PFD report

Paul Price · Prevention of Future Deaths report

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Issued 18 Sep 2018•Birmingham and Solihull

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to accurately record mental health information
    Part of recurring concern: Unreliable recording of safety-critical mental health information
  2. Delays in transferring critical mental health information between mental health services and GPs
    Part of recurring concern: Failure to communicate clinically important information reliably between care services
  3. Failure to arrange follow-up after mental health concerns are raised
    Part of recurring concern: Failure to reliably follow up identified mental-health safety concerns
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. Action

    Invest in electronic recording, listening devices, and hybrid mail to support timely GP correspondence.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2018.
  2. Action

    Establish Trustwide timescales and targets for completing GP letters.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2018.
  3. Action

    Implement system changes, including an automated phone system, to record and audit internal and external calls and support message forwarding.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 September 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The Trust disputes that its computer systems were down on 1 June 2018; it attributes the missed message to staff error.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to accurately record mental health information

Wider context from the report

“2. A call was made to the Mental Health team on 01/06/18 raising a concern about Paul’s mental health. The caller was told that the computer systems were down and the mental health team would call back – they did not call back. There is concern that staff are not accurately recording information and arranging follow-up. ”

Is this part of a recurring concern?

Yes — Unreliable recording of safety-critical mental health information.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in transferring critical mental health information between mental health services and GPs

Wider context from the report

“1. Paul was seen for a full assessment on 04/05/18. The summary of that attendance in a letter was not received by the GP until 29/05/18. In the meantime Paul had attended his GP with ongoing concerns about his mental health and requesting further medication. The delay in receiving critical information about vulnerable patients could put them a risk and result in over prescribing medication. In addition I was told that the IT systems for Birmingham and Solihull Mental Health Trust and the GPs are incompatible meaning that letters have to be faxed or posted causing further delay. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to arrange follow-up after mental health concerns are raised

Wider context from the report

“2. A call was made to the Mental Health team on 01/06/18 raising a concern about Paul’s mental health. The caller was told that the computer systems were down and the mental health team would call back – they did not call back. There is concern that staff are not accurately recording information and arranging follow-up. ”

Is this part of a recurring concern?

Yes — Failure to reliably follow up identified mental-health safety concerns.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Invest in electronic recording, listening devices, and hybrid mail to support timely GP correspondence.

Verbatim wording from the response

“1. In relation to the delay in Paul’s GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devices and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.”

Source location

Paul-Price-Response
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish Trustwide timescales and targets for completing GP letters.

Verbatim wording from the response

“1. In relation to the delay in Paul’s GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devices and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.”

Source location

Paul-Price-Response
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement system changes, including an automated phone system, to record and audit internal and external calls and support message forwarding.

Verbatim wording from the response

“3. On the matter of computer systems, staff recording information and following up, we have checked our IT systems and there is no record of unplanned downtime for the 1st June 2018. Any planned downtime tends to be very late into the day and before the start of the morning shift. The failure to pass on the message was a staff error but we are also looking to implement system changes which will support the recording and forwarding of messages. This includes an automated phone call system which will log and audit all phone calls made internally and externally to the Trust. Again I would like to be able to write to you in three months to advise you of our progress in making this system available and implemented across all our hundred plus teams.”

Source location

Paul-Price-Response
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Participate in developing and implementing Docman electronic mail links with local GP surgeries.

Verbatim wording from the response

“We are also in the process of developing an electronic mail system linking to GP surgeries via Hybrid Mail. This system is called Docman and currently there is a project working group being led by Birmingham Women and Children’s NHS Foundation Trust which we have joined. This group is working to implement Docman across all GP surgeries locally and then to develop it as a national system.”

Source location

Paul-Price-Response
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Recruit additional Home Treatment service staff, proceeding ahead of funding confirmation after submitting a business case to Commissioners.

Verbatim wording from the response

“To immediately address this issue we have increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm-2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by our administrative staff and handed over with a signature to qualified staff to action. In the longer term we are seeking to recruit additional staff to our Home Treatment service and have submitted a business case to our Commissioners in this regard. Given the urgency of this issue, we have decided to proceed with recruitment to this team ahead of funding confirmation. Recruitment is about to go live.”

Source location

Paul-Price-Response2
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement monthly monitoring to ensure GP letters are issued within the nationally required two-week timescale.

Verbatim wording from the response

“In addition to this we have implemented a monthly monitoring process to ensure that letters are provided within the nationally required 2 week timescale.”

Source location

Paul-Price-Response2
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Increase out-of-hours capacity by assigning a Band 7 senior clinician each evening to manage, triage and assess Home Treatment Team calls.

Verbatim wording from the response

“To immediately address this issue we have increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm-2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by our administrative staff and handed over with a signature to qualified staff to action. In the longer term we are seeking to recruit additional staff to our Home Treatment service and have submitted a business case to our Commissioners in this regard. Given the urgency of this issue, we have decided to proceed with recruitment to this team ahead of funding confirmation. Recruitment is about to go live.”

Source location

Paul-Price-Response2
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Reorganise administrative call handling and signed handover to qualified staff for action.

Verbatim wording from the response

“To immediately address this issue we have increased the capacity of our out of hours service by putting a senior clinician (Band 7) on duty each evening from 4pm-2am to manage and triage activity across our Home Treatment Teams. They take calls as well as assess if additional support is required. Alongside this we have re-organised how calls are taken by our administrative staff and handed over with a signature to qualified staff to action. In the longer term we are seeking to recruit additional staff to our Home Treatment service and have submitted a business case to our Commissioners in this regard. Given the urgency of this issue, we have decided to proceed with recruitment to this team ahead of funding confirmation. Recruitment is about to go live.”

Source location

Paul-Price-Response2
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish an out-of-hours switchboard safeguard requiring advice from a 24/7 bed-management clinician when clinical staff cannot respond.

Verbatim wording from the response

“In addition, we have placed an additional safeguard in place via our out of hours main switchboard, whereby in the event of failure to secure a response from clinical”

Source location

Paul-Price-Response2
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement electronic GP correspondence through the Trust-wide Hybrid Mail rollout and Docman, supported by GP-practice IT infrastructure.

Verbatim wording from the response

“I am pleased to be able to advise you that since issuing this Prevention of Future Deaths report, we have implemented significant improvements in relation to both the quality and timeliness of communication with GPs. This includes the full roll out of a hybrid mail system across the Trust. On 5 March 2019, we enabled a new feature within Hybrid Mail called Docman. This feature dramatically reduces the time it takes for GPs to receive letters from the Trust. Instead of letters being posted, they are sent electronically and we have worked in partnership with our Local Clinical Commissioning Group to ensure that GP practices have the necessary IT infrastructure to receive such communication. Letters sent to GPs via Docman will normally arrive at their destination on the same working day and are released from Hybrid mail every 15 minutes.”

Source location

Paul-Price-Response2
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Trust disputes that its computer systems were down on 1 June 2018; it attributes the missed message to staff error.

Verbatim wording from the response

“3. On the matter of computer systems, staff recording information and following up, we have checked our IT systems and there is no record of unplanned downtime for the 1st June 2018. Any planned downtime tends to be very late into the day and before the start of the morning shift. The failure to pass on the message was a staff error but we are also looking to implement system changes which will support the recording and forwarding of messages. This includes an automated phone call system which will log and audit all phone calls made internally and externally to the Trust. Again I would like to be able to write to you in three months to advise you of our progress in making this system available and implemented across all our hundred plus teams.”

Source location

Paul-Price-Response
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Trustwide timescales, electronic recording, hybrid mail and management oversight are considered sufficient to address delays in completing GP letters.

Verbatim wording from the response

“1. In relation to the delay in Paul’s GP receiving critical information this has highlighted a potential systemic issue that is not localised to one service. We have established Trustwide timescales and targets for the completion of GP letters but have found, on investigation, that across the Trust different Consultants and teams have different local arrangements and that with staff leave and absence, there are variations in capacity to complete these within defined timescales. The Trust has invested heavily in electronic recording and listening devices and the use of hybrid mail and along with a management focus on dealing with team and capacity variations should give us confidence that we have addressed these issues. I would ask if I may, that I write to you in three months to update you on the outcome and progress made to address the concern.”

Source location

Paul-Price-Response
Page 2 · response
Published 19 September 2018

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Rapid information sharing across NHS providers requires a national solution beyond the Trust’s local systems and arrangements.

Verbatim wording from the response

“2. With respect to the incompatibility of BSMHFT and GP systems, this is a local issue that is reflected nationally and we have previously written to you about this more general topic. We are, and continue to be of the view that there does need to be a national solution to rapid information sharing between NHS care providers. We have previously written to NHS England (NHSE) about this need, however there is no solution at present, which means that risk remains in our systems. We have worked collaboratively with our local MERIT mental health partners (Birmingham Childrens, D&W, BCP and CWP) to find a local solution to this; we do now have a single system in place that allows us to access each other’s information electronically.”

Source location

Paul-Price-Response
Page 2 · response
Published 19 September 2018

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Implement a shared electronic system with local mental health partners to access one another’s information.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2018.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    NHS111, not the Trust, is responsible for commissioning and providing the crisis telephone line and responding to crisis calls.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement a shared electronic system with local mental health partners to access one another’s information.

Verbatim wording from the response

“2. With respect to the incompatibility of BSMHFT and GP systems, this is a local issue that is reflected nationally and we have previously written to you about this more general topic. We are, and continue to be of the view that there does need to be a national solution to rapid information sharing between NHS care providers. We have previously written to NHS England (NHSE) about this need, however there is no solution at present, which means that risk remains in our systems. We have worked collaboratively with our local MERIT mental health partners (Birmingham Childrens, D&W, BCP and CWP) to find a local solution to this; we do now have a single system in place that allows us to access each other’s information electronically.”

Source location

Paul-Price-Response
Page 2 · response
Published 19 September 2018

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

NHS111, not the Trust, is responsible for commissioning and providing the crisis telephone line and responding to crisis calls.

Verbatim wording from the response

“We do hope that this additional infrastructure will help to mitigate the likelihood of any future incidents. We should highlight at this stage that whilst we will always try our very best to respond to patients in crisis, a crisis telephone line is not commissioned via BSMHFT from our Commissioners. The commissioning of this service is via NHS111 who are required to provide support and respond to crisis calls. We are however aware that a lack of mental health professionals within NHS111 can lead to increased demands on our own services.”

Source location

Paul-Price-Response2
Page 3 · response
Published 19 September 2018

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

Data last updated 7 September 2026