BTCM Limited

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First report 12 Aug 2025•Latest report 12 Aug 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
1

Described in responses

Concerns and recipient responses

Statements from BTCM Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Essex

    AI-generated summary

    Resmije Ahmetaj · 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

    Resmije Ahmetaj, also known as Merita Brahimi, died on 30 June 2024 from a traumatic head injury after falling from a height at a multi-storey car park while suffering an exacerbation of psychosis. The report identifies concerns about subtherapeutic antipsychotic medication levels not being acted on, communication and escalation within the mental health team, incomplete record-keeping, medication prescribing confusion, and safety mitigation on the car park’s penultimate floor.

    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 BTCM Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Incomplete mental health care records

    Wider context from the report

    “(4) The mental health Trust record-keeping did not contain all relevant information relating to the care and treatment there were omissions relating to symptoms and potential signs of deterioration and compliance with medication. ”
    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 BTCM Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate and act on markedly subtherapeutic clozapine levels

    Wider context from the report

    “(3) There were issues around communication and escalation within the Trust mental health team. A routine 6-month blood anti-psychotic to check clozapine levels assay was taken on 3 June and the results reported on 7 June were sent to the psychiatrist and showed markedly subtherapeutic blood levels of antipsychotic medication. This subtherapeutic level was not acted upon and was contrary to: a. Ms Ahmetaj insisting she was compliant with her medication b. Ms Ahmetaj did not have any noted risks that would cause interference with her medication. c. Ms Ahmetaj informed EPUT clinicians that: i. On 24 June she thought her medication Clozapine was not working ii. On 27 June she no longer wished to take her prescribed antipsychotic medication , and iii. Did not agree she had Schizophrenia, and iv. wanted to revert to a previous medication Quetiapine. These matters were not escalated to the psychiatrist and Ms Ahmetaj was informed to continue her clozapine and wait for her appointment on 1 July and there was no consideration of the risk of relapse of psychosis. ”
    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 BTCM Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider the risk of psychosis relapse

    Wider context from the report

    “(3) There were issues around communication and escalation within the Trust mental health team. A routine 6-month blood anti-psychotic to check clozapine levels assay was taken on 3 June and the results reported on 7 June were sent to the psychiatrist and showed markedly subtherapeutic blood levels of antipsychotic medication. This subtherapeutic level was not acted upon and was contrary to: a. Ms Ahmetaj insisting she was compliant with her medication b. Ms Ahmetaj did not have any noted risks that would cause interference with her medication. c. Ms Ahmetaj informed EPUT clinicians that: i. On 24 June she thought her medication Clozapine was not working ii. On 27 June she no longer wished to take her prescribed antipsychotic medication , and iii. Did not agree she had Schizophrenia, and iv. wanted to revert to a previous medication Quetiapine. These matters were not escalated to the psychiatrist and Ms Ahmetaj was informed to continue her clozapine and wait for her appointment on 1 July and there was no consideration of the risk of relapse of psychosis. ”
    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 BTCM Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to verify antidepressant prescription doses

    Wider context from the report

    “(2) There was confusion about the mental health Trust prescribing dose for Ms Ahmetaj antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed. ”
    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 BTCM Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the mental health team to undertake mental state examinations

    Wider context from the report

    “(1) EPUT mental health team were relying on the clozapine clinic staff to monitor Ms Ahmetaj’s mental health, but this was not the purpose of the clinic. Staff took blood samples and vital signs with a quick chat that took about 5 minutes and were not undertaking a mental state examination. ”
    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 BTCM Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of fall mitigation on the penultimate car park floor with a pedestrian link walkway

    Wider context from the report

    “(6) The car park has a link walkway to residential housing on the penultimate floor from where Resmije Ahmetaj fell. The top floor has mitigation that would prevent a person from jumping/falling but the penultimate floor that has a pedestrian link walkway does not. There is likely to be more pedestrian footfall on the penultimate floor as a consequence and any fall from this height would inevitably be fatal. ”
    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 BTCM Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in managing clozapine constipation

    Wider context from the report

    “(5) Clozapine constipation was raised as a serious side effect such that there is a Trust policy to manage this matter. This was not dealt with within the Trust for Ms Ahmetaj, and it took two weeks to raise this for the GP to manage. This did not cause or contribute to Ms Ahmetaj’s death however there is a concern for the long delay for other 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 BTCM Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in communication with the GP about antidepressant prescribing

    Wider context from the report

    “(2) There was confusion about the mental health Trust prescribing dose for Ms Ahmetaj antidepressant medication and an overreliance on discussions with her rather than checking the prescription dose and communication with the GP was delayed. ”
    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

    Obtain contractor quotes for proposed mesh stairway covers and extended railings at the car park pedestrian link walkway.

    Verbatim wording from the response

    “In response to the Coroner’s opinion concerning actions BTCM Limited can take, we have approached contractors with a view to installing mitigation measures at the car park level concerned (pedestrian link walkway). The mitigation measures will be to cover up the stairways using mesh and to extend the railings 1m either side of the stairwells from Level 10 to Level 4 on both sides of the car park.”

    Source location

    Response from Basildon Car Park Management
    Page 1 · response
    Published 14 August 2025

    Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026