NHS Birmingham and Solihull Integrated Care Board

Health and care · Integrated care board

Request correction

First report 26 Sep 2014•Latest report 7 May 2026

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports: 29
Published responses: 76%
Concerns addressed: 63
Stated actions: 145

Concerns and recipient responses

Statements from NHS Birmingham and Solihull Integrated Care Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

15 Mar2017
Birmingham and Solihull
Concerns raised4
1. Lack of early approved social worker involvement in Mental Health Act assessments
2. Unclear responsibility for patients during transfer between mental health services
3. Failure to share and access mental health records effectively between organisations
1. Lack of coordinated mental health care during crisis and transfer
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Leah Abby Ratheram · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Leah Abby Ratheram, who had autism, foetal alcohol syndrome and a history of self-harm, died after being found hanging from a tree on 7 October 2016. The report raised concerns about the lack of coordinated care and unclear responsibility between mental health organisations, ineffective sharing of records and risk information, and uncertainty about the Mental Health Act assessment process.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of early approved social worker involvement in Mental Health Act assessments
Wider context from the report
“3. The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed. There is a concern that lack of involvement of this specialty at any early stage will affect the quality of mental health act assessments and the safety of patients. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Unclear responsibility for patients during transfer between mental health services
Wider context from the report
“1. Adults aged between 18 – 25 now have mental health services provided by two organisations – Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust. If a patient presents in crisis to A&E they will be seen by someone from the RAID team who work for Birmingham and Solihull Mental Health Trust. If they require ongoing treatment they will be referred to forward Thinking Birmingham. There is a concern that patients will have no coordinated approach to their care at a time of crisis. It is also unclear who will ultimately be responsible for the patient, particularly during the period of transfer. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to share and access mental health records effectively between organisations
Wider context from the report
“2. Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process. It was unclear how staff from each organisation would access each other’s records when patients present to one or other of the services. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Lack of coordinated mental health care during crisis and transfer
Wider context from the report
“1. Adults aged between 18 – 25 now have mental health services provided by two organisations – Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust. If a patient presents in crisis to A&E they will be seen by someone from the RAID team who work for Birmingham and Solihull Mental Health Trust. If they require ongoing treatment they will be referred to forward Thinking Birmingham. There is a concern that patients will have no coordinated approach to their care at a time of crisis. It is also unclear who will ultimately be responsible for the patient, particularly during the period of transfer. ”
Open source report
24 Nov2016
Birmingham and Solihull
Concerns raised6
1. Failure to prescribe the appropriate antibiotics for specific clinical situations
2. Failure to provide GP clinical assessment for patients with deteriorating conditions and complex needs
3. Failure to maintain accurate records of patient contacts and clinical decisions
1. Failure of the home visit policy to address complex chronic conditions in care or residential facilities
2. Failure to distinguish clinical assessment tasks from true administration tasks
3. Failure to clearly request and document home visits
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Timothy Simon 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

Timothy Simon Jones, who had Down syndrome, epilepsy and dementia and required PEG feeding, was admitted to hospital with breathing difficulties and aspiration pneumonia, was discharged and readmitted the same day, and died on 17 July 2016. Concerns included incomplete GP record keeping, unclear communication and documentation of requests for home visits, lack of GP clinical assessment despite deteriorating health and complex needs, a home-visit policy that did not address residents with complex chronic conditions, and antibiotic prescribing for aspiration pneumonia.

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 prescribe the appropriate antibiotics for specific clinical situations
Wider context from the report
“5. The deceased was diagnosed with aspiration pneumonia when he was admitted to hospital. He was at high risk of aspiration pneumonia. I heard evidence that the best antibiotics for aspiration pneumonia are co-amoxiclav. The deceased was not prescribed these in the community he was given amoxicillin instead. Consideration needs to be given whether guidelines should be produced to clarify which antibiotics are required in specific situations. ”
Open source report
Source evidence
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 GP clinical assessment for patients with deteriorating conditions and complex needs
Wider context from the report
“3. There was no clinical assessment of the deceased by a GP after the 25 May 2016 despite his deteriorating condition and complex needs. ”
Open source report
Source evidence
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 patient contacts and clinical decisions
Wider context from the report
“1. I have concerns about record keeping at the practice. The residential home records recorded that the GP had visited the patient on 25 May 2016, however the GP could not find a record of that visit in the electronic notes. It is vital the accurate records are kept of contact with patients and clinical decisions made. ”
Open source report
Source evidence
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 home visit policy to address complex chronic conditions in care or residential facilities
Wider context from the report
“4. The GP’s policy for home visits (copy attached) did not contain any reference to those with complex chronic conditions who were residents in care or residential facilities. The policy actively seeks to avoid home visits which may have influenced decision making in this case. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Birmingham and Solihull Integrated Care Board; that does not assign responsibility.
PFD Monitor interpretation
Failure to distinguish clinical assessment tasks from true administration tasks
Wider context from the report
“2. I heard evidence at the inquest that the residential home had requested several home visits from the GP, on 5 July 2016, 12 July 2016 and 13 July 2016, but the GP disputed this. The mechanism of communication within the GP practice caused concern in that several aspects of care were classified as “admin tasks” when they required further clinical assessment. The process of requesting and documenting requests for home visits needs to be clearer. The role of “admin tasks” needs to be clarified so that these are only used for true administration tasks. ”
Open source report
Source evidence
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 clearly request and document home visits
Wider context from the report
“2. I heard evidence at the inquest that the residential home had requested several home visits from the GP, on 5 July 2016, 12 July 2016 and 13 July 2016, but the GP disputed this. The mechanism of communication within the GP practice caused concern in that several aspects of care were classified as “admin tasks” when they required further clinical assessment. The process of requesting and documenting requests for home visits needs to be clearer. The role of “admin tasks” needs to be clarified so that these are only used for true administration tasks. ”
Open source report
15 Jul2016
Birmingham and Solihull
Concerns raised5
1. Insufficient resuscitation expertise in GP practices
2. Inadequate ventilation during resuscitation in GP practices
3. Insufficient emergency equipment in GP practices
1. Failure to provide oxygen during resuscitation in GP practices
2. Failure to use suction during resuscitation in GP practices
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Sydney Mya Neil · 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

Sydney Mya Neil suffered from severe brittle asthma and died at Birmingham Children's Hospital after collapsing at a GP surgery following breathing difficulties. The report raised concerns about inadequate ventilation, lack of suction and lack of oxygen during resuscitation, and whether GP practices have sufficient expertise and equipment for emergencies.

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
Insufficient resuscitation expertise in GP practices
Wider context from the report
“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”
Open source report
Source evidence
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 ventilation during resuscitation in GP practices
Wider context from the report
“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”
Open source report
Source evidence
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 emergency equipment in GP practices
Wider context from the report
“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”
Open source report
Source evidence
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 oxygen during resuscitation in GP practices
Wider context from the report
“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”
Open source report
Source evidence
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 suction during resuscitation in GP practices
Wider context from the report
“Once Sydney collapsed in the GP surgery there was inadequate ventilation for 8 minutes. No suction was used nor was oxygen provided. I am concerned about the level of expertise in GP practices when resuscitation is required and whether they have sufficient equipment to deal with emergency situations. ”
Open source report
26 Sep2014
Birmingham and Solihull
Concerns raised2
1. Lack of clear West Midlands guidelines and protocols for the management and treatment location of patients with sickle cell disease
2. Lack of staff knowledge of sickle cell crisis signs, symptoms and necessary treatment
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Emmanuel Tobiloba Akinmuyiwa · 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

Emmanuel Tobiloba Akinmuyiwa was a 7-year-old boy with sickle cell disease who died after developing severe anaemia during a sickle cell crisis. The report identified failures to check his haemoglobin and provide an earlier blood transfusion, and raised concerns about the lack of clear regional protocols and staff knowledge for managing sickle cell disease.

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 clear West Midlands guidelines and protocols for the management and treatment location of patients with sickle cell disease
Wider context from the report
“Evidence at the inquest confirmed that there needed to be a clear protocol in the West Midlands for the management of patients with Sickle cell disease. Ordinarily they are managed at Birmingham Children's hospital. In this case as Emmanuel was admitted to Heartlands hospital various telephone calls were made to Birmingham Children's hospital. It was acknowledged in an internal investigation by Birmingham Heartlands hospital that staff had a lack of knowledge and appreciation for the signs and symptoms of a sickle cell crisis and what treatment was necessary. I was informed at the inquest that clinicians would prefer a hub and spoke approach to treatment of sickle cell disease with clear guidelines and protocols for how and where patients should be treated. I was informed that this had not happened to date due to the lack of funding available to liaise with all local hospitals and produce and put in place such protocol and guidance. A lack of guidelines and protocols for the West Midlands means future patients are at risk of death. ”
Open source report
Source evidence
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 staff knowledge of sickle cell crisis signs, symptoms and necessary treatment
Wider context from the report
“Evidence at the inquest confirmed that there needed to be a clear protocol in the West Midlands for the management of patients with Sickle cell disease. Ordinarily they are managed at Birmingham Children's hospital. In this case as Emmanuel was admitted to Heartlands hospital various telephone calls were made to Birmingham Children's hospital. It was acknowledged in an internal investigation by Birmingham Heartlands hospital that staff had a lack of knowledge and appreciation for the signs and symptoms of a sickle cell crisis and what treatment was necessary. I was informed at the inquest that clinicians would prefer a hub and spoke approach to treatment of sickle cell disease with clear guidelines and protocols for how and where patients should be treated. I was informed that this had not happened to date due to the lack of funding available to liaise with all local hospitals and produce and put in place such protocol and guidance. A lack of guidelines and protocols for the West Midlands means future patients are at risk of death. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised4

Lack of early approved social worker involvement in Mental Health Act assessments

Unclear responsibility for patients during transfer between mental health services

Failure to share and access mental health records effectively between organisations

Lack of coordinated mental health care during crisis and transfer

Concerns raised6

Failure to prescribe the appropriate antibiotics for specific clinical situations

Failure to provide GP clinical assessment for patients with deteriorating conditions and complex needs

Failure to maintain accurate records of patient contacts and clinical decisions

Failure of the home visit policy to address complex chronic conditions in care or residential facilities

Failure to distinguish clinical assessment tasks from true administration tasks

Failure to clearly request and document home visits

Concerns raised5

Insufficient resuscitation expertise in GP practices

Inadequate ventilation during resuscitation in GP practices

Insufficient emergency equipment in GP practices

Failure to provide oxygen during resuscitation in GP practices

Failure to use suction during resuscitation in GP practices

Concerns raised2

Lack of clear West Midlands guidelines and protocols for the management and treatment location of patients with sickle cell disease

Lack of staff knowledge of sickle cell crisis signs, symptoms and necessary treatment