of the service's continuous improvement framework and TSA accreditation requirements.” Source location Response from Birmingham City County
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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 training and operator competency arrangements, embedding learning on alarm distinctions, individual assessment and escalation through procedures, briefings and supervision.
Verbatim wording from the response “In addition to the procedural changes outlined above, the organisation recognises that effective operator training is fundamental to the safe operation of the Alarm Receiving Centre. Training requirements and operator competency arrangements have therefore been reviewed following this incident to ensure staff clearly understand the distinction between different alarm types, the need to assess each notification and the requirement to follow escalation procedures regardless of whether another notification from the same property is already being managed. This learning has been embedded through written procedures, management briefings, individual supervision and staff acknowledgement processes.” Source location Response from Birmingham City County
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add mandatory electronic pop-up reminders requiring operators to acknowledge review of notifications before continuing call handling.
Verbatim wording from the response “• Electronic Pop-Up notifications created in the system as a reminder on every call to review all notifications even if they are received in close succession from the same property. Each ‘Pop-Up’ has to be acknowledged & closed by operators before they can continue to handle that or any further calls.” Source location Response from Birmingham City County
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update procedures so duplicate or successive notifications are individually acknowledged, assessed, actioned and escalated.
Verbatim wording from the response “Following the incident, all procedures relating to the management of duplicate notifications and multiple alerts from the same site have been reviewed and updated. The revised procedures now make explicit that each notification must be individually acknowledged, assessed, actioned and closed, regardless of whether another notification has already been received from the same property.” Source location Response from Birmingham City County
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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 Obtain written confirmation from all operators that they have read, understood and will comply with revised procedures.
Verbatim wording from the response “• Written confirmation is being obtained from all operators to confirm they have read, understood and will comply with the revised procedures. This assurance exercise will be completed by the end of August 2026.” Source location Response from Birmingham City County
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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 Issue written instructions and deliver verbal briefings reinforcing separate assessment of each notification and verification of its wording and classification.
Verbatim wording from the response “Immediately following the incident, management issued written instructions to all operators reinforcing that duplicate notifications from the same site must not be assumed to relate to an existing incident and that each notification must be reviewed and actioned separately. This requirement was further reinforced through verbal briefings at the commencement of shifts and more recently through individual recorded discussions with all call handling operators.” Source location Response from Birmingham City County
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue individual operator discussions through supervision to reinforce learning and maintain compliance with revised procedures.
Verbatim wording from the response “• Further individual discussions have subsequently been undertaken and are ongoing and being formally recorded with each operator.” Source location Response from Birmingham City County
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The sprinkler notification transmitter was correctly configured and wired, so the signals were not sent in the wrong order because of installation error.
Verbatim wording from the response “Post-incident investigations undertaken by servicing and maintenance contractors identified that the CHUBB Skyresponse platform transmitter had been correctly configured and wired correctly. There was not an error in installation configuration sending notifications the incorrect way around.” Source location Response from Birmingham City County
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The sprinkler system is subject to annual servicing and maintenance in accordance with the applicable British Standard.
Verbatim wording from the response “The sprinkler system at Hobbis House is subject to annual servicing and maintenance in accordance with BS 9251:2021, the British Standard Code of Practice for fire sprinkler systems in domestic and residential occupancies.” Source location Response from Birmingham City County
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12 Aug 2025 Charlotte NOORDAM · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Failure of the junction layout, signage and road markings to mitigate incident risk at the stop junction 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
Charlotte NOORDAM · 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
Charlotte NOORDAM died on 8 March 2025 after her motorbike collided with a car at the junction of Frederick Road and St James Road in Edgbaston. The report raises concerns about the junction's safety, noting at least 27 other road traffic incidents there and an ongoing risk to life despite existing signage and road markings.
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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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the junction layout, signage and road markings to mitigate incident risk at the stop junction
Wider context from the report “3. Whilst the road layout, including signage and road markings, complies with the legal requirements this does not appear to have mitigated against the prevalence of incidents at the stop junction .
4. There have been at least 27 other road traffic incidents at the same junction during the period 23rd May 2014 to the 8th March 25.
5. The police investigator gave evidence that, in his experience, the number of collisions at the stop junction raises questions about the safety of the junction .
6. Evidence from Birmingham City Council suggested that there were potentially additional measures that could be considered to mitigate any safety risks so far as reasonably practicable.
7. I am concerned that there is still a risk to life for users of the junction .
” 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 Design and assess traffic-management measures to redirect vehicles away from the junction before proceeding to implementation.
Verbatim wording from the response “This decision reflects our commitment to prioritise public safety and prevent future loss of life, as set out in our adopted Road Harm Reduction Strategy. Vehicular traffic will be redirected away from residential areas towards the city’s classified road network, which is better equipped to handle higher vehicular traffic volumes safely.” Source location Response from Birmingham City Council
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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 vertical traffic-calming measures and additional junction warning signage within six months.
Verbatim wording from the response “In accordance with the statutory timeframe, the Council is implementing its Fatal Collision Response Protocol to assess the specific site conditions to identify locally appropriate interventions which we intend to deliver in two phases. The first of these will be implementation of vertical traffic calming measures and additional signage to better alert drivers to the presence of the junction. We will deliver these measures within a six-month period of the date of this letter.” Source location Response from Birmingham City Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Fatal Collision Response Protocol to assess site conditions and identify locally appropriate safety interventions.
Verbatim wording from the response “In accordance with the statutory timeframe, the Council is implementing its Fatal Collision Response Protocol to assess the specific site conditions to identify locally appropriate interventions which we intend to deliver in two phases. The first of these will be implementation of vertical traffic calming measures and additional signage to better alert drivers to the presence of the junction. We will deliver these measures within a six-month period of the date of this letter.” Source location Response from Birmingham City Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meaningful Safe System redesign is not feasible because it would require significant demolition of the surrounding built environment.
Verbatim wording from the response “As meaningful redesign in alignment with the Safe System approach would require significant demolition of the surrounding built environment, this approach is wholly inappropriate for this setting. Therefore, the Council confirms its intention to take decisive steps to address the volume of vehicular traffic using this junction.” Source location Response from Birmingham City Council
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4 Mar 2025 Matthew John LYNCH · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 5 Failure of internal investigations to verify relevant witness information and clinical address records View source Insufficient interagency information sharing with landlords View source Failure of internal investigations to examine medication monitoring View source Barriers to accurate Mental Health Act section assessments View source Insufficient support worker training on enduring mental health conditions View source See 2 more concerns
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
Matthew John LYNCH · 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
Matthew John Lynch was attacked in the garden of his supported living accommodation in Birmingham on 11 July 2023 and was killed by decapitation. The concerns included whether medication non-compliance and a change of address had been adequately followed up, the quality of mental health assessments, and information sharing and training between mental health services, the council, housing providers and support workers.
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× 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to verify relevant witness information and clinical address records
Wider context from the report “1. Internal investigation: The internal investigation did not address how and whether the offender’s use of medication should have been monitored after the clinic visit on 12/05/23. This was important as non compliance with medication was a risk factor for relapse. In addition, during the inquest the trust confirmed they had not spoken to the CPN who attempted to visit the offender on 24/05/23 to verify whether they had attended the old or new address . This was a critical issue as the new address had not been updated on the clinical notes . This raises a concern about the quality of the investigation and whether the Trust is adequately learning from incidents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient interagency information sharing with landlords
Wider context from the report “3. Information sharing between agencies and support worker training: The inquest heard evidence that Landlords have to rely on the information given to them by the residents and do not have access to other key information held by other agencies . This means the landlord is often not aware of key information about an individual . Given the potential for harm for residents and support workers consideration needs to be given to how best to share information to ensure residents are receiving the right care and landlords have sufficient information to be able to monitor residents and undertake risk assessments . The inquest heard evidence that support workers need more focussed training on mental health conditions and how to manage and help residents with enduring mental health conditions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to examine medication monitoring
Wider context from the report “1. Internal investigation: The internal investigation did not address how and whether the offender’s use of medication should have been monitored after the clinic visit on 12/05/23 . This was important as non compliance with medication was a risk factor for relapse. In addition, during the inquest the trust confirmed they had not spoken to the CPN who attempted to visit the offender on 24/05/23 to verify whether they had attended the old or new address. This was a critical issue as the new address had not been updated on the clinical notes. This raises a concern about the quality of the investigation and whether the Trust is adequately learning from incidents.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Barriers to accurate Mental Health Act section assessments
Wider context from the report “2. Mental Health assessments: The inquest heard evidence that there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing . This raises a concern that incorrect MHA assessments are taking place and patients may be detained on an inappropriate section impacting patient care. A copy of a report prepared by ████████ is attached.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient support worker training on enduring mental health conditions
Wider context from the report “3. Information sharing between agencies and support worker training: The inquest heard evidence that Landlords have to rely on the information given to them by the residents and do not have access to other key information held by other agencies. This means the landlord is often not aware of key information about an individual. Given the potential for harm for residents and support workers consideration needs to be given to how best to share information to ensure residents are receiving the right care and landlords have sufficient information to be able to monitor residents and undertake risk assessments. The inquest heard evidence that support workers need more focussed training on mental health conditions and how to manage and help residents with enduring mental health conditions .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prepare guidance on using Section 2 versus Section 3 for inclusion in the Mental Health Policy.
Verbatim wording from the response “BCC has agreed to prepare a guidance statement to be added to the Mental Health Policy owned by Birmingham and Solihull Mental Health Foundation Trust regarding the use of Section 2 versus Section 3.” Source location Response from Birmingham City Council
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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 Recruit and train AMHPs to increase BCC staffing by 35 over five years.
Verbatim wording from the response “AMHP resourcing is an issue nationally with there being a shortage of AMHPs across the country. Latest figures suggest there are approximately 93,000 registered social workers with around 3000 AMHPs. BCC are actively recruiting and training AMHPs with a plan to increase numbers by 35 new AMHPs over the next 5 years. The number of AMHPs employed within BCC is not a barrier to the use of Section 2 or Section 3, it has no bearing on the use of sections under the Mental Health Act.” Source location Response from Birmingham City Council
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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 Suggestions that incorrect Mental Health Act detentions are being made are fundamentally inaccurate because AMHPs, not doctors, make detention and section decisions.
Verbatim wording from the response “Decisions pertaining to whether an application is made to detain a citizen under the Mental Health Act 1983 are made solely by the AMHP and with two medical recommendations from Doctors, one of whom must be approved under Section 12 of the MHA 1983 and preferably, where one Doctor has knowledge of the patient. The actual decision as to whether the criteria for detention is met and whether detention should be made and under which Section, is for the AMHP to make. Therefore, the report and suggestions that the wrong detentions are being made, are fundamentally inaccurate, as it is not for the Doctor to decide which section or whether the patient is detained. They make a recommendation which the AMHP then uses to make their decision and the AMHP makes the application which is the formal detention.” Source location Response from Birmingham City Council
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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 Landlords are responsible for providing appropriate training and ongoing development to their support workers.
Verbatim wording from the response “The landlord should provide the appropriate training and ongoing development of their support workers, so that residents can be appropriately supported.” Source location Response from Birmingham City Council
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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 AMHPs are responsible for deciding whether detention occurs and which Mental Health Act section applies, based on medical recommendations.
Verbatim wording from the response “Decisions pertaining to whether an application is made to detain a citizen under the Mental Health Act 1983 are made solely by the AMHP and with two medical recommendations from Doctors, one of whom must be approved under Section 12 of the MHA 1983 and preferably, where one Doctor has knowledge of the patient. The actual decision as to whether the criteria for detention is met and whether detention should be made and under which Section, is for the AMHP to make. Therefore, the report and suggestions that the wrong detentions are being made, are fundamentally inaccurate, as it is not for the Doctor to decide which section or whether the patient is detained. They make a recommendation which the AMHP then uses to make their decision and the AMHP makes the application which is the formal detention.” Source location Response from Birmingham City Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The referring agency is responsible for providing landlords with available resident information, largely based on the resident’s disclosures.
Verbatim wording from the response “The responsibility for providing information to Landlords about residents depends on how the resident accesses the accommodation. If the provision is direct access, then the resident will provide details directly with no other agency involved. If an agency or Local Authority makes the referral, a referral form will be completed. The information that goes to the landlord is based on the referring agencies discussion with the resident. Often there is a need to provide proof of income, which the resident can do by logging on to their Universal Credit portal. Given the emergency nature of lots of these placements, it is likely that the referring agency has limited information to begin with. Referrals from prison, hospital or care facilities are an exception as the resident is likely to have known the agency for a longer period of time,” Source location Response from Birmingham City Council
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2 Jan 2024 Sylvia May NASH · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to involve the care home in decisions about removal of observations View source Failure to understand and follow the correct inter-agency decision-making process 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
Sylvia May NASH · 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
Sylvia May NASH fell at The Orchards Nursing Home on 11 March 2023 and sustained a fractured neck of femur, which was surgically fixed at Birmingham Heartlands Hospital. She developed septic shock and died in hospital on 14 April 2023. Concerns were raised that agencies did not adequately understand or follow the process for decisions such as removing 1:1 observations, and that communication about responsibilities was insufficient.
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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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the care home in decisions about removal of observations
Wider context from the report “1. It was clear both from the evidence and subsequent correspondence that the correct process for making decisions, such as (but not exclusively), removal of 1:1 observations, is not understood adequately by all parties who should be involved in that decision making process.
2. Whilst the Council understood this to be a multi-disciplinary process involving any professional involved in the patient’s care, the care home, Connaught House, indicated that this decision rests solely with the Council .
3. This is concerning for two reasons. Firstly, the correct procedure is not understood and therefore has not been followed. Secondly, the fact that the care home, where the patient resides is of the view that they are not responsible for making decisions as to removal of observations ahead of transfer . They, in my view, should be pivotal in this decision as the organisation who have had the most contact with the patient and therefore in a position to provide important information as to risk and behaviour .
4. I am concerned that the communication and understanding of the correct process between agencies is insufficient.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and follow the correct inter-agency decision-making process
Wider context from the report “1. It was clear both from the evidence and subsequent correspondence that the correct process for making decisions, such as (but not exclusively), removal of 1:1 observations, is not understood adequately by all parties who should be involved in that decision making process .
2. Whilst the Council understood this to be a multi-disciplinary process involving any professional involved in the patient’s care, the care home, Connaught House, indicated that this decision rests solely with the Council.
3. This is concerning for two reasons. Firstly, the correct procedure is not understood and therefore has not been followed . Secondly, the fact that the care home, where the patient resides is of the view that they are not responsible for making decisions as to removal of observations ahead of transfer. They, in my view, should be pivotal in this decision as the organisation who have had the most contact with the patient and therefore in a position to provide important information as to risk and behaviour.
4. I am concerned that the communication and understanding of the correct process between agencies is insufficient .
” 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 procedures requiring multidisciplinary decisions before removing one-to-one support in P2 beds.
Verbatim wording from the response “BCC has worked with colleagues in the Integrated Care Board (ICB) to develop procedures around 1 to 1 support. The P2 (assessment) beds that Sylvia stayed in at Connaught House are funded by the ICB, so the ICB are taking a lead on developing this and embedding the new procedures across P2 beds. The procedure now clearly states that 1 to 1 support can only be removed following an MDT decision involving the care home nurse, social worker, and the clinical need.” Source location Response from Birmingham City Council
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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 Introduce a template for recording multidisciplinary discussions, agreed actions and risk mitigations.
Verbatim wording from the response “In Sylvia’s case, the care record does not evidence the multi-disciplinary input and decision-making process. To address this, there have been staff engagement sessions and discussions with the Social Work staff around evidencing the multi-disciplinary decision making. There is now a template that workers need to complete to record the discussion, any agreed actions, and any risk mitigations.” Source location Response from Birmingham City Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Integrated Care Board leads development and implementation of procedures for one-to-one support across P2 beds.
Verbatim wording from the response “BCC has worked with colleagues in the Integrated Care Board (ICB) to develop procedures around 1 to 1 support. The P2 (assessment) beds that Sylvia stayed in at Connaught House are funded by the ICB, so the ICB are taking a lead on developing this and embedding the new procedures across P2 beds. The procedure now clearly states that 1 to 1 support can only be removed following an MDT decision involving the care home nurse, social worker, and the clinical need.” Source location Response from Birmingham City Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Removal of one-to-one support at Connaught House is an MDT decision, not the responsibility of Birmingham City Council’s P2 team.
Verbatim wording from the response “BCC does not use Connaught House for P2 provision. However, the ICB when required does spot purchase beds at Connaught House, which the ICB then oversees. Discussions have taken place between Connaught House and the ICB to ensure Connaught House understands that responsibility for removing 1 to 1 support does not sit with the BCC P2 team but is an MDT decision, which should include the care home nurse, clinical lead, and the social worker.” Source location Response from Birmingham City Council
Open published response
14 Jul 2023 PETER MARTIN AARON FLEMING · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 9 Failure of medication-management processes to identify proposed carbamazepine treatment View source Lack of care-coordinators for seriously mentally ill patients View source Lack of GP resources for proactively checking collection of prescribed medication View source Delays in primary care organisations providing important patient updates to GPs View source Unavailability of approved mental health practitioners within 24 hours View source Unavailability of mental health places of safety View source Failure of digital systems used by different health organisations to communicate View source Unavailability of mental health inpatient beds View source Ineffective communication between specialist mental health teams View source See 6 more concerns
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PETER MARTIN AARON FLEMING · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of medication-management processes to identify proposed carbamazepine treatment
Wider context from the report “3. Carbamazepine management was proposed in 2012 to manage the deceased’s mental health however this was not picked up by his GP and was only noted by a BSMHFT consultant in August 2022 . Therefore, the deceased went 10 years without this medication. BSMHFT could not explain at the inquest why this omission had not been identified sooner . BSMHFT’s RCA action plan does not have any action to avoid a repeat occurrence. My concern is this RCA indicates a problem with process and systems and further consideration is required to avoid a repeat occurrence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of care-coordinators for seriously mentally ill patients
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull . In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators , mental health inpatient beds, ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of GP resources for proactively checking collection of prescribed medication
Wider context from the report “5. The deceased’s GP raised concerns that current resources do not allow GPs to pro-actively check patients are collecting prescribed medication due to excessive patient lists . My concern is that this is a consequence of lack of resources at a national level .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in primary care organisations providing important patient updates to GPs
Wider context from the report “4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other. Further, GPs often do not get important patient updates from primary care organisations for many days or weeks . (See examples above: the GP did not pick up the carbamazepine prescription, and could not prescribe the medication in October 2022). My concern is communication between different health organisations is not as effective as it could be and important information is being missed , and consequently a material delay in treatment is occurring .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of approved mental health practitioners within 24 hours
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period . When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’, and AMHPs , presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health places of safety
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available, and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds, ‘place of safety’ , and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of digital systems used by different health organisations to communicate
Wider context from the report “4. The deceased’s GP raised concerns that different health organisations use different digital systems that do not communicate with each other . Further, GPs often do not get important patient updates from primary care organisations for many days or weeks. (See examples above: the GP did not pick up the carbamazepine prescription, and could not prescribe the medication in October 2022). My concern is communication between different health organisations is not as effective as it could be and important information is being missed, and consequently a material delay in treatment is occurring.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mental health inpatient beds
Wider context from the report “1. There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull. In the summer of 2022 Birmingham and Solihull Mental Health Trust (‘BSMHFT’) wanted to admit the deceased to an inpatient psychiatric unit, however, no bed was available , and he remained in the community. Shortly before his death, the deceased had been detained by the police under section 136 of the mental health act. There was no available ‘place of safety’ and he had to be taken to an emergency department. The police, BSMHFT, and hospital Drs agreed the deceased needed to be assessed under the mental health act, however Birmingham City Council could not provide an approved mental health practitioner (‘AMPH’) to attend in a 24-hour period. When the section 136 lapsed the deceased was discharged home after a review by a mental health nurse. At the time of his death the deceased was on BSMHFT’s waiting list for a care-coordinator. The lack of care-coordinators, mental health inpatient beds , ‘place of safety’, and AMHPs, presents a risk seriously mentally ill people are not receiving necessary treatment. The evidence is that these issues are a consequence of a chronic lack of resources at a local and national level. The Birmingham and Solihull coroners have been repeating identical concerns in Prevention of Future Death Reports for many years.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication between specialist mental health teams
Wider context from the report “2. BSMHFT utilizes self-contained specialist teams. The deceased was treated by (a) crisis team/home treatment team, (b) community mental health team, and (b) psychiatric liaison team. The evidence demonstrated communication between the specialist teams was not effective and this caused delays. For example, the psychiatric liaison team nurse that reviewed the deceased updated the community mental health team. However, the GP could not prescribe the deceased’s medication in October 2022 because it had not been approved by the community mental health team consultant via an ESCA and the deceased went without his medication. The deceased’s GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse’s involvement. The deceased cited this delay as making his mental health worse shortly before his death. My concern is communication between the specialist teams is not effective enough . BSMHFT’s RCA action plan is to seek assurance from the CCG/ICB that communication between the specialist teams is being strengthened. My concern is that this does not go far enough and there should be consideration of a formal process or policy.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fund Approved Mental Health Professional training for eligible NHS staff.
Verbatim wording from the response “Birmingham City Council has the responsibility under the AMHP regulations to Approve and Authorise AMHPs who work for or on behalf of the Local Authority. Birmingham City Council, Birmingham and Solihull Mental Health Foundation Trust and Birmingham Women’s and Children’s Trust are currently consulting on a new Memorandum of Understanding which will mean that AMHPs employed directly by the NHS in Birmingham will all contribute to the AMHP rota increasing the capacity by a further 14 AMHPs available to cover AMHP duties on a monthly basis. This includes a commitment from Birmingham City Council to fund AMHP training for NHS staff who meet the criteria for the course.” Source location Response from Birmingham City Council
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PFD Monitor interpretation Train eight additional Approved Mental Health Professionals using Skills for Care funding.
Verbatim wording from the response “In 2022 we received funding from Skills For Care for an additional 10 AMHPs and we were successful in training 8 AMHPs in the first year – AMHP Training takes 2 years to complete with a period of supported practice following successful completion of the qualification. Birmingham City Council aims to train 5 AMHPs per year . Birmingham City Council has the responsibility under the AMHP regulations to Approve and Authorise AMHPs who work for or on behalf of the Local Authority. Birmingham City Council, Birmingham and Solihull Mental Health Foundation Trust and Birmingham Women’s and Children’s Trust are currently consulting on a new Memorandum of Understanding which will mean that AMHPs employed directly by the NHS in Birmingham will all contribute to the AMHP rota increasing the capacity by a further 14 AMHPs available to cover AMHP duties on a monthly basis.” Source location Response from Birmingham City Council
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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 agency workers to maximise Approved Mental Health Professional service capacity.
Verbatim wording from the response “Birmingham City Council is actively seeking to recruit, retain and train Approved Mental Health Professionals and is maximising AMHP resources through use of Agency Workers and requiring all AMHPs to contribute to our AMHP service on a daily basis. We recognise the impartiality of the AMHP role and we reserve the right under s13 Mental Health Act 1983 to consider all requests for Mental Health Act Assessments and we encourage staff to look at alternatives to assessment where possible. BCC has seen an increase in requests for assessments which has risen by at least 20% this year suggesting that the acuity of people requiring formal admission under the Act has increased.” Source location Response from Birmingham City Council
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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 Recruit, retain and train additional Approved Mental Health Professionals.
Verbatim wording from the response “Birmingham City Council is actively seeking to recruit, retain and train Approved Mental Health Professionals and is maximising AMHP resources through use of Agency Workers and requiring all AMHPs to contribute to our AMHP service on a daily basis. We recognise the impartiality of the AMHP role and we reserve the right under s13 Mental Health Act 1983 to consider all requests for Mental Health Act Assessments and we encourage staff to look at alternatives to assessment where possible. BCC has seen an increase in requests for assessments which has risen by at least 20% this year suggesting that the acuity of people requiring formal admission under the Act has increased.” Source location Response from Birmingham City Council
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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 Consult with partner organisations on a Memorandum of Understanding to expand the Approved Mental Health Professional rota.
Verbatim wording from the response “Birmingham City Council has the responsibility under the AMHP regulations to Approve and Authorise AMHPs who work for or on behalf of the Local Authority. Birmingham City Council, Birmingham and Solihull Mental Health Foundation Trust and Birmingham Women’s and Children’s Trust are currently consulting on a new Memorandum of Understanding which will mean that AMHPs employed directly by the NHS in Birmingham will all contribute to the AMHP rota increasing the capacity by a further 14 AMHPs available to cover AMHP duties on a monthly basis. This includes a commitment from Birmingham City Council to fund AMHP training for NHS staff who meet the criteria for the course.” Source location Response from Birmingham City Council
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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 Require all Approved Mental Health Professionals to contribute to the service daily.
Verbatim wording from the response “Birmingham City Council is actively seeking to recruit, retain and train Approved Mental Health Professionals and is maximising AMHP resources through use of Agency Workers and requiring all AMHPs to contribute to our AMHP service on a daily basis. We recognise the impartiality of the AMHP role and we reserve the right under s13 Mental Health Act 1983 to consider all requests for Mental Health Act Assessments and we encourage staff to look at alternatives to assessment where possible. BCC has seen an increase in requests for assessments which has risen by at least 20% this year suggesting that the acuity of people requiring formal admission under the Act has increased.” Source location Response from Birmingham City Council
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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 Promote and actively support Approved Mental Health Professional training through the dedicated AMHP Lead.
Verbatim wording from the response “Within the regulation 28 report the Coroner recognises the chronic lack of resources including Care Coordinators, Mental health Inpatient beds and Approved Mental Health Professionals (AMHPs) at a local and national level. This is also recognised by the Chief Social Worker and their staff including ████████ who represents Mental Health Services at a National Level. As a Local Authority BCC is represented at the National AMHP Leads Network and we have a dedicated AMHP Lead who is promoting and actively supporting the training of AMHPs in Birmingham both within the Local Authority and with local NHS partners.” Source location Response from Birmingham City Council
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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 Existing arrangements result in attendance at almost all s136 assessment requests within the statutory timeframe.
Verbatim wording from the response “Birmingham City Council regrets that Mr Fleming felt compelled to take his own life, however we cannot predict what the outcome of a Mental Health Act Assessment may have been if completed within the 24 hour timeframe allowed for this assessment. We attend almost 100% of s136 assessment requests within the timeframe and we would remind partners that Police can apply for an extension if they feel the risk necessitates this.” Source location Response from Birmingham City Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The delay was not caused by insufficient AMHP staffing; sufficient AMHPs were on duty before the statutory deadline.
Verbatim wording from the response “There was a delay in allocating the assessment to an AMHP as there were multiple calls between Heartlands Hospital and the dedicated Place of Safety Oleaster to determine whether Mr Fleming would be transferred.” Source location Response from Birmingham City Council
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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 Police can apply for an extension when they consider that the risk requires additional time.
Verbatim wording from the response “Birmingham City Council regrets that Mr Fleming felt compelled to take his own life, however we cannot predict what the outcome of a Mental Health Act Assessment may have been if completed within the 24 hour timeframe allowed for this assessment. We attend almost 100% of s136 assessment requests within the timeframe and we would remind partners that Police can apply for an extension if they feel the risk necessitates this.” Source location Response from Birmingham City Council
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8 Dec 2022 Mervyn Charles Gladstone Leonard HOLBROOK · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure to provide a safe route for mobility scooter users to exit the carriageway at the opposite side of the junction View source Failure to maintain the kerb at the junction to prevent it appearing to be an official crossing point 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
Mervyn Charles Gladstone Leonard HOLBROOK · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 16 June 2022, Mervyn Charles Gladstone Leonard Holbrook was knocked from his mobility scooter and run over at a junction after entering the carriageway where a kerb had been worn down. He suffered catastrophic thoracic injuries and was pronounced deceased at the scene. The concern was that the worn and defective kerb could be mistaken for an official crossing point by vulnerable road users, particularly mobility scooter and bicycle users, creating a risk of entering the carriageway unsafely.
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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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a safe route for mobility scooter users to exit the carriageway at the opposite side of the junction
Wider context from the report “1. I heard and considered evidence from West Midlands Police's Forensic Collision Unit which confirmed that where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road, it appears that there is a dropped kerb at the apex. On the opposite side of the junction, the kerbs are raised. West Midlands Police advise that this indicates that the dropped kerbs at this side of the junction are a result of vehicles mounting the kerb as they turn left from Livingstone Road to Alcester Road and therefore causing them to be eroded to be level with the road surface. There is also no tactile paving next to these kerbs, which indicate that this dropped kerb is not an "official" pedestrian crossing point - the same being situated approximately 9m from the end of Livingstone Road.
2. Mr Holbrook was able to leave the carriageway on his mobility scooter at apex/mouth of the junction due to the kerb being worn down to the road surface, and was struck in the carriageway.
3. On 12 September 2022, PC ████████ of West Midlands Police submitted a notification via Birmingham City Council's Highway Department's online portal of the defect, with the Highways responding via email on 20 September 2022 stating that it did not meet the intervention levels that require repair.
4. I am concerned that vulnerable road users - particularly users of mobility scooters or bicycles - may inadvertently consider the worn down and defective kerb to be an "official" crossing point and enter the carriageway when it is unsafe to do so.
5. Furthermore, if a mobility scooter or similar were to enter the carriageway at the mouth of the junction (as Mr Holbrook did), they would then be unable to mount the curb at the opposite side - they would have to travel West down the carriageway of Livingstone road to the official crossing point, or alternatively (and more dangerously) navigate South on the carriageway into oncoming traffic onto Alcester Road .
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the kerb at the junction to prevent it appearing to be an official crossing point
Wider context from the report “1. I heard and considered evidence from West Midlands Police's Forensic Collision Unit which confirmed that where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road, it appears that there is a dropped kerb at the apex. On the opposite side of the junction, the kerbs are raised. West Midlands Police advise that this indicates that the dropped kerbs at this side of the junction are a result of vehicles mounting the kerb as they turn left from Livingstone Road to Alcester Road and therefore causing them to be eroded to be level with the road surface . There is also no tactile paving next to these kerbs, which indicate that this dropped kerb is not an "official" pedestrian crossing point - the same being situated approximately 9m from the end of Livingstone Road.
2. Mr Holbrook was able to leave the carriageway on his mobility scooter at apex/mouth of the junction due to the kerb being worn down to the road surface , and was struck in the carriageway.
3. On 12 September 2022, PC ████████ of West Midlands Police submitted a notification via Birmingham City Council's Highway Department's online portal of the defect , with the Highways responding via email on 20 September 2022 stating that it did not meet the intervention levels that require repair.
4. I am concerned that vulnerable road users - particularly users of mobility scooters or bicycles - may inadvertently consider the worn down and defective kerb to be an "official" crossing point and enter the carriageway when it is unsafe to do so .
5. Furthermore, if a mobility scooter or similar were to enter the carriageway at the mouth of the junction (as Mr Holbrook did), they would then be unable to mount the curb at the opposite side - they would have to travel West down the carriageway of Livingstone road to the official crossing point, or alternatively (and more dangerously) navigate South on the carriageway into oncoming traffic onto Alcester Road.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the kerb height at the footpath outside 214 Alcester Road South at the Livingstone Road junction.
Verbatim wording from the response “1. I confirm the height of the kerb where the footpath outside 214 Alcester Road South reaches the junction of Livingstone Road was amended by the City Council in early January 2023 as per your recommendations.” Source location Response from Birmingham City Council
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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 network kerb-defect information and intervention criteria to identify similar locations and incorporate necessary maintenance processes.
Verbatim wording from the response “2. We have also commissioned to undertake a review of the available kerb defect information to identify locations similar to the incident site on the network so that the necessary processes are incorporated and similar sites are addressed as part of the Council’s maintenance activities. The scope of the study also includes a review of the intervention criteria and whether these need to be revised in the light of this incident.
This study is well underway and is expected to be completed by March 2023. A copy of the report will be shared with you as soon as it is available along with details of further proposed actions.” Source location Response from Birmingham City Council
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22 Oct 2019 Nigel Byron Abbott · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 10 Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community View source Failure to learn and correct identified unsafe beliefs about section 135 warrants View source Mental health professionals operating caseloads well in excess of recommended levels View source Failure of agencies to work together effectively View source Failure to use section 4 for urgent cases View source Failure to provide section 140 beds View source Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments View source Chronic shortage of psychiatric beds View source Failure of agencies to work together effectively on mental health detention processes View source Misunderstanding between agencies about urgent section 135 warrant requirements View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Nigel Byron Abbott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.
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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 City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to learn and correct identified unsafe beliefs about section 135 warrants
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected .
My on-going concern is that the agencies involved in this area are not working together effectively. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Mental health professionals operating caseloads well in excess of recommended levels
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to work together effectively
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to use section 4 for urgent cases
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used .
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide section 140 beds
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT .
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments .
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Chronic shortage of psychiatric beds
Wider context from the report “Summary of Concerns
In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
The five generic on-going matters of concern:
(1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments.
(2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds .
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of agencies to work together effectively on mental health detention processes
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation. This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available. All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process , reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected.
My on-going concern is that the agencies involved in this area are not working together effectively . The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding between agencies about urgent section 135 warrant requirements
Wider context from the report “It appears on the current evidence that there is a misunderstanding between the agencies as to how section 135 Mental Health Act 1983 can work in an urgent situation . This includes both whether or not WMP need 24 hours’ notice and whether or not a bed first needs to be available . All agencies need to urgently review the ‘Joint Memorandum of Understanding For Mental Health Professionals Requesting Police Assistance With Mental health Act Assessments and s135(1) & (2) Warrants, June 2018’ and their own practices both individually and jointly to ensure that all staff working in this area understand what is achievable and how.
The context for this report is:
(1) The evidence from WMP is that they do not require 24 hours’ notice to execute a section 135 warrant, whereas the AMHPs (BCC) are of the view there was no point in applying for a section 135 warrant because WMP need 24 hours’ notice.
(2) BSMHFT have stated that BCC refused to co-operate with their Root Cause Analysis process, reviewing what lessons could be learnt from the incident.
(3) I was only made aware that BCC had conducted an Internal Management Review Report - that acknowledged AMHPs were fixed on the operational difficulties of applying for the warrant out of hours and police availability as they required 24 hours’ notice – by a witness on day 1 of the inquest. BCC had not volunteered this report existed.
(4) The BCC Internal Management Review Report – which is designed to be the ‘organisational learning process’ - confirms that BCC has not learnt lessons from the incident effectively. In the action plan there is no mention of the incorrect belief amongst AMHPs, that WMP require 24 hours’ notice, having been corrected.
My on-going concern is that the agencies involved in this area are not working together effectively. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them.
” Open source report
10 Sep 2019 Gurdeep Singh Dundhal · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Delays in organising timely mental health assessments View source Failure to obtain and have available key information and documentation for mental health assessments View source Failure to undertake internal investigations into assessment delays and resource concerns View source Failure to engage with other agencies to learn lessons from complex cases View source Failure to place patients on the recommended Mental Health Act section 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
Gurdeep Singh Dundhal · 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
Gurdeep Singh Dundhal, who had paranoid schizophrenia and used illicit substances, died after jumping from the fifth storey of a car park on 27 April 2019; he passed away in hospital on 28 April 2019. The concerns included delays and resource problems in arranging a mental health assessment, missing information during the assessment, the decision to use section 2 rather than the recommended section 3, and failure to investigate and learn lessons across agencies.
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 City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in organising timely mental health assessments
Wider context from the report “1. There was a delay in organising the assessment of Mr Dundhal when he was detained on S5(2) of the Mental Health Act on 11/04/19. The evidence confirmed there appeared to be confusion as to who was undertaking the assessment between Walsall MBC and Birmingham City Council . In addition there was a lack of resources to enable the assessment to be carried out in a timely manner . This meant the assessment was carried out just a few hours before the time period for the S5(2) was to expire.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and have available key information and documentation for mental health assessments
Wider context from the report “2. Evidence at the inquest from the approved Mental health practitioner confirmed that key information and documentation were either unavailable and/or not asked for during the mental health act assessment on 14/04/19. I was unable to confirm which at the inquest. This meant the true nature of Mr Dundhal’s long term condition was not known and the assessors were unable to see the “bigger picture”. The delay in arranging the assessment contributed to the lack of available 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake internal investigations into assessment delays and resource concerns
Wider context from the report “4. Walsall MBC has failed to undertake an internal investigation into the delays and resources concerns during the assessment in April 19 . They have also failed to engage with other agencies to ensure lessons are learnt. It is essential in complex cases like this that all agencies work together after a tragedy to ensure lessons are learnt to protect others.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to engage with other agencies to learn lessons from complex cases
Wider context from the report “4. Walsall MBC has failed to undertake an internal investigation into the delays and resources concerns during the assessment in April 19. They have also failed to engage with other agencies to ensure lessons are learnt . It is essential in complex cases like this that all agencies work together after a tragedy to ensure lessons are learnt to protect others .
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to place patients on the recommended Mental Health Act section
Wider context from the report “3. When Mr Dundhal was admitted to hospital on 15/03/19 he was placed on S2 of the Mental Health Act when his clinical team had specifically recommended he be placed on S3 . No explanation was available for this . Evidence at the inquest suggested this was a decision made by the Approved Mental health practitioner from Birmingham City Council. Consideration needs to given as to why a S3 was not put in place in accordance with the recommendation .
” Open source report
22 Jul 2019 Richard Patrick Carlon · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Unavailability of approved Mental Health practitioners for Mental Health Act assessments View source Failure to advise BSMHT when a person is found safe and well at home View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Patrick Carlon · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Patrick Carlon, who had paranoid schizophrenia and a history of relapsing after taking illicit substances, was detained under the Mental Health Act after stating that he would kill himself. He later left care, was found at his father’s home, and subsequently stepped in front of a lorry; he died in hospital from polytrauma following the road traffic collision. The concerns included the lack of an approved Mental Health practitioner to conduct an assessment and failures in communication between the police and mental health services after he was found safe and well.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of approved Mental Health practitioners for Mental Health Act assessments
Wider context from the report “1. No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr Carlon on 14/11/18. I was told this was an ongoing problem and was delaying assessments .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Birmingham City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to advise BSMHT when a person is found safe and well at home
Wider context from the report “2. When Mr Carlon was found safe and well at home WMP did not advise BSMHT . This was a missed opportunity for Mental health to re-engage with Mr Carlon and make a further assessment of his condition. Consideration need to be given to how agencies can improve communication.
” Open source report
×
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 Hold a workshop with the Mental Health Trust and AMHP service to improve joint working.
Verbatim wording from the response “The other area that was agreed on was a workshop being held to agree improved joint working between the Mental Health Trust and the AMHP service. This workshop will be set up very shortly. The board has agreed to meet on a monthly basis and will become the vehicle for overseeing the improvement work.” Source location 2019-0287-Response-by-Birmingham-City-Council
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 current AMHP service-delivery model to improve AMHP availability.
Verbatim wording from the response “AMHP availability
In response to the ongoing issue of AMHP availability leading to delays in assessments, below is a brief synopsis of the process adopted and the work currently being undertaken by BCC to bring about improvements around the availability of the AMHP service.” Source location 2019-0287-Response-by-Birmingham-City-Council
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 improvement plan addressing system-wide issues affecting AMHP services.
Verbatim wording from the response “A project board meeting which serves as a governance body for the improvement work around the AMHP service in Birmingham was held on 11th September 2019. The board reviewed the plan providing solutions to system wide issues impacting the work of the AMHPs. It should be reiterated that the review identified a total of 60 areas for improvement and 20 of these were related to whole systems partnership working.” Source location 2019-0287-Response-by-Birmingham-City-Council
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 Coroner stated that completing the requested mental health assessment would not have changed the outcome.
Verbatim wording from the response “The matter of concern relating to BCC was that no Approved Mental Health Professional (AMHP) was available to make the requested Mental Health Act Assessment (MHAA) of Mr Carlon in the early hours of the 14th November 2018, the Coroner having been told that this was an ongoing problem and was delaying assessments. It is understood that in delivering her findings of fact, the Coroner stated in the inquest that had the MHAA taken place it would not have changed the outcome for Mr Carlon.” Source location 2019-0287-Response-by-Birmingham-City-Council
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 referral screening and prioritisation treated hospital patients as in a place of safety, prioritising community and police-custody cases.
Verbatim wording from the response “• All MHAA referrals are screened and prioritised and as Mr Carlon was in a hospital setting therefore deemed to be in a place of safety. In situations like this where the service is in receipt of multiple referrals the priority would always be those in the community or those individuals in police custody presenting a risk to themselves and the public.” Source location 2019-0287-Response-by-Birmingham-City-Council
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 Assessment times depend on partner-agency resources, which the AMHP coordinates but lacks authority to prioritise.
Verbatim wording from the response “The coordination role involves the AMHP being multi agency dependant. It is this that will often impact on time scales for MHAAs being completed rather than availability of AMHPs who may well be coordinating MHAAs and chasing up partner agencies. The availability of partner agency resources as opposed to AMHP prioritisation decisions by AMHPs and partners, can involve people undergoing more than one MHAA before resources become available to allow a suitable outcome.” Source location 2019-0287-Response-by-Birmingham-City-Council
Open published response
1 Jun 2018 Imtiaz Mohammed · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Lack of monitoring and testing of taxi drivers for compliance with drug-driving limits View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Imtiaz Mohammed · 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
Imtiaz Mohammed died in a serious road traffic collision in Birmingham on 17 December 2017, when a taxi was struck by an Audi travelling at between 94 and 100 mph. Toxicology showed the taxi driver was over the legal drug-driving limit for a cocaine metabolite, and concerns were raised that there was no system to monitor whether taxi drivers were over the drug limit while driving.
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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring and testing of taxi drivers for compliance with drug-driving limits
Wider context from the report “1. Toxicology was obtained for the deceased who was driving the Taxi involved in the collision. This confirmed the following blood levels:
Cocaine 0.010mg/l
Benzoylecgonine (a cocaine metabolite) 0.40mg/l
Carboxy THC 0.10 mg/l
The level of the cocaine metabolite would have resulted in the deceased being over the legal drug driver limit. This did not contribute to this collision.
However the Midlands Police raised concerns at the inquest that there was presently no system in place to monitor and check whether taxi drivers are over the drug limit whilst driving . They confirmed in evidence that some sort of testing was required for the safety of passengers .
” Open source report
1 Sep 2017 Mohammad Ismaeel Ashraf · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Unsafe and unreliable lanyard identification of children’s food allergies View source Delays in issuing care plans for children with allergies View source Lack of a process for immediately communicating safety recommendations to affected parties View source Failure to provide issued care plans to the food provider View source Lack of care plans for all pupils who require them View source Inaccurate care plans 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
Mohammad Ismaeel Ashraf · 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
Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.
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 City Council; that does not assign responsibility.
PFD Monitor interpretation Unsafe and unreliable lanyard identification of children’s food allergies
Wider context from the report “4. As an interim measure lanyards had been used to try and identify which food children were allergic to when buying their lunch. The Inquest heard how some lanyards were not accurate and lanyards themselves are not as safe as they may be amended or worn by a different pupil .
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in issuing care plans for children with allergies
Wider context from the report “2. That there are delays in issuing care plans . Care plans need to be issued quickly where a child has an allergy.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for immediately communicating safety recommendations to affected parties
Wider context from the report “5. Immediately following this tragic event, the Local Authority procured a report to look at the safety of food delivery in the school. That report identified a number of matters requiring attention which included identifying that the lanyard system that the school had introduced as an interim measure was not safe. This recommendation and others were not communicated to the school or anyone else, to enable them to make essential changes to processes to ensure the management of children with food allergies was adequate. I am therefore concerned that the local authority has no process in place to ensure that recommendations are immediately communicated to those affected by them so that practices can be changed and processes put in place to rectify the problem.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide issued care plans to the food provider
Wider context from the report “3. All issued care plans had not been provided to Caterlink by the school and communication between the school and Caterlink was not as effective as they could be .
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of care plans for all pupils who require them
Wider context from the report “1. That care plans are not in place for all pupils that require them . Evidence was heard at the Inquest that the deceased’s sister’s care plan is still inaccurate, despite this having been identified to the school.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Inaccurate care plans
Wider context from the report “1. That care plans are not in place for all pupils that require them. Evidence was heard at the Inquest that the deceased’s sister’s care plan is still inaccurate , despite this having been identified to the school .
” 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 City Council; 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 City Council; 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 City Council; 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 City Council; 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
16 Dec 2016 Exauce Mbiyi Paoulen · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to maintain driver visibility of pedestrians approaching the road edge View source Lack of a pedestrian crossing near the park gates View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Exauce Mbiyi Paoulen · 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
Exauce Mbiyi Paoulen died at Birmingham Children’s Hospital on 29 June 2016 from injuries sustained when he was struck by a vehicle while crossing Grove Lane, Handsworth. The report raised concerns that vehicle speeds and a frequently occupied parking bay obscured drivers’ views of pedestrians, particularly children, and that there was no pedestrian crossing near the park gates.
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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain driver visibility of pedestrians approaching the road edge
Wider context from the report “In the area of Grove Lane bordering Handsworth Park children and adults often cross the road to access the park gates. The road has a speed limit of 30mph and there is not a pedestrian crossing near the park gates. Opposite Handsworth Park there is a parking bay on the west side of Grove Lane that is frequently parked up and obscures the view for drivers proceeding along Grove Lane of pedestrians, particularly children, approaching the edge of the road . There have been several other serious accidents involving pedestrians crossing the road in the vicinity in the past 2 years. This evidence suggests that the speed along this section of road in conjunction with the parking bay creates a risk to pedestrians crossing the road.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a pedestrian crossing near the park gates
Wider context from the report “In the area of Grove Lane bordering Handsworth Park children and adults often cross the road to access the park gates. The road has a speed limit of 30mph and there is not a pedestrian crossing near the park gates . Opposite Handsworth Park there is a parking bay on the west side of Grove Lane that is frequently parked up and obscures the view for drivers proceeding along Grove Lane of pedestrians, particularly children, approaching the edge of the road. There have been several other serious accidents involving pedestrians crossing the road in the vicinity in the past 2 years. This evidence suggests that the speed along this section of road in conjunction with the parking bay creates a risk to pedestrians crossing the road.
” 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 consult on a local road safety scheme for Grove Lane, incorporating the report’s suggestions and stakeholder views.
Verbatim wording from the response “Prior to receiving your report Grove Lane had been identified for assessment through this monitoring system and initial investigations are being undertaken to develop a local safety scheme at this location. The scope of these investigations will incorporate the suggestions contained in your report. A scheme proposal will be developed in consultation with the local residents, Ward Councillors and West Midlands Police. Following consultation, formal approval will be sought to secure funding to implement the scheme in line with the City's Governance procedures. It is my intention to implement a scheme in the financial year 2017/18 but would hope that if consultation goes well this could be as early as June /July 2017.” Source location 2016-0452-Response-by-Birmingham-City-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Grove Lane road safety scheme, programmed for the 2017/18 financial year.
Verbatim wording from the response “Prior to receiving your report Grove Lane had been identified for assessment through this monitoring system and initial investigations are being undertaken to develop a local safety scheme at this location. The scope of these investigations will incorporate the suggestions contained in your report. A scheme proposal will be developed in consultation with the local residents, Ward Councillors and West Midlands Police. Following consultation, formal approval will be sought to secure funding to implement the scheme in line with the City's Governance procedures. It is my intention to implement a scheme in the financial year 2017/18 but would hope that if consultation goes well this could be as early as June /July 2017.” Source location 2016-0452-Response-by-Birmingham-City-Council
Open published response
3 Aug 2016 Winston Harris · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to communicate absconding risk in written hospital transfer documentation View source Failure to consider emergency DOLS for a person presenting a relevant deprivation-of-liberty risk View source Delays in processing DOLS applications View source Failure to include absconding risk and previous absconding behaviour in the care plan View source Failure to provide written confirmation of DOLS applications during hospital transfer View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Winston Harris · 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
Winston Harris, a resident with dementia, left hospital on 17 March 2016 after previously attempting to leave the ward. He was found at a bus stop the following day, severely hypothermic with an acute kidney injury, and died on 22 March 2016; the inquest concluded that he died from dilated cardiomyopathy contributed to by hypothermia and acute kidney injury. Concerns included inadequate documentation of his absconding risk and pending deprivation of liberty application, failure to consider an emergency deprivation of liberty safeguard, and delays in processing the application.
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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate absconding risk in written hospital transfer documentation
Wider context from the report “(2)When Mr Harris was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to consider emergency DOLS for a person presenting a relevant deprivation-of-liberty risk
Wider context from the report “(3) At no time did staff consider if Mr Harris should be subject to an emergency DOLS despite him having dementia and having tried to leave the ward on 16/03/2016. He had previously been assessed as requiring and DOLS.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in processing DOLS applications
Wider context from the report “(4) The application for DOLS order was not processed before Mr Harris’s death . I heard evidence that it often takes many months to process a DOLS application . Given these are extremely vulnerable people applications should be processed more quickly.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to include absconding risk and previous absconding behaviour in the care plan
Wider context from the report “(1) The care plan for Mr Harris did not deal with his risk of absconding . As a result when he was transferred to City Hospital with his care plan there were no details of his previous absconding behaviour .
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written confirmation of DOLS applications during hospital transfer
Wider context from the report “(2)When Mr Harris was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding 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 Invest resources to reduce the backlog of Deprivation of Liberty Safeguards assessments.
Verbatim wording from the response “Following the Supreme Court judgment in P v Cheshire West and Chester County Council and Another; P and Q v Surrey County Council [2013] UKSC 19, [2014] COPLR 313, SC (referred to as Cheshire West and MIG and MEG), there was an immediate eleven-fold increase in the number of applications for Deprivation of Liberty Safeguards (DOLS) in England. Birmingham, as in every other local authority area, experienced this increase and saw its referrals for this work rise from 198 in 2013/14 to 3,278 authorised in the last 12 months. No additional resources have been made available to local authorities to meet this increase. In such circumstances, very large backlogs of assessments mounted, and in Birmingham this was the case as in all other areas.” Source location 2016-0280-Response-by-Birmingham-City-Council
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 Process future Deprivation of Liberty Safeguards applications more quickly.
Verbatim wording from the response “In Birmingham great efforts and resources have been invested to address the problem, which is now delivering significant results, with the waiting list for assessment considerably reduced. Plans are thereafter in place to ensure that in future applications will be processed more quickly.” Source location 2016-0280-Response-by-Birmingham-City-Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The council could not immediately process DOLS applications faster because resources and nationally qualified assessors and advocates were insufficient.
Verbatim wording from the response “Following the Supreme Court judgment in P v Cheshire West and Chester County Council and Another; P and Q v Surrey County Council [2013] UKSC 19, [2014] COPLR 313, SC (referred to as Cheshire West and MIG and MEG), there was an immediate eleven-fold increase in the number of applications for Deprivation of Liberty Safeguards (DOLS) in England. Birmingham, as in every other local authority area, experienced this increase and saw its referrals for this work rise from 198 in 2013/14 to 3,278 authorised in the last 12 months. No additional resources have been made available to local authorities to meet this increase. In such circumstances, very large backlogs of assessments mounted, and in Birmingham this was the case as in all other areas.” Source location 2016-0280-Response-by-Birmingham-City-Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation For a person's new hospital circumstances, the hospital must determine whether deprivation exists and request a fresh DOLS process.
Verbatim wording from the response “In relation to the case of Mr Harris, his application for a DOLS had been prioritised for action on receipt in February 2016, but by the time the lengthy assessment process had been completed, he had been admitted to hospital. Since a DOLS assessment is specific to each care setting, this could not then be authorised. It was therefore the duty of the hospital to judge if his new circumstances also constituted a deprivation of liberty and request the process be started afresh. Indeed, had the DOLS been in place in the care home, this would have had no legal power or application once Mr Harris was admitted to hospital.” Source location 2016-0280-Response-by-Birmingham-City-Council
Open published response
15 Dec 2015 Kamrul Hassan RUBEL · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to enforce use of the emergency cord View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Kamrul Hassan RUBEL · 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
Kamrul Hassan RUBEL fell from a treadmill at Small Heath Wellbeing Centre on 10 August 2015, sustained a traumatic brain injury, and died despite treatment. Evidence at the inquest raised concern that gym users were not routinely required to attach the treadmill’s emergency cord and that appropriate advice and warnings should be given.
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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to enforce use of the emergency cord
Wider context from the report “(1) During the inquest I heard evidence that during initial gym induction users are advised, in accordance with the manufacturer's instruction, that they attach a cord which acts as an emergency stop if anything untoward should occur. At the time in question the deceased did not attach the cord and evidence confirmed it was not normal practice for the gym to enforce use of the emergency cord . It is impossible to say whether this would have made any difference to the deceased but steps should be taken to ensure that appropriate advice and warnings are given to all users regarding the correct use of the emergency cord.
” Open source report
27 Aug 2015 Eliza Simpson · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to reassess and renew deprivation of liberty safeguarding orders when required View source Lack of CCTV View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Eliza Simpson · 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
Eliza Simpson left Roseneath Care Home unobserved on 2 April 2015 and was found recently deceased at a local allotment on 6 April 2015. The inquest recorded the medical cause of death as ischaemic heart disease due to coronary artery disease and concluded that the death was accidental. Concerns included the lack of a system to reassess and renew expired deprivation of liberty safeguarding orders and the absence of CCTV, which hampered the police investigation.
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 City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess and renew deprivation of liberty safeguarding orders when required
Wider context from the report “(1) The Roseneath Care Home appeared to have no system for ensuring that when deprivation of liberty safeguarding orders expired the client was re-assessed to determine whether the need for an order persisted and, where appropriate, seeking further order . In this case the home would have had no legal authority to hold Mrs. Simpson if she had been detected attempting to leave the premises on the 2nd April 2015. The very act of assessing Mrs. Simpson and renewing an application would have served to enforce to the Care Home and its staff the risk of her absconding and may have resulted in closer observation. Although the Roseneath Care Home has now closed if such a system is not standard in Care Homes this issue may arise elsewhere.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of CCTV
Wider context from the report “(2) The absence of CCTV hampered the Police investigation , although this is unlikely to have contributed to Mrs. Simpson’s death this may not always be the case and did mean that a very vulnerable member of society was left wondering around on her own when she might otherwise have been found with the aid of CCTV footage .
” Open source report
11 Mar 2014 Saleh Ali Dalie · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Lack of appropriate crossing measures on a residential road View source Lack of parking restrictions on a residential road View source Lack of road calming measures on a residential road View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Saleh Ali Dalie · 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
Saleh Ali Dalie was hit by a van while crossing Kyotts Lake Road to attend his local mosque and later died from his injuries in hospital. The report raised concerns about the safety of the residential road, noting several incidents and two fatalities, and that requested road-calming, parking restrictions and crossing measures had not been introduced.
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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate crossing measures on a residential road
Wider context from the report “(1) There have been several incidents and 2 fatalities on this road. Residents have campaigned for road calming measures and parking restrictions and appropriate crossing measures which have not been introduced . I am concerned about the safety of this road given it is a residential area.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of parking restrictions on a residential road
Wider context from the report “(1) There have been several incidents and 2 fatalities on this road. Residents have campaigned for road calming measures and parking restrictions and appropriate crossing measures which have not been introduced . I am concerned about the safety of this road given it is a residential area.
” 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 City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of road calming measures on a residential road
Wider context from the report “(1) There have been several incidents and 2 fatalities on this road. Residents have campaigned for road calming measures and parking restrictions and appropriate crossing measures which have not been introduced . I am concerned about the safety of this road given it is a residential area.
” 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 Install temporary vehicle-activated speed signs on Kyotts Lake Road to collect speed data and warn speeding motorists.
Verbatim wording from the response “I can confirm that this site has been identified through our monitoring system and that initial investigations are being undertaken. The provision of temporary vehicle activated speed signs has been agreed and these will be installed early in the next financial year. These will collect speed data and warn motorists that they are exceeding the speed limit.” Source location 2014-0108-Response-by-Birmingham-City-Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Further highway actions depend on effectiveness, affordability and successful public consultation, preventing an unconditional commitment to undertake additional works.
Verbatim wording from the response “There is a meeting arranged for later this month with local residents and the Police to ascertain local concerns and to consider further actions, should they be necessary. Any further actions will be dependent on an assessment of whether the works proposed are likely to be effective in reducing the accident pattern identified, whether the proposals are affordable and on a successful public consultation.” Source location 2014-0108-Response-by-Birmingham-City-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations