PFD report

Stephen Anthony Kennedy · Prevention of Future Deaths report

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Issued 7 Feb 2019•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
2

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
23

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 raised2

  1. Unavailability of acute inpatient beds
    Part of recurring concern: Insufficient psychiatric inpatient bed capacity
  2. Unavailability of timely psychological services due to internal service structures and waiting lists
    Part of recurring concern: Excessive waiting times for NHS mental health servicesPart of recurring concern: Failure to provide indicated psychological interventions in mental health carePart of recurring concern: Unreliable access to talking therapies
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.12

  1. Action

    Formalise distinct community mental-health treatment pathways through the 2019/20 Service Development and Improvement Plan.

    Stated by NHS Birmingham and Solihull Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 26 May 2019.
  2. Action

    Fund individual Section 117 health-and-social-care packages where required to facilitate hospital discharge.

    Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 26 May 2019.
  3. Action

    Negotiate 2019/20 contract measures to improve capacity through investment and service development.

    Stated by NHS Birmingham and Solihull Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 26 May 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Local commissioners are responsible for determining acute mental health bed provision according to their populations’ needs.

    Stated by Department of Health and Social CareRedirects 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 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. ”

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

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. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for NHS mental health services; Failure to provide indicated psychological interventions in mental health care; Unreliable access to talking therapies.

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
Page 3 · response
Published 26 May 2019

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
Page 4 · response
Published 26 May 2019

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
Page 5 · response
Published 26 May 2019

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
Page 5 · response
Published 26 May 2019

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
Page 3 · response
Published 26 May 2019

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
Page 4 · response
Published 26 May 2019

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
Page 4 · response
Published 26 May 2019

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 clinical psychology capacity within every Home Treatment Team.

Verbatim wording from the response

“With regard to the matter of Psychological Therapy, I am able to confirm that we now have a plan for investing in clinical psychology capacity within our Home Treatment Team services. From September 2019, subject to recruitment, we anticipate to be in a position whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist within their team. Approval has been given to advertise these posts and this will help us to ensure compliance with NICE guidance and to deliver clinically effective care as per recommended guidelines. The Clinical Psychologist will also contribute to multi disciplinary team assessments, discussions and decisions relating to care planning and treatment options for patients, as well as providing supervision to other members of the team. We are also increasing nursing capacity to ensure that community caseloads are more manageable.”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 26 May 2019

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

Reduce delayed discharges to improve acute bed availability.

Verbatim wording from the response

“On the matter of bed availability, it is recognised that at times patients are unable to access a bed at the point of clinical decision making and that this can lead to increased risk, despite best efforts to manage patients safely in an alternative environment. We are undertaking a number of initiatives to try to mitigate this risk including:-”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 26 May 2019

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

Appoint patient flow coordinators to mitigate inpatient bed availability risks.

Verbatim wording from the response

“On the matter of bed availability, it is recognised that at times patients are unable to access a bed at the point of clinical decision making and that this can lead to increased risk, despite best efforts to manage patients safely in an alternative environment. We are undertaking a number of initiatives to try to mitigate this risk including:-”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 26 May 2019

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 patient flow to mitigate risks associated with unavailable inpatient beds.

Verbatim wording from the response

“On the matter of bed availability, it is recognised that at times patients are unable to access a bed at the point of clinical decision making and that this can lead to increased risk, despite best efforts to manage patients safely in an alternative environment. We are undertaking a number of initiatives to try to mitigate this risk including:-”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 26 May 2019

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 community-based Severe Mental Illness offer including psychological therapies, physical healthcare, employment support, personalised care and related support.

Verbatim wording from the response

“A new community-based offer for people with Severe Mental Illness will include access to psychological therapies; improved physical health care; employment support; personalised and trauma-informed care; medicines management; and support for self-harm and coexisting substance use. This will give 370,000 adults and older adults greater choice and control over their care, and support them to live well in their communities.”

Source location

2019-0039-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 26 May 2019

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

Local commissioners are responsible for determining acute mental health bed provision according to their populations’ needs.

Verbatim wording from the response

“On the availability of beds in the acute mental health sector, we are aware that the number of mental health beds overall have reduced and this is in large part due to the growth of care in the community. It may also be of interest to note that mental health bed occupancy rates have remained stable at between 87.1 per cent and 90.8 per cent (from Quarter 1, 2010-11 to Quarter 3, 2018-19), and that latest data for Quarter 3, 2018-19 shows a bed occupancy of 88.5 per cent. However, it remains the responsibility of local commissioners to determine the levels of service provision based on the needs of their local populations, and I note that the NHS in Birmingham and Solihull has taken action to commission a further 32 inpatient beds.”

Source location

2019-0039-Response-by-Department-of-Health-and-Social-Care
Page 2 · response
Published 26 May 2019

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

Local NHS organisations are responsible for providing mental health services, while NHS England commissions specialised services.

Verbatim wording from the response

“You will know that the provision of mental health services is a matter for the NHS locally, except where specialised services are required and NHS England is the responsible commissioner. You have issued your report to the Birmingham and Solihull Mental Health NHS Foundation Trust and the Birmingham and Solihull Clinical Commissioning Group (CCG), and I expect the local NHS to take firm action to respond to the concerns and learn from Stephen’s death to ensure the safety of healthcare services.”

Source location

2019-0039-Response-by-Department-of-Health-and-Social-Care
Page 1 · response
Published 26 May 2019

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.11

  1. 1

    Provide additional funding for a BSMHFT Clinical Lead for Personality Disorder to lead implementation of the personality-disorder strategy.

    Stated by NHS Birmingham and Solihull Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 26 May 2019.
  2. 2

    Review serious-incident management processes and whether funding shortages contributed to the reported deaths.

    Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 26 May 2019.
  3. 3

    Work with providers through the NHS England collaborative to identify ways to reduce out-of-area admissions, including considering internal resource shifts.

    Stated by NHS Birmingham and Solihull Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 26 May 2019.
  4. 4

    Roll out clinical standards for patients diagnosed with Personality Disorder.

    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 26 May 2019.
  5. 5

    Implement mandated training for Home Treatment Team staff on best-practice management of Personality Disorder.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 May 2019.
  6. 6

    Increase nursing capacity to make community caseloads more manageable.

    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 26 May 2019.
  7. 7

    Pursue commissioner investment and identify further improvement opportunities for Personality Disorder care.

    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 26 May 2019.
  8. 8

    Provide over £400 million over four years to support expansion of Crisis Resolution and Home Treatment Teams in line with CORE criteria.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 26 May 2019.
  9. 9

    Provide full national coverage of the existing suicide reduction programme as part of further suicide-prevention measures.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 May 2019.
  10. 10

    Expand mental health services through an additional £2.3 billion real-terms investment by 2023–24.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 May 2019.
  11. 11

    Establish a national single point of contact for mental health crisis through NHS111, providing access to a trained mental health professional.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 26 May 2019.

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

  1. 1

    The review found no correlation between funding levels and this death.

    Stated by NHS Birmingham and Solihull Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 funding for a BSMHFT Clinical Lead for Personality Disorder to lead implementation of the personality-disorder strategy.

Verbatim wording from the response

“3.5.1 An independent system simulation modelling exercise, which was jointly commissioned with Forward Thinking Birmingham (FTB), the provider of mental health services for those aged up to 25 years, and BSMHFT, to develop an informed response on the best solutions to address demand and where investment should be prioritised. This followed a sharp increase in demand for inpatient beds in 2016. A key recommendation of the exercise was to agree a strategy for the support and treatment of people with a diagnosis of personality disorder. This strategy is now being mobilised by BSMHFT and FTB. An SDIP has been developed for 2019/20 which formalises the implementation of the strategy and the CCG has provided additional funding for the appointment of a Clinical Lead for Personality Disorder within BSMHFT who will lead this work.”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-CCG
Page 3 · response
Published 26 May 2019

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 serious-incident management processes and whether funding shortages contributed to the reported deaths.

Verbatim wording from the response

“4.2 In response to concerns previously raised by HM Coroner, the CCG has undertaken a review of the processes for managing serious incidents, but also whether a shortage of funding may have contributed to these untimely deaths. The CCG has been unable to identify any correlation between funding and this death, but has recognised the need to continually improve its quality monitoring function and to also improve processes for learning from deaths at the earliest opportunity.”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-CCG
Page 5 · response
Published 26 May 2019

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 providers through the NHS England collaborative to identify ways to reduce out-of-area admissions, including considering internal resource shifts.

Verbatim wording from the response

“3.5.6 Working closely with BSMHFT and FTB as part of an NHS England collaborative to seek further ways to reduce the need to admit patients out of the local area. This work includes taking learning from other areas that have enjoyed success in achieving change. Commissioners are in discussion with BSMHFT to agree ways in which resource can be shifted internally to support this work.”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-CCG
Page 4 · response
Published 26 May 2019

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

Roll out clinical standards for patients diagnosed with Personality Disorder.

Verbatim wording from the response

“Our Chief Psychologist is leading a Personality Disorders Strategy which includes clinical standards to be met for patients with a diagnosis of Personality Disorder. We are currently in discussion with our Clinical Director of Community Mental Health Teams about the opportunities to roll out these standards in a clinically effective way. There are some challenges relating to resources which we have raised with our Commissioners and at the time of writing this response these have not yet been resolved. We will continue to pursue this matter and also seek to understand any further opportunities for improvement if investment is not forthcoming.”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 26 May 2019

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 mandated training for Home Treatment Team staff on best-practice management of Personality Disorder.

Verbatim wording from the response

“In addition, we have developed a tiered training programme in the best practice management of patients with Personality Disorder. This will be a mandated training requirement for all staff working within our Home Treatment Teams during 2019/20.”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 26 May 2019

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 nursing capacity to make community caseloads more manageable.

Verbatim wording from the response

“With regard to the matter of Psychological Therapy, I am able to confirm that we now have a plan for investing in clinical psychology capacity within our Home Treatment Team services. From September 2019, subject to recruitment, we anticipate to be in a position whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist within their team. Approval has been given to advertise these posts and this will help us to ensure compliance with NICE guidance and to deliver clinically effective care as per recommended guidelines. The Clinical Psychologist will also contribute to multi disciplinary team assessments, discussions and decisions relating to care planning and treatment options for patients, as well as providing supervision to other members of the team. We are also increasing nursing capacity to ensure that community caseloads are more manageable.”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 26 May 2019

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

Pursue commissioner investment and identify further improvement opportunities for Personality Disorder care.

Verbatim wording from the response

“Our Chief Psychologist is leading a Personality Disorders Strategy which includes clinical standards to be met for patients with a diagnosis of Personality Disorder. We are currently in discussion with our Clinical Director of Community Mental Health Teams about the opportunities to roll out these standards in a clinically effective way. There are some challenges relating to resources which we have raised with our Commissioners and at the time of writing this response these have not yet been resolved. We will continue to pursue this matter and also seek to understand any further opportunities for improvement if investment is not forthcoming.”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
Page 2 · response
Published 26 May 2019

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 over £400 million over four years to support expansion of Crisis Resolution and Home Treatment Teams in line with CORE criteria.

Verbatim wording from the response

“Over £400million of supporting investment is being made available over four years from April 2017 for the expansion of CRHTTs, in line with CORE criteria.”

Source location

2019-0039-Response-by-Department-of-Health-and-Social-Care
Page 2 · response
Published 26 May 2019

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 full national coverage of the existing suicide reduction programme as part of further suicide-prevention measures.

Verbatim wording from the response

“Finally, the long-term plan reaffirms the NHS’s commitment to make suicide prevention a priority over the next decade, and sets out further measures for suicide prevention, including full coverage across the country of the existing suicide reduction programme.”

Source location

2019-0039-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 26 May 2019

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

Expand mental health services through an additional £2.3 billion real-terms investment by 2023–24.

Verbatim wording from the response

“To support the NHS, we have committed to a comprehensive expansion of mental health services and are backing this up with an additional £2.3billion investment in real terms by 2023-24. This investment is made clear in the NHS Long Term Plan¹, published in January 2019 by NHS England.”

Source location

2019-0039-Response-by-Department-of-Health-and-Social-Care
Page 2 · response
Published 26 May 2019

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 national single point of contact for mental health crisis through NHS111, providing access to a trained mental health professional.

Verbatim wording from the response

“Crisis care is also a key element of the Long Term Plan and this includes establishing a national, single point of contact, for anyone experiencing mental health crisis through the NHS111 service. This means that people in crisis will be able to access a trained mental health professional when they need to.”

Source location

2019-0039-Response-by-Department-of-Health-and-Social-Care
Page 3 · response
Published 26 May 2019

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 review found no correlation between funding levels and this death.

Verbatim wording from the response

“4.2 In response to concerns previously raised by HM Coroner, the CCG has undertaken a review of the processes for managing serious incidents, but also whether a shortage of funding may have contributed to these untimely deaths. The CCG has been unable to identify any correlation between funding and this death, but has recognised the need to continually improve its quality monitoring function and to also improve processes for learning from deaths at the earliest opportunity.”

Source location

2019-0039-Response-by-Birmingham-and-Solihull-CCG
Page 5 · response
Published 26 May 2019

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