PFD report

Patricia Ann Cleghorn · Prevention of Future Deaths report

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Issued 25 Jul 2016•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.

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Concerns
4

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
20

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 raised4

  1. Unavailability of acute mental health inpatient beds
    Part of recurring concern: Insufficient psychiatric inpatient bed capacity
  2. Limited resources and care for vulnerable people in the community
  3. Failure to control access to available medication for a person at risk of overdose
    Part of recurring concern: Failure to secure and control medicationPart of recurring concern: Inadequate control of access to means of self-harm
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.11

  1. Action

    Meet with the Trust in December 2016 to review the impact of its action plans and monitor continued action to minimise risks to vulnerable people.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 25 July 2016.
  2. Action

    Set the expectation that beds must always be available for people who need them.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 25 July 2016.
  3. Action

    Issue a formal practice alert reinforcing suicide-risk, medicines-management and safe-medication-administration requirements, with staff acknowledgement.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 July 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Provision of acute mental health beds rests with the Trust and clinical commissioning groups.

    Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Unavailability of acute mental health inpatient beds

Wider context from the report

“(1) The deceased could not be admitted to hospital as there were no inpatient beds available. I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care. ”

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Limited resources and care for vulnerable people in the community

Wider context from the report

“(1) The deceased could not be admitted to hospital as there were no inpatient beds available. I heard evidence at the inquest that had she been admitted it is unlikely she would have died when she did. The availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 control access to available medication for a person at risk of overdose

Wider context from the report

“(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oromorph. No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her. ”

Is this part of a recurring concern?

Yes — Failure to secure and control medication; Inadequate control of access to means of self-harm.

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 undertake a formal suicide and overdose risk assessment

Wider context from the report

“(2) The deceased had repeatedly stated that she would end her life by taking an overdose. Despite this she was left at home self-medicating drugs including amitriptyline, MST and oromorph. No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her. ”

Is this part of a recurring concern?

Yes — Inadequate mental health risk assessment.

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

Meet with the Trust in December 2016 to review the impact of its action plans and monitor continued action to minimise risks to vulnerable people.

Verbatim wording from the response

“A quarterly meeting between CQC and the Trust took place 15th September 2016 where we discussed what actions they had taken. We will be meeting with the Trust again in December 2016 to review the impact of their action plans.”

Source location

2016-0270-Response-by-Care-Quality-Commission
Page 2 · response
Published 25 July 2016

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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

Set the expectation that beds must always be available for people who need them.

Verbatim wording from the response

“The Government has made it clear that beds must always be available for those who need them.”

Source location

2016-0270-Response-by-Department-of-Health
Page 1 · response
Published 25 July 2016

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

Issue a formal practice alert reinforcing suicide-risk, medicines-management and safe-medication-administration requirements, with staff acknowledgement.

Verbatim wording from the response

“2. The Senior Nurse for Professional Standards issued a formal practice alert on 12th September 2016 to registered and unregistered clinicians in our crisis and community teams to reinforce the requirements for:”

Source location

2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 4 · response
Published 25 July 2016

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Add a consultant psychiatrist to each home treatment team for daily medical review or opinion of high-risk patients.

Verbatim wording from the response

“• One consultant psychiatrist will form part of each home treatment team to ensure that all patients who are presenting high levels of risk have daily access to medical review or medical opinion. This will be in place across all of our home treatment teams by the end of October 2016”

Source location

2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 2 · response
Published 25 July 2016

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement a standard enhanced-care pathway for patients awaiting beds, including updated assessments, care plans, daily reviews and crisis plans.

Verbatim wording from the response

“All of these patients have received:”

Source location

2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 2 · response
Published 25 July 2016

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 Clinical Risk Management Group addressing risk-management training, suicide prevention and crisis-care-plan implementation.

Verbatim wording from the response

“3. We have established a Clinical Risk Management Group which is addressing:”

Source location

2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 4 · response
Published 25 July 2016

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 bed-management and community processes to enhance care for patients awaiting inpatient admission.

Verbatim wording from the response

“As a result of the unfortunate death of Mrs Cleghorn we have taken immediate action to review our bed management processes and community processes, so that we can ensure that any patient awaiting access to an inpatient bed receives enhanced care from our community staff.”

Source location

2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 2 · response
Published 25 July 2016

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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 Medicines Code and supporting staff guidance to address medication-administration and risk-assessment issues, and report through internal governance.

Verbatim wording from the response

“Proposed Action Plan – All of the actions are in place with the exception of item 4 which will be delivered by the end of November 2016”

Source location

2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 4 · response
Published 25 July 2016

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

Take action to manage the medicines-policy breach.

Verbatim wording from the response

“Proposed Action Plan – All of the actions are in place with the exception of item 4 which will be delivered by the end of November 2016”

Source location

2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 4 · response
Published 25 July 2016

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

Ensure all areas have evidence-based, high-quality 24/7 Crisis Resolution Home Treatment Teams providing intensive home treatment and acute-bed gatekeeping by 2020/21.

Verbatim wording from the response

“As noted in ████████ recent letter, we are aware that Crisis Resolution Home Treatment Teams are not always resourced to fully meet their core functions in”

Source location

2016-0270-Response-by-NHS-England
Page 1 · response
Published 25 July 2016

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop evidence-based mental health treatment pathways and commissioning tools, including acute-care quality standards for inpatient and community services.

Verbatim wording from the response

“Further, we are working with the National Collaborating Centre for Mental Health at the Royal College of Psychiatrists to develop a series of evidence-based treatment pathways for mental health care with accompanying commissioning support tools. This includes the development of an acute care pathway comprising a comprehensive set of quality standards, which is planned for completion within 2016/17. The work involves a range of multi-agency experts, including clinicians, social workers, service managers, service users and carers, and will focus on access to care, patient safety, patient experience and clinical outcomes. The scope of the pathway comprises both inpatient and community settings, reflecting the need to ensure services are commissioned and delivered in the context of a whole system approach based on clinical need and the safe management of patients.”

Source location

2016-0270-Response-by-NHS-England
Page 2 · response
Published 25 July 2016

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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

Provision of acute mental health beds rests with the Trust and clinical commissioning groups.

Verbatim wording from the response

“There remains a shortage of acute beds in this Trust and in other Mental Health Trusts in the region. This shortage will continue to impact on vulnerable people in the community. The provision of acute mental health beds rests with the Trust and with the clinical commissioning groups (CCGs). The role of the CCGs is to get the best possible health outcomes for the local population, by assessing local needs, deciding priorities and strategies, and then buying services (including mental health services) on behalf of the population from providers such as this Trust. The CCGs also check on the quality and safety of such services.”

Source location

2016-0270-Response-by-Care-Quality-Commission
Page 2 · response
Published 25 July 2016

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 is responsible for addressing concerns about medication access, risk assessment and staff recognition of available drugs.

Verbatim wording from the response

“The second issue is one for the Trust to answer:”

Source location

2016-0270-Response-by-Department-of-Health
Page 1 · response
Published 25 July 2016

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

Availability of acute mental health beds is a matter for local commissioners.

Verbatim wording from the response

“The Crisis Care Concordat makes it clear that local commissioners should commission a range of mental health services that allow beds to be available for a person in urgent need. Each local area in England has produced its own ‘Mental Health Crisis Declaration’.”

Source location

2016-0270-Response-by-Department-of-Health
Page 2 · response
Published 25 July 2016

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

Medication checks and removal of excessive medicines are limited by service users’ capacity and willingness to disclose information and permit searches.

Verbatim wording from the response

“Where risks are identified then medicines supply should be tightly controlled and overall medicines possession checked regularly as far as possible. If indicated, following appropriate risk assessment we will work with service users and carers to remove excessive medication in the interests of safety. It has to be recognised that we have to work within reasonable limits which are determined by the services user’s capacity and preparedness to fully disclose information and allow checks/searches. If our staff are in any way unsure that it is safe to supply medication, the team will need to consider whether to withhold supply and explain why.”

Source location

2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 4 · response
Published 25 July 2016

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.9

  1. 1

    Continue meeting with local services through the local inspection team.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 25 July 2016.
  2. 2

    Formally review the Trust’s implemented actions and their impact on patients at the December 2016 quarterly meeting.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 25 July 2016.
  3. 3

    Carry out a comprehensive re-inspection of the Trust in 2017, using the Report’s issues as a key line of enquiry.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 25 July 2016.
  4. 4

    Develop consistent regional crisis-care pathways with MERIT partner organisations.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 July 2016.
  5. 5

    Establish a substantive urgent care assessment team for patients in crisis.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 July 2016.
  6. 6

    Work with NHS Improvement and the Care Quality Commission to use learning from NHS-service suicide deaths to prevent repeat events.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 25 July 2016.
  7. 7

    Publish and disseminate the document Implementing the Five Year Forward View for Mental Health to explain delivery of the national mental health service transformation.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 25 July 2016.
  8. 8

    Establish and operate a national adult mental health programme covering crisis, acute, community and primary care services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 25 July 2016.
  9. 9

    Continue participating in national suicide-prevention partnership work through the Department of Health’s National Suicide Prevention Strategy Advisory Group.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 25 July 2016.

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 meeting with local services through the local inspection team.

Verbatim wording from the response

“The CQC local Inspection team continue to meet with ‘local services’ and in addition we will formally review the actions put in place by the Trust and their impact of those actions on patients at our quarterly meeting with the Trust in December 2016.”

Source location

2016-0270-Response-by-Care-Quality-Commission
Page 2 · response
Published 25 July 2016

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

Formally review the Trust’s implemented actions and their impact on patients at the December 2016 quarterly meeting.

Verbatim wording from the response

“The CQC local Inspection team continue to meet with ‘local services’ and in addition we will formally review the actions put in place by the Trust and their impact of those actions on patients at our quarterly meeting with the Trust in December 2016.”

Source location

2016-0270-Response-by-Care-Quality-Commission
Page 2 · response
Published 25 July 2016

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

Carry out a comprehensive re-inspection of the Trust in 2017, using the Report’s issues as a key line of enquiry.

Verbatim wording from the response

“Birmingham and Solihull Mental Health NHS Foundation Trust (‘the Trust’) is the CQC Registered provider of services received by Mrs Cleghorn. In May 2014 we carried out a comprehensive inspection of the Trust and it was rated ‘Good’ overall. We will be carrying out a fully comprehensive re-inspection in 2017 and intend to use the issues highlighted in your Report as a ‘key line of enquiry’.”

Source location

2016-0270-Response-by-Care-Quality-Commission
Page 1 · response
Published 25 July 2016

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 consistent regional crisis-care pathways with MERIT partner organisations.

Verbatim wording from the response

“More strategically we are working with our MERIT partners, who include; Dudley and Walsall Mental Health Partnership NHS Trust, Coventry and Warwickshire Partnership Trust and Black Country Partnership NHS Foundation Trust, across the region to develop consistent and unified pathways of care for patients in crisis.”

Source location

2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 3 · response
Published 25 July 2016

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 substantive urgent care assessment team for patients in crisis.

Verbatim wording from the response

“• Creation of an urgent care assessment team to concentrate specifically on the assessment of patients who are in crisis. This approach has been piloted and has demonstrated that having an urgent care assessment team improves outcomes for patients at this vulnerable time. The substantive team will be in place by the end of September 2016”

Source location

2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust
Page 2 · response
Published 25 July 2016

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 NHS Improvement and the Care Quality Commission to use learning from NHS-service suicide deaths to prevent repeat events.

Verbatim wording from the response

“In line with recommendation 57 of The Five Year Forward View for Mental Health, NHS England is working with NHS Improvement and the Care Quality Commission to ensure that learning from all deaths by suicide of people in the care of NHS services is used to try to prevent repeat events. Moreover, NHS”

Source location

2016-0270-Response-by-NHS-England
Page 2 · response
Published 25 July 2016

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

Publish and disseminate the document Implementing the Five Year Forward View for Mental Health to explain delivery of the national mental health service transformation.

Verbatim wording from the response

“For further detail on how the transformation of mental health services will be delivered over the next five years, please see Implementing the Five Year Forward View for Mental Health (https://www.england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf), published by NHS England on 19th July.”

Source location

2016-0270-Response-by-NHS-England
Page 3 · response
Published 25 July 2016

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 operate a national adult mental health programme covering crisis, acute, community and primary care services.

Verbatim wording from the response

“NHS England recently established an adult mental health programme which is taking a whole system approach comprising crisis, acute, and community/primary care work streams. The acute care work stream has been developed in response to a number of recommendations set out by the Commission on Acute Adult Psychiatric Care and The Five Year Forward View for Mental Health, and is particularly relevant to the concerns outlined in your report.”

Source location

2016-0270-Response-by-NHS-England
Page 1 · response
Published 25 July 2016

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 participating in national suicide-prevention partnership work through the Department of Health’s National Suicide Prevention Strategy Advisory Group.

Verbatim wording from the response

“England will continue to play its part in wider national partnership work as a member of the Department of Health’s National Suicide Prevention Strategy Advisory Group.”

Source location

2016-0270-Response-by-NHS-England
Page 3 · response
Published 25 July 2016

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