7 May 2026 Elsie Margaret Jones · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 3 Inadequate supervision of patients with severe dementia on acute hospital wards View source Delays in finding suitable specialist placements for patients with severe dementia View source Delays in securing funding for specialist placements for patients with severe dementia 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
Elsie Margaret Jones · 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
Elsie Margaret Jones, who had advanced dementia and was at high risk of falling, spent several months in hospital while awaiting discharge to a specialist service. She experienced several falls, including a fall on 1 November 2025 that caused a hip fracture, and died on 16 November 2025 after receiving palliative care. The concern was that lengthy delays in securing funding and suitable specialist placements for patients with severe dementia can leave them inadequately supervised on acute hospital wards, creating a risk of future deaths.
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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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision of patients with severe dementia on acute hospital wards
Wider context from the report “The inquest heard evidence that patients who suffer from severe dementia who need specialist placements often spend many months in hospital whilst funding and suitable placements are being found. Given the resources available on acute hospital wards this puts these patients at risk as they cannot always be adequately supervised . I am concerned that the lengthy delays in securing funding and finding suitable placements for these most vulnerable patients creates a risk of future deaths and I consider action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in finding suitable specialist placements for patients with severe dementia
Wider context from the report “The inquest heard evidence that patients who suffer from severe dementia who need specialist placements often spend many months in hospital whilst funding and suitable placements are being found. Given the resources available on acute hospital wards this puts these patients at risk as they cannot always be adequately supervised. I am concerned that the lengthy delays in securing funding and finding suitable placements for these most vulnerable patients creates a risk of future deaths and I consider action should be taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in securing funding for specialist placements for patients with severe dementia
Wider context from the report “The inquest heard evidence that patients who suffer from severe dementia who need specialist placements often spend many months in hospital whilst funding and suitable placements are being found. Given the resources available on acute hospital wards this puts these patients at risk as they cannot always be adequately supervised. I am concerned that the lengthy delays in securing funding and finding suitable placements for these most vulnerable patients creates a risk of future deaths and I consider action should be taken.
” Open source report
16 Sep 2025 Mohammed Ismail KHAN · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Lack of mandatory and comprehensive paramedic training in obstetric emergencies View source Failure to adhere to clinical guidance for assessing and managing delayed breech birth 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
Mohammed Ismail KHAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mohammed Ismail Khan sustained a catastrophic brain injury during a breech delivery at 35 weeks and 2 days gestation on 6 September 2022, after his mother had been discharged from hospital earlier that day despite antenatal risk factors. He later died following a respiratory infection, with the medical cause of death recorded as respiratory failure due to parainfluenza virus infection, with hypoxic-ischaemic brain damage. The investigation identified delayed and suboptimal emergency care, failure to adhere to breech-delivery guidance, and the absence of mandatory paramedic training in obstetric emergencies as substantive concerns.
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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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory and comprehensive paramedic training in obstetric emergencies
Wider context from the report “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted.
3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development .
4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.
5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.
6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course .
7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to clinical guidance for assessing and managing delayed breech birth
Wider context from the report “2. The WMAS investigation concluded that the national, JRCALC guidelines for the clinical assessment and management of breech birth were not adhered by the paramedics and regional trauma desk as the clinicians did not appreciate that the delivery was delayed and that intervention to aid delivery should be attempted .
3. Whilst the JRCALC guidance has since been updated (October 2023) to be clearer and provide much better assistance ████████ explained that it is not mandatory for paramedics to receive specific training on obstetric emergencies, including breech delivery, either in their foundation training/education or as part of continuing professional development.
4. The clinicians who attended Mrs Khan said they would not have felt confident to attempt the techniques advised by JRCALC even if they had realised they were advised.
5. ████████ explained that maternity and obstetric care makes up 3 per cent of emergency ambulance responses.
6. Whilst WMAS have purchased specific training equipment and an online course for clinicians on the management of obstetric emergencies in response to the findings of the investigation, resourcing is such that it has not been possible for all paramedics to receive this additional training e.g. less than a third of paramedics with WMAS have completed the online course.
7. ████████ evidence was that in her opinion the absence of any mandatory training on obstetric emergencies was putting lives at risk.
” Open source report
24 Jan 2025 Neville Daniel Elisha MCKENZIE · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Lack of knowledge of anti-choking devices in care settings View source Failure to make anti-choking devices available in care homes serving residents at high risk of choking 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
Neville Daniel Elisha MCKENZIE · 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
Neville Daniel Elisha MCKENZIE died in hospital on 25 August 2024 after choking at his care home on 13 August 2024, which led to cardiac arrest and an unsurvivable brain injury. The report raised concerns about limited awareness and availability of anti-choking devices in care settings, including homes with residents at high risk of choking.
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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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of anti-choking devices in care settings
Wider context from the report “1. The inquest heard evidence from ████████, Director of Operations for 1st Care Limited, the company which owns Acorn Care Home where Mr McKenzie was a resident. ████████ explained that since Mr McKenzie's death they have purchased a number of anti choking devices and provided training to all staff on the use of them as part of their first aid training. This arose from investigations and research carried out by 1st Care Limited to try and avoid a fatal incident occurring again. Prior to Mr McKenzie's death 1st Care Limited had no knowledge of the availability of these devices. ████████ explained that there is no legal or regulatory requirement for Care or Nursing Homes to have these devices available.
2. ████████, who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home .
3. I heard evidence that the devices are relatively inexpensive and do not require extensive training.
4. ████████ evidence was that she felt the devices could save lives in the event of choking incidents and the fact that most homes would not have them, even those with a high risk resident cohort, was creating an avoidable risk of deaths.
5. It was my finding that there is not wide knowledge of the availability of these devices in care settings and if more homes had them it is likely that deaths from choking could be reduced.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to make anti-choking devices available in care homes serving residents at high risk of choking
Wider context from the report “1. The inquest heard evidence from ████████, Director of Operations for 1st Care Limited, the company which owns Acorn Care Home where Mr McKenzie was a resident. ████████ explained that since Mr McKenzie's death they have purchased a number of anti choking devices and provided training to all staff on the use of them as part of their first aid training. This arose from investigations and research carried out by 1st Care Limited to try and avoid a fatal incident occurring again. Prior to Mr McKenzie's death 1st Care Limited had no knowledge of the availability of these devices. ████████ explained that there is no legal or regulatory requirement for Care or Nursing Homes to have these devices available.
2. ████████, who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home.
3. I heard evidence that the devices are relatively inexpensive and do not require extensive training.
4. ████████ evidence was that she felt the devices could save lives in the event of choking incidents and the fact that most homes would not have them, even those with a high risk resident cohort, was creating an avoidable risk of deaths .
5. It was my finding that there is not wide knowledge of the availability of these devices in care settings and if more homes had them it is likely that deaths from choking could be reduced .
” Open source report
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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 Current evidence and clinical guidance do not support routine use of anti-choking devices in nursing homes; established choking techniques remain recommended.
Verbatim wording from the response “1.1 NICE Guidelines: At present, there are no specific guidelines from the National Institute for Health and Care Excellence (NICE) that mandate the use of anti-choking devices in nursing homes. NICE guidelines focus on evidence-based practices, and currently, there is insufficient evidence to support the routine use of these devices in such settings.” Source location Response from Birmingham and Solihull Integrated Care Board
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 Care homes are responsible for deciding whether to purchase and use anti-choking devices; the ICB does not directly purchase them.
Verbatim wording from the response “The ICB does not directly purchase anti-choking devices for care homes. However, we are committed to ensuring that care homes have the information and support they need to make informed decisions about whether to purchase and use these devices, in alignment with Resuscitation Council UK (RCUK) guidelines. The ICB adheres to the RCUK guideline which emphasises that any use of anti-choking devices should be adjunctive to, and not a replacement for, the established techniques recommended by the RCUK for managing choking, which include encouraging coughing, back blows, and abdominal thrusts.” Source location Response from Birmingham and Solihull Integrated Care Board
Open published response
23 Apr 2024 Ronald Henry SPENCER · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure to maintain sufficient staffing for timely patient medical care View source Inadequate cohesive planning for short-term staffing pressures and longer-term solutions 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
Ronald Henry SPENCER · 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
Ronald Henry Spencer had an oesophageal stent placed on 13 November 2023, which migrated into the small bowel and caused a suspected bowel perforation. He underwent surgery to remove the stent and repair the bowel, initially recovered, then deteriorated and died on 2 December 2023. The report raised concerns about significant staffing issues and resulting delays in treatment, as well as inadequate cohesive planning for short- and long-term staffing pressures; it stated there was no direct evidence that the delays caused or contributed to his death.
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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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficient staffing for timely patient medical care
Wider context from the report “1. I heard evidence that there were significant staffing issues during the Ronald's period of in-patient care that caused delays to his treatment . Whilst there was no direct evidence at the inquest that these delays caused or contributed to death, any delays in patients receiving medical care due to a lack of staff clearly presents a risk of future deaths occurring.
2. It is recognised that the reasons for delay can be multifactorial, with so called "winter pressures" causing an influx of ill patients and heightened staff absences. "Winter pressures" are now a regular annual event and put significant strain on the NHS. There can be no doubt that patients have died, and will continue to die, from avoidable deaths due to delays caused by these staffing inadequacies .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate cohesive planning for short-term staffing pressures and longer-term solutions
Wider context from the report “5. I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. "winter pressures") or with a view to finding longer term solutions .
” 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 Consider all recommendations from the independent upper-GI service review.
Verbatim wording from the response “It has also been recognised that the current staffing model in place, which includes four dedicated esophago-gastric consultants running the specialist upper GI on-call service for the region, may represent an additional vulnerability within the service, particularly at times of increased demand. The UHB upper GI service has recently undergone an independent invited review which has been conducted by the East Midlands Clinical Senate. The review encompassed all aspects of elective and emergency upper GI care at the QEΗ. The final report is awaited, but it is anticipated that recommendations will likely include reviewing the current esophago-gastric service configuration and increasing the number of consultants” Source location Response from Birmingham and Solihull
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver workforce programmes addressing diagnostic risks, including sustainable staffing, retention, training and workforce-plan foundations.
Verbatim wording from the response “• Deliver key programmes of work that have been identified as critical to address the risks and challenges identified within the workforce diagnostics which will enable:” Source location Response from Birmingham and Solihull
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the 4R’s Workforce Delivery Framework with allocated resources supporting implementation over two years.
Verbatim wording from the response “The 4R’s Workforce Delivery Framework is now operational and significant resource has been allocated to support implementation over the next two years. This investment will be used to sustain the delivery of existing programmes where they have been identified as supporting the 4R’s as well as a range of additional priorities identified as part of the Workforce Diagnostic.” Source location Response from Birmingham and Solihull
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 Introduce the NHS Long Term Workforce Plan and Framework 15.
Verbatim wording from the response “BSol ICB recognises the need for a workforce that is sufficient in numbers and skills to care for patients throughout the calendar year and works with all system partners to ensure this. We are also committed to the introduction of the NHS Long Term Workforce Plan and Framework 15.” Source location Response from Birmingham and Solihull
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 Complete an independent review of elective and emergency upper-GI care and service configuration.
Verbatim wording from the response “It has also been recognised that the current staffing model in place, which includes four dedicated esophago-gastric consultants running the specialist upper GI on-call service for the region, may represent an additional vulnerability within the service, particularly at times of increased demand. The UHB upper GI service has recently undergone an independent invited review which has been conducted by the East Midlands Clinical Senate. The review encompassed all aspects of elective and emergency upper GI care at the QEΗ. The final report is awaited, but it is anticipated that recommendations will likely include reviewing the current esophago-gastric service configuration and increasing the number of consultants” Source location Response from Birmingham and Solihull
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 Appoint three emergency-surgery locum consultants and an academic colorectal consultant to increase rota resilience.
Verbatim wording from the response “Since the time of Mr Spencer’s admission in December 2023, three locum consultants in emergency surgery have been appointed as well as an academic colorectal consultant. As a result, there is increased resilience in the emergency surgery rota than was the case when Mr Spencer was admitted.” Source location Response from Birmingham and Solihull
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 Deploy senior fellows to cover consultant rota gaps with consultant oversight.
Verbatim wording from the response “In response to matters of concern in relation to staff shortages at UHB, it is noted that the Inquest found no evidence to suggest that the standard of clinical care provided to Mr Spencer contributed to his death. However, we recognise that at the time of his death there was an unprecedented strain on the general surgical consultant workforce at UHB as a result of anticipated sickness absence of three surgeons. Steps had been taken to mitigate the impact of the exceptional workforce pressures which included arranging for two senior fellows, both of whom had completed registrar training, to "act up" and cover any identified gaps on the consultant rota. Both fellows were considered to be sufficiently skilled and experienced and consultant support was also put in place so that there was oversight of their temporary roles.” Source location Response from Birmingham and Solihull
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 Complete a high-level diagnostic of current and future workforce demand and supply.
Verbatim wording from the response “In June 2023, BSol ICB carried out a high-level diagnostic of the current and future workforce looking at both demand and supply drawing upon BSol strategy and operational documents. It identified that workforce is an immediate and urgent priority for the ICB and supports the system in responding to the NHS Long Term Workforce Plan and Framework 15.” Source location Response from Birmingham and Solihull
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 Open the refurbished elective surgical hub at Solihull Hospital, adding six theatres and capacity for 11,500 procedures annually.
Verbatim wording from the response “In addition to the above and recognising the impact of increased urgent and emergency admissions on our healthcare system, there are also plans underway to open the refurbished elective surgical hub at Solihull Hospital in September 2024. There has been significant investment in the hub which includes six new operating theatres and will enable an additional 11,500 procedures a year for patients from Birmingham and Solihull, thereby alleviating pressure on bed occupancy and treatment capacity across the Trust.” Source location Response from Birmingham and Solihull
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 inquest found no evidence that the standard of clinical care contributed to Mr Spencer’s death.
Verbatim wording from the response “In response to matters of concern in relation to staff shortages at UHB, it is noted that the Inquest found no evidence to suggest that the standard of clinical care provided to Mr Spencer contributed to his death. However, we recognise that at the time of his death there was an unprecedented strain on the general surgical consultant workforce at UHB as a result of anticipated sickness absence of three surgeons. Steps had been taken to mitigate the impact of the exceptional workforce pressures which included arranging for two senior fellows, both of whom had completed registrar training, to "act up" and cover any identified gaps on the consultant rota. Both fellows were considered to be sufficiently skilled and experienced and consultant support was also put in place so that there was oversight of their temporary roles.” Source location Response from Birmingham and Solihull
Open published response
17 Apr 2024 Jade Marie GRIFFITHS-JONES · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to meet target ambulance response times View source Delays in hospital handover compromising ambulance crew availability 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
Jade Marie GRIFFITHS-JONES · 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
Jade Marie Griffiths-Jones died in hospital on 4 June 2023 after suffering a cardiac arrest caused by coronary artery disease and sustaining severe hypoxic brain injury. An ambulance was not available to attend her earlier chest-pain call within target times, with concerns about ambulance response delays linked to increased demand and hospital handover delays.
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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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to meet target ambulance response times
Wider context from the report “1. During the inquest evidence was given on behalf of West Midlands Ambulance Service from ████████, Learning Response Lead, that at the time of Jade's initial call reporting centralised chest pain at 13:33 on the 31st May 2023 the Trust was experiencing increased volume of calls and significant hospital delays and therefore could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes). The call was still unresourced when she was reported to be in cardiac arrest during a further call at 15:01 (the 4th call). The Trust's Gold Dashboard that was captured closest to the clock start time for the first call (captured at 13:00:32) identified that there were delays in the mean and 90th percentile response times for Category 1, 2, 3 calls . There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation, and 16 cases yet to be prioritised. There were regional hospital delays of up to 218 minutes.
2. For the 2 hours before Jade's call the Birmingham sector had been experiencing a 2 hour spike in demand. However, the real problem affecting resourcing was pandemic crews being stuck at hospitals awaiting handover. In 2023 to 2024 West Midlands Ambulance Service lost approximately 250,000 response hours due to delays at hospitals.
3. West Midlands Ambulance Service have taken a broad range of measures in recent years to tackle increasing response times including measures to reduce call demand through public education, to avert calls away from ambulance services and hospitals via clinical validation, to improve patient flow through intelligent conveying and to increase the number of resources in operation. Aside from seeking funding to recruit further paramedics and increase ambulance numbers alongside continued monitoring and learning there is nothing West Midlands Ambulance Service can identify that they can do to improve the situation further.
4. West Midlands Ambulance Service continue to fail to meet target response times and have been made the subject of a regulation 12 notice on this topic by the CQC.
5. The evidence of West Midlands Ambulance Service is that if hospital handover delays didn’t exist they would be likely to be meeting their response targets as they did before hospital delays became chronic.
In the circumstances it is my conclusion that the availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in hospital handover compromising ambulance crew availability
Wider context from the report “1. During the inquest evidence was given on behalf of West Midlands Ambulance Service from ████████, Learning Response Lead, that at the time of Jade's initial call reporting centralised chest pain at 13:33 on the 31st May 2023 the Trust was experiencing increased volume of calls and significant hospital delays and therefore could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes). The call was still unresourced when she was reported to be in cardiac arrest during a further call at 15:01 (the 4th call). The Trust's Gold Dashboard that was captured closest to the clock start time for the first call (captured at 13:00:32) identified that there were delays in the mean and 90th percentile response times for Category 1, 2, 3 calls. There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation, and 16 cases yet to be prioritised. There were regional hospital delays of up to 218 minutes.
2. For the 2 hours before Jade's call the Birmingham sector had been experiencing a 2 hour spike in demand. However, the real problem affecting resourcing was pandemic crews being stuck at hospitals awaiting handover . In 2023 to 2024 West Midlands Ambulance Service lost approximately 250,000 response hours due to delays at hospitals .
3. West Midlands Ambulance Service have taken a broad range of measures in recent years to tackle increasing response times including measures to reduce call demand through public education, to avert calls away from ambulance services and hospitals via clinical validation, to improve patient flow through intelligent conveying and to increase the number of resources in operation. Aside from seeking funding to recruit further paramedics and increase ambulance numbers alongside continued monitoring and learning there is nothing West Midlands Ambulance Service can identify that they can do to improve the situation further.
4. West Midlands Ambulance Service continue to fail to meet target response times and have been made the subject of a regulation 12 notice on this topic by the CQC.
5. The evidence of West Midlands Ambulance Service is that if hospital handover delays didn’t exist they would be likely to be meeting their response targets as they did before hospital delays became chronic.
In the circumstances it is my conclusion that the availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.
” 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 Maintain accredited System Co-ordination Centre capability to coordinate pressure-point interventions, joined-up problem solving and safety across urgent and emergency care pathways.
Verbatim wording from the response “The ICB hosts the SCC, which holds full accreditation status from NHS England in compliance with the national SCC specification. The team are responsible for co-ordinating the system-wide response to pressure points, such as ambulance handovers and increases of activity in EDs, and supporting interventions in all pathways. They have access to a wide range of data to enable their role and bring system partners together throughout the day, and into the out-of-hours period, to ensure joined up problem solving, effective flow and maintenance of safety.” Source location Response from NHS Birmingham and Solihull
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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 urgent treatment centre provision against local population needs and national guidance.
Verbatim wording from the response “BSOL has six UTCs across the footprint; these can be accessed either by walking-in or via direction from NHS 111. They provide an alternative pathway away from ED for those patients who require swift medical attention with urgent but non-life-threatening conditions. The UTCs can also offer clinical telephone advice to ambulance crews on the scene and can accept conveyances when and where agreed. On average, 714 patients have been treated daily within UTCs over the last 12 months. A full review of UTC provision was instigated in May 2024 to ensure it meets the needs of both our local population and new national guidance published in October 2023.” Source location Response from NHS Birmingham and Solihull
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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 Operate a single transfer-of-care hub approach with local partners to reduce handoffs and accelerate movement from acute hospitals into community services.
Verbatim wording from the response “A single transfer of care hub approach was implemented by UHB, BCHC, Birmingham City Council and Solihull Metropolitan Borough Council in May 2024 to improve the flow of patients out of the acute hospital and into community services. The new process enables fewer handoffs between teams and will enable hospitals to ‘free up’ beds earlier, and therefore, admit patients from ED in a more timely way.” Source location Response from NHS Birmingham and Solihull
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the “Call before you convey” service to divert suitable older patients from hospital attendance into urgent community or wider community services.
Verbatim wording from the response “‘Call before you convey’ is a direct service available to WMAS colleagues whilst with the patient in their own home, offering diversion pathways to use where appropriate, other than hospital attendance. This service is primarily aimed to support patients over the age of 75 years, offering diversion into the UCR or wider community services. Since the commencement of this service in December 2023 there have been an average of just over 65 calls per week equating to nearly 10 patients per day.” Source location Response from NHS Birmingham and Solihull
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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 Coordinate system-wide urgent and emergency care responses through the Delivery and Improvement Board and System Co-ordination Centre, with escalation and safety oversight.
Verbatim wording from the response “For this reason, oversight is via a UEC Delivery and Improvement Board which is chaired by the ICB Chief Delivery Officer with senior representation from all system partners. This Board provides integrated system leadership to set and deliver the Urgent and Emergency Care Strategy, with a focus on equity of access and system efficiency.” Source location Response from NHS Birmingham and Solihull
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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 Ambulance service commissioning is undertaken by Black Country ICB on behalf of West Midlands ICBs, with BSOL as an associate commissioner.
Verbatim wording from the response “WMAS is not directly commissioned by BSOL, but by the Black Country ICB on behalf of the West Midlands ICBs, with BSOL as associate commissioners. As such BSOL contributes to discussion on performance and quality via established routes with Black Country colleagues. Operationally, however, WMAS colleagues are very integrated into BSOL provision and daily oversight rhythm. This not only includes the paramedic crews themselves, but presence of a senior co-ordinating role, the Hospital Ambulance Liaison Officer (HALO), and until recently provision within UHB with Ambulance Decision Areas (as below). The overall objective of the HALO service is to facilitate the handover of patients presenting at ED by ambulance, in a clinically safe, effective and efficient manner, thus enabling crews to turnaround ambulances in readiness to respond to other emergency calls.” Source location Response from NHS Birmingham and Solihull
Open published response
23 Nov 2023 Philip Laurence Justin MALONE · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients View source Inadequate psychiatric bed capacity in Birmingham and Solihull View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Philip Laurence Justin MALONE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip Laurence Justin Malone, who had treatment-resistant schizophrenia and had deteriorated significantly in late June 2023, was found deceased in his supported accommodation on 3 July 2023. The inquest concluded that his death was the consequence of suicide. The principal concern was inadequate psychiatric bed capacity in Birmingham and Solihull, after clinicians sought to admit him but no inpatient bed was available, creating an ongoing risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients
Wider context from the report “1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action.
2. The Patient Safety Manager ████████ gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved, and there is a genuine risk of the same problem with another patient in the future.
3. ████████ added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged . In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged , and amplifies the chronic shortage of beds.
4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board.
The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding.
My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate. Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Inadequate psychiatric bed capacity in Birmingham and Solihull
Wider context from the report “1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action.
2. The Patient Safety Manager ████████ gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved , and there is a genuine risk of the same problem with another patient in the future.
3. ████████ added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged. In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged, and amplifies the chronic shortage of beds.
4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board.
The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding.
My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate . Whilst some action may have been taken it is insufficient to resolve the problem . It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.
” Open source report
14 Jul 2023 PETER MARTIN AARON FLEMING · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 9 Failure of medication-management processes to identify proposed carbamazepine treatment View source Lack of care-coordinators for seriously mentally ill patients View source Lack of GP resources for proactively checking collection of prescribed medication View source Delays in primary care organisations providing important patient updates to GPs View source Unavailability of approved mental health practitioners within 24 hours View source Unavailability of mental health places of safety View source Failure of digital systems used by different health organisations to communicate View source Unavailability of mental health inpatient beds View source Ineffective communication between specialist mental health teams View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
PETER MARTIN AARON FLEMING · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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
11 Jan 2023 Leroy Patrick HAMILTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of inpatient mental health beds View source Lack of an agreed multi-agency protocol for informal patients absconding from emergency departments View source Failure to undertake and appropriately classify risk assessments for missing persons View source Failure to classify reported people as missing persons View source Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed View source Lack of Psychiatric decisions unit spaces View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Leroy Patrick HAMILTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient mental health beds
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU. Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed multi-agency protocol for informal patients absconding from emergency departments
Wider context from the report “3. Multi agency protocol for informal missing patients: The inquest heard how there is no agreed protocol to deal with informal patients who abscond from emergency departments . Consideration should be given to setting up an agreed protocol so that all agencies involved understand their respective roles and responsibilities.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and appropriately classify risk assessments for missing persons
Wider context from the report “5. WMP risk assessments for missing persons: When Mr Hamilton was first reported as missing no risk assessment was undertaken about his level of risk to himself . The call had confirmed he was at risk of harming himself . The leads to a concern that staff do not understand when and how to risk assesses incidents and when to identify high risk incidents .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to classify reported people as missing persons
Wider context from the report “4. WMP Missing person investigations: The inquest heard how on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr Hamilton as a missing person when he was reported as missing . On both occasions he should have been treated as a high risk missing person. This raises a serious concern that staff do not understand when people should be classified as missing . Consideration should be given to ensuring staff properly understand how to assess if someone should be treated as a missing person and WMP should consider whether further training is required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed
Wider context from the report “2. Safe space: The inquest heard how it is often the case that due to the lack of inpatient beds and PDU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed . This means that acutely ill mental health patients are often left for long periods without any specialist care, support or observation . Consideration should be given to setting up a safe space where patients can wait for a bed or PDU space which is able to cater for their special needs and keep them safe.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of Psychiatric decisions unit spaces
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces : The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU . Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
” Open source report
×
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 Explore alternative Psychiatric Decision Unit models to meet system need.
Verbatim wording from the response “We recognise as an ICS that even with the introduction of the significant focus on pathways for individuals described above, the care for this group of people must remain a priority for us all. We have therefore established a system wide clinical oversight group to lead together this piece of work. This emphasizes joint ownership of care and pathways and will be a single liaison point with external agencies. Through the Mental Health Collaborative we are also ensuring that all work in this area is being streamlined and joined up under one programme linking clinical and operational elements along the whole pathway across all provider organisations. The clinical work programme includes an immediate adoption of jointly owned care standards across the pathway, with audit and learning against provided care, and exploration of different PDU models to meet ICS need.” Source location Response from Birmingham and Solihull Integrated Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a consistent multi-agency protocol for informal missing mental health patients across urgent care services.
Verbatim wording from the response “BSMHFT and UHB both have Missing Patients Policies in place. These are single agency policies and it is recognised that there will be significant potential benefit in establishing a consistent system wide protocol across urgent care services for mental health patients who go missing, consistent with the National Framework Document (‘The multi-agency response for adults missing from mental health care settings’ (Updated August 2021). A multi-agency agreement of this type defines roles and responsibilities, allows for consistency across services, and includes clear escalation pathways. This work will be led by the Mental Health Provider Collaborative with input from all system stakeholders.” Source location Response from Birmingham and Solihull Integrated Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use implemented processes to divert suitable patients from emergency departments to Psychiatric Decision Unit capacity.
Verbatim wording from the response “The Psychiatric Decision Unit (PDU) based at Oleaster Unit in BSMHFT, has been commissioned for patients who have capacity, are able to consent to attend the PDU and who are assessed as “low risk”. It is an ambulant assessment area which provides a calming environment for the assessment and development of treatment and pathway plans. As such it is not an admission area; it does not have beds within it. Like ED, there are no powers of detention for individuals accessing the PDU. There are six spaces (three male, three female) in the PDU. Processes implemented by the ICS help to divert suitable people to the PDU capacity rather than attendance at ED and the capacity is used regularly to take people from ED who meet the relevant criteria.” Source location Response from Birmingham and Solihull Integrated Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Psychiatric Decision Unit service, including higher-acuity capacity, access and onward-care pathways, and clinical support.
Verbatim wording from the response “However, it is recognised that review of the current PDU service is required; we need capacity that provides care for people with higher acuity of MH need, with clear pathways for access and onward care. As part of the review we will also be looking at the clinical support for PDU. As a system we recognise accessing help prior to coming to ED or PDU will be best for many patients.” Source location Response from Birmingham and Solihull Integrated Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission additional mental health beds to improve flow through bedded capacity and support step-down and return from out-of-area placements.
Verbatim wording from the response “Over this winter period the ICB have commissioned additional beds to aid flow through bedded capacity to enable step down ahead of discharge and to facilitate return into the system from out of area placement. There is also a considerable focus on flow through all MH bedded capacity, with a focus on overcoming delays in discharge of stable patients to maximise productivity of available capacity.” Source location Response from Birmingham and Solihull Integrated Care
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 Mental Health Provider Collaborative is responsible for designing and delivering services and leading strategic cases for additional mental health bed capacity.
Verbatim wording from the response “A Mental Health Provider Collaborative was formed April 2023 within Birmingham and Solihull ICS with responsibility for designing and delivering appropriate mental health services across the ICS. This collaborative is leading on the strategic cases to establish further bedded capacity, but we recognise that this will take time. The developing health infrastructure strategy for the local NHS will highlight additional inpatient mental health facilities as a priority for any bids for national capital.” Source location Response from Birmingham and Solihull Integrated Care
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 Mental Health Provider Collaborative will lead development of a system-wide multi-agency protocol for informal missing mental health patients.
Verbatim wording from the response “BSMHFT and UHB both have Missing Patients Policies in place. These are single agency policies and it is recognised that there will be significant potential benefit in establishing a consistent system wide protocol across urgent care services for mental health patients who go missing, consistent with the National Framework Document (‘The multi-agency response for adults missing from mental health care settings’ (Updated August 2021). A multi-agency agreement of this type defines roles and responsibilities, allows for consistency across services, and includes clear escalation pathways. This work will be led by the Mental Health Provider Collaborative with input from all system stakeholders.” Source location Response from Birmingham and Solihull Integrated Care
Open published response
16 Jun 2022 Lee Anthony CARUANA · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Delays in handing over ambulance patients at hospitals 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
Lee Anthony CARUANA · 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
Lee Anthony CARUANA died at the Queen Elizabeth Hospital, Birmingham, on 6 October 2021 after suffering from COVID-19 and experiencing a delay in ambulance attendance. The report identified delays caused by ambulance crews waiting to hand over patients at hospitals, compromising ambulance availability and creating a risk to life.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in handing over ambulance patients at hospitals
Wider context from the report “1. During the inquest, evidence was given on behalf of West Midlands Ambulance Service from Clinical Governance Lead ████████ and Trust Investigations Officer ████████ that at the time of Mr Caruana's death the Trust was experiencing unprecedented demand due to high call volume and delays in handing over patients to hospitals . At the time Mr Caruana was identified as needing an ambulance following a 999 call at 23:53 on the 6 October 2021, 71 of the Trusts 253 ambulance crews on duty were at hospital awaiting handover, the longest wait that day had been 7 hours and 45 minutes for a crew waiting at Birmingham Heartlands Hospital.
2. Since October 2021 the number of calls received has started to reduce to normal levels. However, the problem of paramedic crews being stuck at hospitals awaiting handover has increased . As an Investigations Officer ████████ said she is continuing to see incidents where ambulance attendance has been delayed because a crew was not available due to the number of crews waiting at hospital . Her evidence was that this is putting lives at risk.
3. ████████, Governance and Performance Manager at London Ambulance Service, gave evidence to the inquest as an independent expert. In the course of his evidence, he explained that the problem of ambulance crews being stuck awaiting handover is a national issue . Based on his anecdotal experience and observations the number of calls that a crew is able to attend to in a 12 hour shift has dropped by approximately 1/3 as a result of this issue.
4. The evidence from West Midlands Ambulance Service is that they have raised awareness of this issue locally, they have taken steps to free up ambulances (such as leaving multiple patients under the care of one paramedic crew at hospital to free up other crews to leave and diverting patients to other services where possible) and there is nothing further that they can do.
5. In the circumstances it is my conclusion that the availability of ambulance crews is being compromised by delays at hospitals resulting in delays in response times which creates a risk to life .
” Open source report
Concerns raised 7 Failure to provide families with direct remote participation in MDT meetings View source Failure to raise incident reports for significant suicide-related information View source Failure to record significant family concerns and patient accounts View source Failure to update risk screens after significant changes in presentation View source Failure to remove or mitigate ligature risks from bedroom-area doors View source Failure to communicate significant risk information in handovers and MDTs View source Continuing ligature risk from en-suite and other doors in unobserved areas of mental health units View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Azra Parveen HUSSAIN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with direct remote participation in MDT meetings
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to raise incident reports for significant suicide-related information
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised , and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant family concerns and patient accounts
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra . Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to update risk screens after significant changes in presentation
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated , an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to remove or mitigate ligature risks from bedroom-area doors
Wider context from the report “2. BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk : the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufactures for 10 years. BSMHT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in-patient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate significant risk information in handovers and MDTs
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020 . Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Continuing ligature risk from en-suite and other doors in unobserved areas of mental health units
Wider context from the report “2. BSMHT had risk assessed ward 2 for ligature points, including the en-suite bathrooms, in November 2019. The en-suite bathroom doors were given the highest risk score possible on an acute ward, but no corrective action was identified to remove or mitigate the risk: the risk assessment relied on clinical assessment and observation of the service user to mitigate the risk. Evidence was given at the inquest that pressure sensor alarms have been available in the UK from numerous manufactures for 10 years. BSMHT had been investigating and testing different pressure sensor alarms for en-suite bathroom doors for approximately 2 years before Azra's death. BSMHT has now identified an appropriate pressure sensor for en-suite bathroom doors and the en-suite bathroom door of room 14 on ward 2 was replaced in November 2020 with a door incorporating a pressure sensor alarm. BSMHT has a 17 month program to fit pressure sensor alarms to all en-suite bathroom doors within its inpatient units. However, this is not being considered for other doors within the bedroom area nor is there any national requirement for in-patient mental health units to place, or consider placing, pressure sensor alarms on doors within areas where patients are afforded privacy and time alone. I am concerned that within BSMHT's inpatient units there will be a continuing risk from other doors in the bedroom area (including the main bedroom door) even when the en-suite bathroom doors are fitted with pressure sensor alarms. Although the outer face of a bedroom door will be on a communal corridor, service users on level 1 and 2 observations will have periods where they are unobserved in their rooms and could wedge a ligature at the top of a door so that it wasn't obviously visible from outside. Furthermore, in the absence of any national regulations or guidance on this topic the risk from en-suite and other doors in areas where service users spend time unobserved will persist in mental health units operated by other Trusts and private providers around the country .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor ligature-risk actions through monthly Trust updates and regular system risk-review meetings.
Verbatim wording from the response “At the time of this incident, as described in the root cause analysis investigation, the Trust had identified a potential risk to inpatients from ligature points and was undertaking a piece of work to assess this risk along with options to mitigate it. This piece of work is continuing and is being overseen by the system and by the Care Quality Commission (CQC). Following a CQC report being issued in November 2020 an action plan was put in place with monthly updates being provided by the Trust to the CQC and to the system. Additionally, regular system risk review meetings were held at which progress was discussed. In response to a” Source location 2021-0082-Response-from-Birmingham-and-Solihull-CCG-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Oversee the continuing assessment of inpatient ligature risks and options to mitigate them.
Verbatim wording from the response “At the time of this incident, as described in the root cause analysis investigation, the Trust had identified a potential risk to inpatients from ligature points and was undertaking a piece of work to assess this risk along with options to mitigate it. This piece of work is continuing and is being overseen by the system and by the Care Quality Commission (CQC). Following a CQC report being issued in November 2020 an action plan was put in place with monthly updates being provided by the Trust to the CQC and to the system. Additionally, regular system risk review meetings were held at which progress was discussed. In response to a” Source location 2021-0082-Response-from-Birmingham-and-Solihull-CCG-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request that the Trust accelerate actions addressing inpatient ligature-risk concerns and provide progress updates.
Verbatim wording from the response “further inpatient death, the Trust were asked to speed up the actions that were being taken to address these concerns and provide updates.” Source location 2021-0082-Response-from-Birmingham-and-Solihull-CCG-Redacted
Open published response
Concerns raised 3 Failure of the EMIS consultation-list mitigation to reliably ensure practitioner logout and re-login View source Failure of EMIS consultation lists to update reliably View source Failure to ensure that all EMIS-using GP surgeries are alerted to the consultation-list error View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Pardeep Singh PLAHE · 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
Pardeep Singh Plahe died at Queen Elizabeth Hospital on 12 August 2020 after inflicting a catastrophic injury to his neck with a decorative samurai sword. He had been increasingly concerned about a physical health complaint and had a scheduled GP telephone consultation that was missed because of a technical problem with the EMIS system. The report raised concerns that consultation lists could fail to update, creating a risk that urgent telephone consultations might be missed, and that the identified mitigation depended on practitioners remembering to log out and back in to the system.
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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the EMIS consultation-list mitigation to reliably ensure practitioner logout and re-login
Wider context from the report “1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been identified. Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred at other surgeries across the country.
2. Particularly for telephone consultations (where there will not be a patient physically present in the surgery to query why they have not been seen), the fact that the consultation lists do not always update creates a risk to life as a consultation could be missed for a patient with a medical emergency.
3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.
4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log out of the EMIS system and then log back on the consultation list will update . Therefore, all practitioners are advised to log out and log back in before completing their consultation lists. However, on one occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and missed an appointment .
5. The methods of mitigating this risk are vulnerable to human error if the practitioner is unaware of the need to log out of EMIS and log back in or if they forget to do so.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of EMIS consultation lists to update reliably
Wider context from the report “1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been identified . Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred at other surgeries across the country.
2. Particularly for telephone consultations (where there will not be a patient physically present in the surgery to query why they have not been seen), the fact that the consultation lists do not always update creates a risk to life as a consultation could be missed for a patient with a medical emergency .
3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.
4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log out of the EMIS system and then log back on the consultation list will update. Therefore, all practitioners are advised to log out and log back in before completing their consultation lists. However, on one occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and missed an appointment.
5. The methods of mitigating this risk are vulnerable to human error if the practitioner is unaware of the need to log out of EMIS and log back in or if they forget to do so.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all EMIS-using GP surgeries are alerted to the consultation-list error
Wider context from the report “1. On the 10th August at 17:30, hours before he inflicted the fatal wound to his neck, Mr. Plahe had a telephone consultation scheduled with his GP at the Ashfield Surgery. The appointment had been booked by his sister that afternoon. Due to a technical issue with the EMIS system the consultation list of the GP due to speak to Mr. Plahe did not update so he did not realise the appointment had been added to his list and did not call Mr. Plahe. Practitioners at the surgery had realised that the system was intermittently not updating consultation lists on or around the 30th July 2020 and had raised the issue with EMIS on the 4th August 2020. To date a solution to correct this intermittent problem has not been identified. Evidence was given at inquest that it does not just affect the Ashfield Surgery but has occurred at other surgeries across the country.
2. Particularly for telephone consultations (where there will not be a patient physically present in the surgery to query why they have not been seen), the fact that the consultation lists do not always update creates a risk to life as a consultation could be missed for a patient with a medical emergency.
3. It is not known whether all GP Surgeries using EMIS have raised an alert that this error can occur.
4. To mitigate the risk of missing appointments the Ashfield Surgery has identified that if practitioners log out of the EMIS system and then log back on the consultation list will update. Therefore, all practitioners are advised to log out and log back in before completing their consultation lists. However, on one occasion since Mr. Plahe's death a locum GP carrying out a list at the surgery did not know to do this and missed an appointment.
5. The methods of mitigating this risk are vulnerable to human error if the practitioner is unaware of the need to log out of EMIS and log back in or if they forget to do so.
” 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 Send all GP practices information about appointment-refresh risks, resolution steps and IT support contacts.
Verbatim wording from the response “The most recent position has been checked by the CCG’s IT Team in light of your report, and I am advised that with the upgrade to Windows 10 there have been a number of reports to EMIS of this problem reoccurring. In response to this information, the CCG has sent a communication to all GP practices highlighting potential problems and providing information on how this can be resolved, as well as providing them with contact details for the IT support service so that they can access assistance on resolving any ongoing problems. In addition, EMIS issued a safety advisory notice on 3rd February to alert practices to the need to identify and address this issue.” Source location 2021-0061-Response-from-CCG-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring appointment-refresh problems and work with EMIS and GP practices to identify and address further issues.
Verbatim wording from the response “The CCG IT Team will continue to monitor the situation and work with both EMIS and the GP practices to identify and address any further problems.” Source location 2021-0061-Response-from-CCG-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue guidance to GP practices on preventing and resolving appointment-refresh problems.
Verbatim wording from the response “I understand that the issue of appointments not refreshing was raised as a concern by a number of GP practices. EMIS investigated and identified that this was due to the page(s) not refreshing if certain firewall ports were not opened or users were working remotely through a VPN (virtual private network) connection. The CCG’s IT Team were made aware of the problem around the time this incident occurred, and worked with EMIS and the GP practices to find a cause for the problem and a solution. Guidance was issued following the cause of the problem being identified.” Source location 2021-0061-Response-from-CCG-Redacted
Open published response
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.
×
AI-generated summary
Nigel Byron Abbott · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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 NHS Birmingham and Solihull Integrated Care Board; 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
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit additional Home Treatment Team doctors, psychologists, administrators, family-support staff and nurses to expand capacity and reduce caseloads.
Verbatim wording from the response “11.1 BSMHFT have recognised the need for additional investment in the Home Treatment Team service and have committed in excess of £1m to create additional teams with smaller caseloads.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop joint standards and policies across agencies.
Verbatim wording from the response “3.5 The group is currently overseeing five main work streams in response to the Coroner’s recommendations, which are:” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement local arrangements delegating access management for Section 140 emergency beds.
Verbatim wording from the response “13.1 The CCG recognises the responsibility to provide emergency beds pursuant to Section 140 of the Mental Health Act.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 Obtain formal multi-agency approval for the revised police-assistance memorandum.
Verbatim wording from the response “5.1 A new Memorandum of Understanding has been developed and agreed by all of the relevant agencies, WMP, BCC, BSMHFT and BWCH. This memorandum has been developed and will receive formal approval at the multi-agency working group on 22nd January 2020.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop electronic action cards setting out staff processes and inter-agency interactions.
Verbatim wording from the response “3.5 The group is currently overseeing five main work streams in response to the Coroner’s recommendations, which are:” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 internal care pathways to maximise capacity in teams meeting patient demand.
Verbatim wording from the response “10 Improving Flow Internally at BSMHFT” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 Monitor Home Treatment Team caseloads daily.
Verbatim wording from the response “11.3 Since 1st August 2019 BSMHFT have been monitoring daily caseloads for each of the Home Treatment Teams and the actions set out above have led to demonstrable reduction in the average caseload of the teams.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 Revise, approve and cascade the Home Treatment Team operational procedure to align safeguards with the Bed Management Policy.
Verbatim wording from the response “15 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.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 Present the revised memorandum to frontline staff and deliver engagement, support and scenario testing.
Verbatim wording from the response “5.3 The new memorandum provides clarity for front line staff working in pressured situations, is clear on the roles and responsibilities of the agencies involved and seeks to remove the ambiguity relating to the incorrect perception that WMP require 24 hours’ notice when providing police support. This approach has been communicated to staff in advance of the final sign off of the full document.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a new urgent care centre integrating urgent mental health assessment, place-of-safety, psychiatric decision and bed-management functions.
Verbatim wording from the response “7 New Urgent Care Centre- expected completion autumn 2020” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 Operate multi-agency call-in and prioritisation for Section 135 requests.
Verbatim wording from the response “3.6 Clarity has been introduced in relation to the use of sections 135 and 136 of the Mental Health Act. Section 135 requests are now subject to multi agency ‘call in’ and prioritisation at 10am and 7pm. This process has only recently been introduced, and it is recognised that a more robust escalation process is needed to determine priority cases.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 Determine management arrangements for Section 136 cases.
Verbatim wording from the response “3.7 In relation to Section 136 matters, the agencies are working to determine the management of these cases. This is likely to comprise a criterion for cases to be identified for urgent admission, with non-urgent cases being managed with positive risk processes and diversion to least restrictive options wherever possible.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 Pool resources to provide a crisis house as an alternative to psychiatric inpatient admission.
Verbatim wording from the response “8 Crisis House- expected completion spring 2020” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 Pilot the Red to Green initiative to improve inpatient flow and reduce length of stay.
Verbatim wording from the response “10.1 BSMHFT have appointed independent experts to help them review their current internal pathways of care, with the aim of ensuring that they have the maximum capacity possible in the right teams to meet patient demand. This work is ongoing. They are also piloting an evidence based national initiative called ‘Red to Green’ aimed at improving flow and reducing length of stay within adult acute inpatient units, by ensuring pre-discharge planning and touch point reviews for all patients. This approach has already demonstrated success in partnerships with other providers.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a crisis pathway to increase capacity in secondary mental health crisis services.
Verbatim wording from the response “6.9 A further £1.7m is being spent on the development of a crisis pathway to increase the capacity in secondary mental health crisis services.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop cross-agency culture and workforce arrangements.
Verbatim wording from the response “3.5 The group is currently overseeing five main work streams in response to the Coroner’s recommendations, which are:” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 policies, clinical discretion and monitoring are considered sufficient safeguards for the exceptional use of Mental Health Act Section 4.
Verbatim wording from the response “14 Whilst section 4 is available to be used, it is not used.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 Delegated local arrangements provide flexible access to emergency beds and are considered to address Section 140 provision adequately.
Verbatim wording from the response “13.4 The difficulties in implementing the Code of Practice was reviewed by Care Quality Commission in their report issued in June 2019, which recommended that “local leadership teams work together to discuss the way this [Section 140 provision] is working for patients and how to improve any problems with local implementation”.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
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 Management of access to emergency Section 140 beds is delegated to BSMHFT and BWCT under local arrangements.
Verbatim wording from the response “13.1 The CCG recognises the responsibility to provide emergency beds pursuant to Section 140 of the Mental Health Act.” Source location 2019-0284-Response-by-Birmingham-and-Solihull-CCG
Open published response
Concerns raised 2 Unavailability of inpatient beds for people assessed and fit for detention View source Failure of home treatment team capacity and resources to support adequate patient assessment and monitoring View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony Joseph McCormack · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony Joseph McCormack was found dead at home on 7 May 2019 after concerns about his wellbeing. He had been identified as in crisis and assessed as fit for detention, but no inpatient bed was available; concerns included inadequate assessment and monitoring by overstretched community mental health services. The inquest concluded that the death was suicide due to the unavailability of an inpatient mental health bed.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of inpatient beds for people assessed and fit for detention
Wider context from the report “1. Between the 16th March 2019 and the 25th April 2019, a bed could not be found for the Deceased even though he had been assessed and fit for detention . The absence of a bed meant that Mr. McCormack was not adequately assessed and appropriate treatment could not be given. With inpatient admission it is unlikely Mr. McCormack would have taken his life. The evidence from witnesses from BSMHT was that there continues to be a shortage of beds .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of home treatment team capacity and resources to support adequate patient assessment and monitoring
Wider context from the report “2. Evidence was given that the case load of the home treatment team to whom Mr. McCormack was referred is carrying 5 times the number of patients it was originally intended for and does not have the resources to provide adequate assessment and monitoring to patients thereby putting lives at risk.
” Open source report
×
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 monitoring pressures on mental health services and developing initiatives to manage patient flow and improve services.
Verbatim wording from the response “4.3 The CCG will continue to keep under review the pressures on mental health services and the need to develop new initiatives to manage patient flow and improve services.” Source location 2019-0317-Response-by-Birmingham-and-Solihull-CCG
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 Consider reinforcing crisis-resolution home-treatment services and identify what an alternative crisis-support service could provide.
Verbatim wording from the response “3.6 Included in this programme is consideration of the need to reinforce services that already exist within secondary mental health services, by increasing the staffing levels in crisis resolution home treatment teams, whilst also understanding what an alternative crisis support service might look like.” Source location 2019-0317-Response-by-Birmingham-and-Solihull-CCG
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 Work with system partners to understand increased crisis-service demand and improve use of existing mental health resources.
Verbatim wording from the response “3.4 In addition, the CCG has been, and continues to work with, system partners to understand the reason for the increased need, and to look at how the system can be improved to make best use of the existing resources.” Source location 2019-0317-Response-by-Birmingham-and-Solihull-CCG
Open published response
Concerns raised 9 Failure to follow through plans made to discuss and assess patients View source Failure to maintain accurate records of contacts, decisions and risk assessments View source Failure of the system to carry out necessary psychiatric assessments in police custody View source Failure to use all available means to locate patients requiring assessment View source Failure to ensure staff compliance with record-keeping duties is detected View source Failure to provide material arrest information for mental health assessments in custody View source Failure to attempt timely assessment after a high-risk patient re-establishes contact View source Failure to pass reliable information between mental health services View source Insufficient HTT capacity to maintain progress notes and risk assessments View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Jonathon Jukes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to follow through plans made to discuss and assess patients
Wider context from the report “5. It was planned that Mr. Jukes would be discussed at a team meeting on the 3rd October 2018 after the psychologist raised concerns on the 2nd. There is no credible evidence he was discussed or a plan made to locate and assess him . No explanation was provided in evidence for why evidence given of a strategy to guard against this occurring in future. Therefore there continues to be a risk that plans to discuss patients in meetings will not be followed through which puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate records of contacts, decisions and risk assessments
Wider context from the report “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes . Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment . There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited. Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of the system to carry out necessary psychiatric assessments in police custody
Wider context from the report “3. Despite not being informed by the BCPFT liaison and diversion nurse that Mr Jukes was in custody the HTT were made aware by his wife that he was in custody on the 28th September 2018. She also gave some information about the circumstances of his arrest, further information about the incident and police involvement had been reported to Street Triage during the night and was noted in the RIO notes. Despite this, no psychiatrist visited or attempted to visit Mr. Jukes in custody which it was stated in evidence was the usual practice of the team. It is not known why this was. Not having a robust and effective system to carry out necessary assessments whilst a patient is detained in police custody puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to use all available means to locate patients requiring assessment
Wider context from the report “4. Following his release from custody on the 28th September 2018 and evidence from a psychologist that he was treating suicide and harm to others, on the 2nd October 2018 the HTT’s only recorded attempt to contact Mr. Jukes before the 9th October 2018 was a single call (which probably mistakenly went to his wife’s phone) on the 4th October 2018. Despite the fact that his location was unknown and he had not attended a planned medical review on the 4th October 2018 there was no email communication to Mr. Jukes (although he had communicated this way with the team before and provided them with his email address) nor a call to his wife to ask her for assistance . There was evidence at inquest from the RCA Author that there should have been more effort to contact him at least from the 4th onwards if not before. Failure to utilise all means of locating a patient whereabouts are unknown, who requires assessment and who is not making contact with the team puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff compliance with record-keeping duties is detected
Wider context from the report “7. Throughout the inquest evidence was given of alleged attempted contact and decision making with respect to Mr. Jukes that was not recorded in his BSMHT RIO notes. Furthermore, his Risk Screen was not updated after information came to HTT’s attention that affected his risk assessment. There was some evidence that HTT do not have capacity to fulfil their obligation to keep records but evidence from some witnesses suggested that they did not view record keeping as a necessity. If, for whatever reason, RIO notes are not an accurate reflection of contacts, actions and decision-making clinicians may be mis-led or ill-informed creating a risk to life. Evidence was given that there is an e-learning module on the topic of record keeping and a ‘Key message’ 3 minute video but it is not compulsory for staff to watch the video or feedback on it and staff are not tested or individually audited . Consequently there continues to be a risk that individuals will not comply with their duty to keep proper records and noncompliance will go undetected.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide material arrest information for mental health assessments in custody
Wider context from the report “1. The psychiatric liaison and diversion practitioner employed by BCPFT who attended to review Mr. Jukes in Oldbury custody suite on the 28th September 2018 did not have sufficient information about the history of arrest to inform her decision making on assessment in custody . She was provided with a print out of the first two pages of the custody record which included the statutory arrest reason and the circumstances of arrest but nothing that indicated that he had barricaded himself in the loft, threatened suicide and harm to others and not come out in response to police negotiators. This information was not included in a verbal handover according to the nurse’s evidence and there is no record of it being handed over to her. She stated in evidence that if she had been aware of the extent of the events overnight on the 27th into the 28th she would have arranged a Mental Health Act assessment when he did not engage with her. There is a risk to life if assessments of mental health in custody are not informed by material information about circumstances connected with arrest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to attempt timely assessment after a high-risk patient re-establishes contact
Wider context from the report “6. On the 9th October 2018 an HTT clinician talked to Mr. Jukes on the phone at which time he sounded intoxicated, was calm and polite, gave his location and agreed to attend an appointment for a medical review on the 12th October 2018 if a bus pass were provided to his location for him to attend. No arrangements were made in an attempt to assess Mr Jukes before the 12th October 2018 . By this time he was reason to suspect Mr. Jukes was at risk of harm to self or others, was under the influence of substances, had not had a full assessment by the team, had recently not been engaging with services and his location had been unknown for over a week. This evidence indicates that those making the decision to ask Mr. Jukes to attend on the 12th underestimated his risk and were not pro-active in making contact . The staff involved maintained in evidence that they acted appropriately, evidence was given that this was not the finding of the Root Cause Analysis investigation review panel. In these circumstances to fail to attempt to assess as soon as reasonably practicable a patient who has come back into contact with the team as soon as reasonably practicable puts lives at risk . No evidence was given of specific action to address the decisions that were made on the 9th October 2018 with the individuals involved or the team generally and therefore the risk continues.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to pass reliable information between mental health services
Wider context from the report “2. The above psychiatric liaison and diversion practitioner gave evidence that she contacted either the duty bed manager for BSMHT or the BSMHT liaison and diversion team based at Perry Barr custody suite and was informed that Mr. Jukes was not known to the service. She stated that if she had been aware that he was open to the HTT she would have sought information about his involvement and would have made the team aware that he was in custody and the events of his previous evening. It was not established during the inquest and has not been established in BSMHT RCA investigation how this breakdown in communication occurred . Evidence was heard that the introduction of the Merit Vanguard system would not give a BCPFT employee in a custody suite access to some information and would mitigate against such circumstances arising again but it doesn’t explain why the nurse was left with the impression that he was not known to services. It is not unusual that clinicians from different mental health trusts will need to discuss patients and as full records are not available through the Merit Vanguard this will continue to arise . If reliable information is not being passed there is a risk to life from ill-informed decision making.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient HTT capacity to maintain progress notes and risk assessments
Wider context from the report “8. Evidence was given at the inquest that the reason HTT may not be maintaining good record keeping was due to insufficient capacity arising from a combination of too few staff arising from under-funding of the service and unnecessary referrals being made to the team . Evidence was given that there is work underway to introduce a systems to prevent inappropriate referrals and that funding has been granted for a further two CPNS for HTTs within BSMHT. However the evidence was that this will not be enough to enable staff to have the time to comply with their obligations to update progress notes and risk assessments . If funding is not sufficient to enable staff to fulfil their professional obligations to their patients, lives are at risk.
” Open source report
×
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 Secure recurrent NHS England transformational funding to support changes to regional crisis management.
Verbatim wording from the response “3.9 As a result of partnership working and guidance from people with lived experience, the CCG has been successful in securing recurrent funding from two separate NHS England Transformational funds, totalling in the region of £2.6m (increasing to £2.9m), to support making these fundamental changes to how crisis is managed within the region.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-CCG
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 Fund development of a crisis pathway to increase capacity in secondary mental-health crisis services.
Verbatim wording from the response “3.11 A further £1.4m (increasing to £1.7m) will be spent on the development of a crisis pathway to increase the capacity in secondary mental health crisis services.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide increased funding and work with system partners to understand and respond to crisis-service capacity and demand.
Verbatim wording from the response “3.1 Since 2016, the CCG (both in the current form and as three former CCGs, prior to the Birmingham and Solihull CCG merger on 01 April 2018) has taken a number of steps, with partner organisations, to understand and respond to concerns about capacity and demand within the local mental health system.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and maintain a mental-health system supporting timely inpatient access and adequately resourced community recovery provision.
Verbatim wording from the response “3.6 The CCG is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment. Part of this approach involves the CCG being an active partner in the STP and the Mental Health Programme Delivery Board. The ambition of the STP is to achieve sustainability, through a strong focus on prevention and recovery.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-CCG
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 Consider reinforcing crisis-resolution home-treatment teams by increasing staffing levels.
Verbatim wording from the response “3.7 Included in this programme is consideration of the need to reinforce services that already exist within secondary mental health services, by increasing the staffing levels in crisis resolution home treatment teams, whilst also understanding what an alternative crisis support service might look like.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-CCG
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 provider’s root cause analysis did not identify capacity or resource as contributing to the care and treatment issues.
Verbatim wording from the response “3.2 The CCG recognises that there has been increased demand for crisis mental health services since 2016, and has responded to this additional pressure with” Source location 2019-0329-Response-by-Birmingham-and-Solihull-CCG
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 Care and treatment concerns are largely for provider organisations to resolve.
Verbatim wording from the response “2.8 These issues are largely within the remit of the provider organisations to resolve, and the CCG confirms that an appropriate action plan has been drawn up and completed by BSMHFT.” Source location 2019-0329-Response-by-Birmingham-and-Solihull-CCG
Open published response
Concerns raised 2 Unavailability of suitably proximate out-of-area inpatient mental health beds View source Insufficient numbers of inpatient mental health beds in Birmingham and Solihull View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anthony John William Watson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony John William Watson, who had recurrent depression and anxiety and was displaying psychosis and suicidal thoughts, died after cutting his wrists and neck and jumping from a first-floor window on 21 October 2018. He sustained an unsurvivable head injury and died in hospital the following day. The principal concern was that no inpatient mental health bed was available locally despite the need for immediate admission, while out-of-area beds were considered too distant, particularly for older patients and their families.
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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of suitably proximate out-of-area inpatient mental health beds
Wider context from the report “1. Mr Watson was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area. Three days later there was still no bed available. Mr Watson was not offered a bed out-of-area.
2. This report has similar themes to the 7 reports issued by the Birmingham and Solihull Coroners on 4/10/18.
3. However, the impact of Mr Watson’s age is a new issue.
4. I heard evidence that:
a. Younger and older adults will not normally be admitted as inpatients on mixed units. Beds on young adult units may have been available on 18-22 October 2018 but these were not considered.
b. Beds in neighbouring areas are unavailable because of contractual issues. The closest out of area option is at least 70 miles away. Although Mr Watson was not offered an out of area bed, his wife was confident that had one been offered he would have declined because 70 miles was so far away. Whilst this distance is likely to deter a patient of any age from accepting the offer, it is particularly problematic for elderly patients and their families.
c. Whilst remedial action is underway in response to the concerns raised in the 7 reports issued on 4/10/18, currently it still remains the position that at least one patient every day in Birmingham and Solihull is advised they require an immediate admission for inpatient mental health treatment but no bed is available within the area.
5. The lack of inpatient beds is a resource issue. My ongoing concerns are that (a) there are insufficient numbers of beds in Birmingham and Solihull, and (b) out-of-area beds are too far away .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient numbers of inpatient mental health beds in Birmingham and Solihull
Wider context from the report “1. Mr Watson was aged 72. The Community Mental Health Team advised on 18/10/18 that he required an immediate admission for inpatient mental health treatment for his own safety. However, this could not happen as no bed was available within the area . Three days later there was still no bed available . Mr Watson was not offered a bed out-of-area.
2. This report has similar themes to the 7 reports issued by the Birmingham and Solihull Coroners on 4/10/18.
3. However, the impact of Mr Watson’s age is a new issue.
4. I heard evidence that:
a. Younger and older adults will not normally be admitted as inpatients on mixed units. Beds on young adult units may have been available on 18-22 October 2018 but these were not considered.
b. Beds in neighbouring areas are unavailable because of contractual issues. The closest out of area option is at least 70 miles away. Although Mr Watson was not offered an out of area bed, his wife was confident that had one been offered he would have declined because 70 miles was so far away. Whilst this distance is likely to deter a patient of any age from accepting the offer, it is particularly problematic for elderly patients and their families.
c. Whilst remedial action is underway in response to the concerns raised in the 7 reports issued on 4/10/18, currently it still remains the position that at least one patient every day in Birmingham and Solihull is advised they require an immediate admission for inpatient mental health treatment but no bed is available within the area .
5. The lack of inpatient beds is a resource issue. My ongoing concerns are that (a) there are insufficient numbers of beds in Birmingham and Solihull , and (b) out-of-area beds are too far away.
” 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 Maintain reciprocal arrangements enabling access to out-of-area inpatient beds when local beds are unavailable.
Verbatim wording from the response “2.7 The CCG has reciprocal arrangements in place for patients to access out of area beds when there are no local beds available. This arrangement is delivered through the MERIT Vanguard, which arose out of the Department of Health New Models of Care Programme and is a partnership between four NHS mental health providers in the Midlands (Birmingham and Solihull Mental Health NHS Foundation Trust, Black Country Partnership NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust and Coventry and Warwickshire Partnership NHS Trust). The Vanguard has sought to improve crisis care through more flexible use of bed stock across the region and by seeking to embed ‘recovery principles’ in practice.” Source location 2019-0044-Response-by-Birmingham-and-Solihull-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate as an active partner in the Sustainability and Transformation Partnership and Mental Health Programme Delivery Board.
Verbatim wording from the response “3.2 The CCG recognises that there has been increased demand for mental health services since 2016, and has responded to this additional pressure with increased funding and through working with Forward Thinking Birmingham (providers of mental health services across Birmingham and Solihull for those aged up to 25), BSMHFT and the local Sustainability and Transformation Partnership (the STP) to look at different ways of working throughout the system. The CCG will continue to monitor the situation to ensure that all partnership working across Birmingham and Solihull is focussed on improving access and the quality of care.” Source location 2019-0044-Response-by-Birmingham-and-Solihull-CCG
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 CCG cannot immediately ensure sufficient inpatient bed capacity because capacity and flow depend on factors beyond investment alone, including care models and practice.
Verbatim wording from the response “4.4 The CCG further recognises that these measures will not provide an immediate solution which ensures there is always sufficient bed capacity, as there are other considerations that impact on the system. Achieving improved capacity and flow cannot be realised solely through investment and must be supported by optimised models of care and practice such as those described above.” Source location 2019-0044-Response-by-Birmingham-and-Solihull-CCG
Open published response
Concerns raised 2 Unavailability of acute inpatient beds View source Unavailability of timely psychological services due to internal service structures and waiting lists View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Anthony Kennedy · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Anthony Kennedy had a history of emotional unstable personality disorder, depression and frequent self-harm, and his condition deteriorated during 2018. He was found hanging at his home on 08/10/18 and was declared deceased. Concerns included that psychological therapy was unavailable because of service structures and long waiting lists, and that a lack of acute inpatient beds contributed to further episodes of self-harm and suicide attempts.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of acute inpatient beds
Wider context from the report “2. In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts. The availability of acute beds is a serious concern .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely psychological services due to internal service structures and waiting lists
Wider context from the report “1. The deceased suffered from emotional unstable personality disorder and was in crisis for most of 2018. The recommended treatment for his condition was psychological therapy. He had not had any psychological input since 2010. The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services . He had to be under the community mental health team to be able to access psychological services . There were periods when he was under the care of the community mental health team but at this time he remained on a long waiting list for psychological services . Throughout 2018 he never received any psychological services . I am concerned that the main treatment option for the deceased was not available to him due to internal structures and long waiting lists .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formalise distinct community mental-health treatment pathways through the 2019/20 Service Development and Improvement Plan.
Verbatim wording from the response “3.4 Psychological therapy services for people under the care of BSMHFT forms part of the provider’s internal pathway and as such waiting times are not monitored by the CCG. The CCG’s approach is to increasingly commission for outcomes rather than inputs. In line with this, commissioners have set out their intention that community-based mental health services should operate distinct treatment pathways for people with psychotic disorders and those with mood and personality disorders. Pathways will be focused on the delivery of treatment and support that promotes recovery alongside the proportionate management of risk. Providers will be expected to put in place a workforce model that reflects this approach and affords access to treatment options including psychological therapies.” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
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 Fund individual Section 117 health-and-social-care packages where required to facilitate hospital discharge.
Verbatim wording from the response “3.5.3 Supporting operational initiatives to reduce delayed transfers of care, where CCG funding of individual packages of care under Section 117 (jointly funded packages of health and social care) are required to facilitate discharge from hospital.” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
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 Negotiate 2019/20 contract measures to improve capacity through investment and service development.
Verbatim wording from the response “3.6 It is acknowledged, through contract review meetings, there have been discussions with BSMHFT about funding and capacity, as capacity and demand issues are discussed through the contract review mechanism. Contract negotiations for services provided in 2019/20 have focused on measures to improve capacity through investment and service development and improvement.” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
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 Keep mental-health service pressures under review and develop new initiatives to manage patient flow and improve services.
Verbatim wording from the response “4.4 The CCG will continue to keep under review the pressures on mental health services and the need to develop new initiatives to manage patient flow and improve services.” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
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 Commission system-simulation modelling with partner organisations to identify solutions and priorities for mental-health demand and capacity.
Verbatim wording from the response “3.5 The CCG has recognised and reacted to the increased demand for mental health services. To date, this has included:” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
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 Hold weekly and daily peak-period delayed-discharge escalation calls with providers and local-authority social-work teams.
Verbatim wording from the response “3.5.4 Weekly, and daily peak period, delayed discharge escalation calls with providers and local authority social work teams, in order to escalate any delays and for swift resolution.” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional investment to BSMHFT above contract value to increase mental-health service capacity.
Verbatim wording from the response “3.5.9 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase).” Source location 2019-0039-Response-by-Birmingham-and-Solihull-CCG
Open published response
Concerns raised 4 Failure to search takeaway food arriving at the unit View source Failure to effectively search staff entering the unit View source Failure to search staff food brought onto the unit View source Failure to effectively search residents returning from unsupervised leave 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
Stephen Keith Harte · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Keith Harte was found unresponsive in his room at the Tamarind Centre on 18 August 2018 and could not be resuscitated. A post-mortem found a fatal dose of heroin, and the medical cause of death was recorded as heroin toxicity. The principal concern was that drugs could too easily enter the medium secure unit through routes including unsupervised takeaway deliveries, residents returning from leave, and staff bringing in unscreened food.
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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to search takeaway food arriving at the unit
Wider context from the report “1) I heard evidence about the potential routes for drugs to enter the medium secure unit. This included:
(a) Residents are allowed unsupervised telephone calls to order food from external ‘takeaways’ of their choice and the food is not searched upon arrival . Historically, residents were only allowed to order from an approved list of ‘takeaways’. However, following a Care Quality Commission inspection the CQC deemed this was too restrictive and asked that the unit relax its rules. The evidence was unclear whether the CQC had similarly asked other units to relax their rules.
(b) Those residents allowed unsupervised leave are not typically searched upon their return. They walk thought a scanner, but this is unlikely to reveal small quantities of drugs on their person.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively search staff entering the unit
Wider context from the report “3) I also heard evidence that staff are not typically searched upon entering the unit . They also walk thought the scanner, but this is unlikely to reveal small quantities of drugs on their person . Further, whilst they are required to leave personal belongings in lockers, they are allowed to take their own food on to the unit which is also not searched.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to search staff food brought onto the unit
Wider context from the report “3) I also heard evidence that staff are not typically searched upon entering the unit. They also walk thought the scanner, but this is unlikely to reveal small quantities of drugs on their person. Further, whilst they are required to leave personal belongings in lockers, they are allowed to take their own food on to the unit which is also not searched .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively search residents returning from unsupervised leave
Wider context from the report “1) I heard evidence about the potential routes for drugs to enter the medium secure unit. This included:
(a) Residents are allowed unsupervised telephone calls to order food from external ‘takeaways’ of their choice and the food is not searched upon arrival. Historically, residents were only allowed to order from an approved list of ‘takeaways’. However, following a Care Quality Commission inspection the CQC deemed this was too restrictive and asked that the unit relax its rules. The evidence was unclear whether the CQC had similarly asked other units to relax their rules.
(b) Those residents allowed unsupervised leave are not typically searched upon their return . They walk thought a scanner, but this is unlikely to reveal small quantities of drugs on their person .
” Open source report
4 Oct 2018 Bradley Jordache Morgan · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Excessive staff caseloads in mental health services View source Chronic underfunding of mental health services View source Failure to provide needed follow-up review in mental health care View source Breakdown in communication between mental health care teams and individuals 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
Bradley Jordache Morgan · 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
Bradley Jordache Morgan was declared dead on 13 May 2018 after falling from the eighth-floor balcony of his home; the medical cause of death was multiple blunt injuries. He had a history of mental illness and was considered at high risk of suicide and self-harm, but was not reviewed by the community mental health team after a missed appointment. Concerns included communication and follow-up failures, excessive staff caseloads, and underfunding of mental health services creating a risk to life.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Excessive staff caseloads in mental health services
Wider context from the report “3. Despite the comprehensive action plan evidence was given by the Medical Director of the Birmingham Women’s and Children’s NHS Foundation Trust that she was concerned that even with the processes and training identified in the action plan similar circumstances could arise again due to the pressures placed on staff who carry caseloads well in excess of the national average as a result of demand on the service .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Chronic underfunding of mental health services
Wider context from the report “4. The evidence given was that chronic underfunding of mental health services is creating a risk to life .
5. The strain on the systems of Mental Health Services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide needed follow-up review in mental health care
Wider context from the report “1. Investigation into Mr. Morgan’s mental health care provided by Forward Thinking Birmingham identified gross failings following an appointment on the 15th December 2017 where despite an obvious need for follow up there was a breakdown in communication between teams and individuals that meant he was not reviewed again before his death in May.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Breakdown in communication between mental health care teams and individuals
Wider context from the report “1. Investigation into Mr. Morgan’s mental health care provided by Forward Thinking Birmingham identified gross failings following an appointment on the 15th December 2017 where despite an obvious need for follow up there was a breakdown in communication between teams and individuals that meant he was not reviewed again before his death in May.
” Open source report
4 Oct 2018 Michael Paul Wheeler · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Unavailability of inpatient mental health beds for patients requiring inpatient treatment View source Underfunding of mental health services View source Failure of home treatment teams to visit all patients requiring a visit each day View source Failure to provide psychiatrist review and treatment planning for patients with acute paranoid or aggressive presentations View source Lack of planned follow-up review for mental health patients View source Unavailability of urgent psychiatrist review through home treatment teams 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
Michael Paul Wheeler · 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
Michael Paul Wheeler died after jumping from a fourth-floor window at his brother’s home on 26 July 2018, following increasing paranoia and bizarre behaviour. The principal concerns were that he was not reviewed by a psychiatrist, had no treatment plan, and had no planned review on 26 July; broader concerns were raised about pressures on mental health services, including the availability of urgent psychiatric reviews and inpatient beds.
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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of inpatient mental health beds for patients requiring inpatient treatment
Wider context from the report “2. The Coroner is aware, although not from evidence obtained in respect of Mr. Wheeler’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT who are currently operating at 109% capacity and are often not available . Consequently, patients who would otherwise have been offered in-patient treatment, are having to be managed by the HTTs . Partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day. One particular problem in the Birmingham and Solihull area is that the occurrence of psychosis is more than 3 times higher than the national average. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Underfunding of mental health services
Wider context from the report “4. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction may arise from underfunding of mental health services .
5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of home treatment teams to visit all patients requiring a visit each day
Wider context from the report “2. The Coroner is aware, although not from evidence obtained in respect of Mr. Wheeler’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT who are currently operating at 109% capacity and are often not available. Consequently, patients who would otherwise have been offered in-patient treatment, are having to be managed by the HTTs. Partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day . One particular problem in the Birmingham and Solihull area is that the occurrence of psychosis is more than 3 times higher than the national average. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide psychiatrist review and treatment planning for patients with acute paranoid or aggressive presentations
Wider context from the report “1. Mr. Wheeler’s family have provided evidence that he was extremely paranoid by the 24th of July 2018 and this was causing him to act irrationally and at times aggressively, they were very fearful for his safety and reported this to the mental health nurses he saw on the 24th and 25th. Despite these concerns Mr. Wheeler was not reviewed by a Psychiatrist and therefore his condition went undiagnosed with no treatment plan. Furthermore it is noted that there was no plan to review Mr. Wheeler at all on the 26th July 2018.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of planned follow-up review for mental health patients
Wider context from the report “1. Mr. Wheeler’s family have provided evidence that he was extremely paranoid by the 24th of July 2018 and this was causing him to act irrationally and at times aggressively, they were very fearful for his safety and reported this to the mental health nurses he saw on the 24th and 25th. Despite these concerns Mr. Wheeler was not reviewed by a Psychiatrist and therefore his condition went undiagnosed with no treatment plan. Furthermore it is noted that there was no plan to review Mr. Wheeler at all on the 26th July 2018 .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of urgent psychiatrist review through home treatment teams
Wider context from the report “3. The fact that at the current time HTT cannot always provide urgent medical review by a psychiatrist creates a risk to life .
” Open source report
4 Oct 2018 Stephen Peter Jackson · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to provide timely mental health follow-up after hospital discharge View source Failure to answer calls to mental health professionals View source Failure to send mental health appointments View source Under-funding of mental health services 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
Stephen Peter Jackson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Peter Jackson was found deceased at home on 11 August 2018 after sending his mother a text message saying “sorry”; drugs paraphernalia and a suicide note were present, and the provisional cause of death was a diamorphine overdose. The report raised concerns that he was not seen by mental health clinicians after his GP requested an urgent appointment, despite reported low mood and negative thoughts, and that delays and possible under-funding of mental health services posed a risk of future deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely mental health follow-up after hospital discharge
Wider context from the report “1. On the 1st August 2018 Mr. Jackson attended his GP and expressed frustration that following his discharge from hospital on the 23rd July 2018. He had not been contacted by the home treatment team and his GP wrote to the Kingstanding and Erdington Home Treatment Team that same day asking them to expedite his appointment , reporting that Mr. Jackson continued to have low mood and negative thoughts and merited an urgent appointment.
2. Mr. Jackson was not seen by mental health clinicians following the GP request.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to answer calls to mental health professionals
Wider context from the report “3. Mr. Jackson wrote a very detailed suicide note within which he refers to feeling unsupported by professionals who did not send him appointments or answers his calls , the context would support this being a reference to mental health professionals.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to send mental health appointments
Wider context from the report “3. Mr. Jackson wrote a very detailed suicide note within which he refers to feeling unsupported by professionals who did not send him appointments or answers his calls, the context would support this being a reference to mental health professionals.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Under-funding of mental health services
Wider context from the report “4. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction, future deaths may arise due to under-funding of mental health services .
5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
6. In addition to this report letters are enclosed from the Medical Directors of both Trusts setting out their concerns.
” Open source report
4 Oct 2018 William Peter Edge · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure of home treatment teams to visit all patients requiring a visit when required View source Unavailability of inpatient mental health beds View source Underfunding of mental health services 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
William Peter Edge · 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
William Peter Edge was found hanging in the shed at his home in Birmingham on 18 August 2018, after an ambulance crew attempted resuscitation. He had depression, a history of self-harm, and had attempted to hang himself the previous day before being assessed and discharged with a referral to the home treatment team. Concerns included the home treatment team being unable to return when his wife reported that he was in imminent danger, and wider pressures on inpatient beds and home treatment services, including a stated risk to life when patients cannot be attended as required.
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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of home treatment teams to visit all patients requiring a visit when required
Wider context from the report “3. The Coroner is aware, although not from evidence obtained in respect of Mr. Edge’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available. Consequently patients who would otherwise have been offered in-patient treatment are having to be managed by the HTTs, partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day which in turn is putting pressure on out of hours services. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
4. The fact that at the current time HTTs cannot attend patients when required creates a risk to life .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Unavailability of inpatient mental health beds
Wider context from the report “3. The Coroner is aware, although not from evidence obtained in respect of Mr. Edge’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available . Consequently patients who would otherwise have been offered in-patient treatment are having to be managed by the HTTs , partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day which in turn is putting pressure on out of hours services. It is understood that the Trust is exploring options to expand its HTT service but funding is required.
4. The fact that at the current time HTTs cannot attend patients when required creates a risk to life.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Underfunding of mental health services
Wider context from the report “5. Although evidence at inquest has yet to be heard there is a concern that this case, along with several other cases being investigated by the Birmingham and Solihull Coroners’ jurisdiction may arise from underfunding of mental health services .
6. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” Open source report
4 Oct 2018 Michael William Cooper · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 7 Out-of-area mental health beds disrupting patient support and continuity of care View source Strain on mental health service systems View source Lack of available inpatient mental health beds View source Insufficient Care Coordinator capacity to review patient histories and assess risk View source Under-funding of mental health services View source Insufficient funding to maintain staff and resources under service demand View source Delays in Care Programme Approach follow-up appointments View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael William Cooper · 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
Michael William Cooper was found dead at home on 22 June 2018 from constriction by a ligature around the neck. The report describes concerns about the lack of face-to-face follow-up and immediate action despite indications of high suicide risk, as well as shortages of inpatient beds, team capacity and funding in mental health services.
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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Out-of-area mental health beds disrupting patient support and continuity of care
Wider context from the report “1. The Home Treatment Team advised on the 13th March 2018 that Mr. Cooper should be admitted for inpatient mental health treatment. However, this could not happen on the day as there was no bed available. The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives. In the absence of an inpatient bed, Mr. Cooper was managed with medication and home treatment team visiting twice a day. Whilst awaiting admission, he was offered an out-of-area bed on the 16th March 2018 but he declined this as he felt it would be detrimental to him to be so far from his wife and family. The Coroner is aware, although this was not an issue that came out in evidence in this case, that placing patients in out of area beds not only causes difficulty for maintaining the patient's support and visits from family and friends which can be prejudicial to their mental health, but also affects their continuity of care thus creating a risk to life .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Strain on mental health service systems
Wider context from the report “5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding.
6. In addition to this report, letters are enclosed from the Medical Directors of both Trusts setting out their concerns .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of available inpatient mental health beds
Wider context from the report “1. The Home Treatment Team advised on the 13th March 2018 that Mr. Cooper should be admitted for inpatient mental health treatment. However, this could not happen on the day as there was no bed available . The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives. In the absence of an inpatient bed, Mr. Cooper was managed with medication and home treatment team visiting twice a day. Whilst awaiting admission, he was offered an out-of-area bed on the 16th March 2018 but he declined this as he felt it would be detrimental to him to be so far from his wife and family. The Coroner is aware, although this was not an issue that came out in evidence in this case, that placing patients in out of area beds not only causes difficulty for maintaining the patient's support and visits from family and friends which can be prejudicial to their mental health, but also affects their continuity of care thus creating a risk to life.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient Care Coordinator capacity to review patient histories and assess risk
Wider context from the report “3. When Mr. Cooper was established on the Care Programme Approach, his Care Co-ordinator did not have the capacity to review his notes prior to her first visit and therefore did not have a clear understanding of his complex history . Care Co-ordinators within Birmingham and Solihull Mental Health Trust are currently carrying a caseload of more than 30 patients . The NICE guidelines for the Care Programme Approach advises that a Care Coordinator should have caseload of 15 patients. Without the time to familiarise themselves with their patients’ histories Care Co-ordinators cannot make informed assessments of their risk which puts lives at risk.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Under-funding of mental health services
Wider context from the report “5. The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Insufficient funding to maintain staff and resources under service demand
Wider context from the report “4. Despite a detailed root cause analysis investigation with a comprehensive action plan arising from Mr. Cooper’s case, without increased funding similar circumstances could arise again due to the pressures placed on staff and resources arising from demand for the service .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Delays in Care Programme Approach follow-up appointments
Wider context from the report “2. An appointment following referral onto the Care Programme Approach on the 18th April 2018 was outside the two week timeframe specified in the Care Programme Approach Policy . This was due to capacity issues within the team and was not an isolated occurrence . Consequently a patient requiring follow up within 2 weeks may be left unsupported which creates a risk to life.
” 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 Incorporate learning-from-deaths and demand-and-capacity improvement plans into contracts as service-delivery improvement plans.
Verbatim wording from the response “8.1.12 Ensuring action plans relating to learning from deaths and improvement plans for managing demand and capacity are incorporated into contracts as service delivery improvement plans.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission an independent review of inpatient journeys to identify alternatives to admission and reduce avoidable discharge delays.
Verbatim wording from the response “5.4.2 An independent review of patients’ journeys into and out of inpatient mental health beds was commissioned by the STP. The review considered whether alternatives to admission could have been used and whether patients stayed in hospital longer than necessary. The review found that in both cases, improvements could be made to help avoid unnecessary admissions and reduce the time taken to discharge patients.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the system-wide mental-health commissioning strategy, including plans to reduce service fragmentation.
Verbatim wording from the response “8.1.10 Updating the system wide mental health commissioning strategy, including developing plans to reduce fragmentation of services and to ensure care is delivered in the most appropriate setting.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
Verbatim wording from the response “5.4.1 An independent system simulation modelling exercise, which was jointly commissioned with FTB and BSMHFT, to develop an informed response on the best solutions to address the demand and where investment should be prioritised. This followed a sharp increase in demand for inpatient beds in 2016.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with partners to address recruitment and retention challenges so services are appropriately resourced.
Verbatim wording from the response “8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional investment to expand commissioned mental-health service capacity and provision.
Verbatim wording from the response “5.4.8 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support delayed-transfer initiatives through funded Section 117 care packages and escalation calls with providers and social-work teams.
Verbatim wording from the response “5.4.3 Supporting operational initiatives to reduce delayed transfers of care, where CCG funding of individual packages of care under Section 117 (jointly funded packages of health and social care) are required to facilitate discharge from hospital.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue supporting out-of-area NHS and independent hospital admissions when locally commissioned beds are unavailable and admission is necessary.
Verbatim wording from the response “5.4.5 Continuing to support the use of admissions to other NHS mental health trusts within the MERIT Vanguard³ and to independent hospitals, where no locally commissioned beds are available, and an admission is deemed necessary.” Source location Birmingham-and-Solihull-CCG-Response
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 There is currently no evidence that insufficient funding contributed to the deaths.
Verbatim wording from the response “7.8 It is noted from the Coroner’s letter and the Regulation 28 reports that under funding may be a contributing factor to these deaths. The CCG is still awaiting detailed investigation reports into all of the deaths. However, at this stage there is no evidence that a lack of funding contributed to the deaths of the individuals concerned. This has been confirmed by BSMHFT in their letter to the Coroner, dated 28 September 2018.” Source location Birmingham-and-Solihull-CCG-Response
Open published response
Concerns raised 6 Failure of support workers to complete suicide prevention training View source Under-funding of mental health services creating a risk of future deaths View source Continuation of lone working during emergencies View source Use of unqualified support workers for suicide risk assessments View source Absence of a scoring system or guide for suicide risk assessments View source Failure to maintain accurate room-key labelling 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
Simon Anthony Graham · 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
Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention training.
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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure of support workers to complete suicide prevention training
Wider context from the report “5. Concern 4: Future Care & Social Care Association have identified that support workers should undertake suicide prevention training. I heard evidence that some support workers have still not undertaken this training despite lone working and support workers continuing to undertake suicide risk 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Under-funding of mental health services creating a risk of future deaths
Wider context from the report “6. The strain on the systems of Mental Health Services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months. Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between May and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding .
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Continuation of lone working during emergencies
Wider context from the report “2. Concern 1: At any one time only one support worker is working . The death of Simon Graham identified a number of concerns arising from lone working during an emergency:
A) Upon concern being raised by Simon Graham’s wife, the support worker was prevented from promptly checking on his wellbeing because he was with another resident at the medicine cupboard. He had to finish with the other resident and ensure the medicine cupboard was left secure. This caused a delay of about 10-15 minutes before the support worker could check on Simon Graham. Further delay was then caused by confusion over rooms – see below.
B) After forcing entry and finding Simon Graham hanging and in cardiac arrest the support worker got him down and commenced CPR. He had to call for help from other residents but no one came. He had to break-off CPR for at least 80 seconds when he ran down three flights of stairs to answer the door thinking it was an ambulance (it was in fact the deceased’s wife). I heard evidence that the lone working still exists because the current financial contract with the NHS is insufficient to cover the cost of a second support worker, despite Future Care & Social Care Association wanting to end lone working.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Use of unqualified support workers for suicide risk assessments
Wider context from the report “4. Concern 3: When a new patient arrives an unqualified support worker completes a suicide risk assessment based on a) the written observations/risk assessment from mental health Drs/nurses faxed over with the referral and b) talking directly to the resident about their intentions. There is no score system or guide to assist support workers. The support worker who completed the risk assessment for Simon Graham was unable to explain what makes him competent to undertake such an assessment and said in terms that he believes they should be undertaken by a mental health nurse. I heard evidence that unqualified support workers are continuing to undertake suicide risk 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Absence of a scoring system or guide for suicide risk assessments
Wider context from the report “4. Concern 3: When a new patient arrives an unqualified support worker completes a suicide risk assessment based on a) the written observations/risk assessment from mental health Drs/nurses faxed over with the referral and b) talking directly to the resident about their intentions. There is no score system or guide to assist support workers. The support worker who completed the risk assessment for Simon Graham was unable to explain what makes him competent to undertake such an assessment and said in terms that he believes they should be undertaken by a mental health nurse. I heard evidence that unqualified support workers are continuing to undertake suicide risk 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate room-key labelling
Wider context from the report “3. Concern 2: Support workers were using keys to check on residents in their rooms knowing that they were labelled incorrectly . The fact Simon Graham’s room key was incorrectly labelled added to the delayed entry to the room and emergency first aid. I heard evidence that after the death of Simon Graham all keys were checked to ensure they were labelled correctly. However, Future Care & Social Care Association want to implement a key fob system, to avoid any confusion and provide quick access in an emergency, but this has still not been implemented. Further funding would be required to implement a key fob system.
” Open source report
Concerns raised 1 Lack of doctors’ awareness of the BNF mobile device app for identifying potential drug interactions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sufia Begum · 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
Sufia Begum was admitted to Queen Elizabeth Hospital with vomiting, confusion and generalised weakness after being prescribed clarithromycin while taking verapamil. She died on 24 April 2018 from multiorgan failure and calcium channel blocker toxicity, with the inquest concluding that she died from an unrecognised adverse drug interaction. The principal concern was that not all doctors were aware of the BNF mobile device app, identified as a useful tool for detecting potential drug interactions.
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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Lack of doctors’ awareness of the BNF mobile device app for identifying potential drug interactions
Wider context from the report “1. I heard evidence at the inquest that the most useful tool to identify potential drug interactions was the BNF mobile device APP. The author of the RCA confirmed that not all doctors were aware of the APP. An alert to all NHS Trusts and GPs would provide this valuable information which may prevent a future death from an unknown drug interaction.
” 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 Publish and circulate a Medicines Newsletter alert promoting use of the BNF App to check drug interactions when clinical-system checking is unavailable.
Verbatim wording from the response “On 14th November the CCG included the following alert in its monthly Medicines Newsletter:” Source location Sufia-Begum-Response
Open published response
Concerns raised 3 Transfer of necessary mental health care placing responsibility for initiating contact on patients View source Failure to follow up with receiving services and patients after mental health care transfers View source Failure to notify the receiving mental health service about care transfers 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
Daniel Hubert Collins · 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
Daniel Hubert Collins attempted to take his own life by overdose on 07/04/18 and was discharged from hospital and then from the FTB crisis team, with responsibility placed on him to contact counselling services. He went missing on 26/04/18 and was found deceased in woodland on 28/04/18; the medical cause of death was venlafaxine overdose. The report identified concern that the transfer between mental health services was not communicated or followed up, creating a risk that patients in or recently out of crisis could be lost to mental health services.
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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Transfer of necessary mental health care placing responsibility for initiating contact on patients
Wider context from the report “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up with receiving services and patients after mental health care transfers
Wider context from the report “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient . Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis.
” 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 NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the receiving mental health service about care transfers
Wider context from the report “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis.
” Open source report
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Addressed to NHS Birmingham and Solihull Clinical Commissioning Group, now represented here by NHS Birmingham and Solihull Integrated Care Board.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations