PFD report

Paula LENIHAN · Prevention of Future Deaths report

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Issued 2 Oct 2023•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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised1

  1. Failure to complete or update risk assessments adequately
    Part of recurring concern: Failure to update risk assessments after material changes or safety eventsPart of recurring concern: Unreliable documentation of safety risk assessments
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.5

  1. Action

    Monitor risk-assessment completion through monthly local clinical governance committees and the trust-wide performance delivery group.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 October 2023.
  2. Action

    Complete the review of the risk management policy.

    Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2023.
  3. Action

    Operate a project group reviewing the risk assessment process, outpatient clinics and documentation for care support patients.

    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 6 October 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The Trust disputes that failing to update risk assessment information already recorded would create a risk of death or meet the PFD threshold.

    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 complete or update risk assessments adequately

Wider context from the report

“1. The evidence given on behalf of the Birmingham & Solihull Mental Health NHS Foundation Trust was that in addition to this present case, where the deceased's risk assessment was not updated between November 2021 and her death in March 2023 despite circumstances which I was told ought to have triggered an update, there were a further number of cases within the Trust in which Root Cause Analysis reports had been produced, where it had also been found that risk assessments were not being completed in line with expectations; further, that it was not clear why this was happening. 2. If risk assessments are not being properly completed or updated, then there is an obvious risk of deaths occurring in the future, as a result of insufficient recording of risk. The fact that risk-relevant information may be recorded in the body of clinical notes is not reassuring, because a risk assessment or risk summary ought to capture the most salient risk information so that a professional looking quickly can absorb it; this is all the more important where professionals are under time pressure. 3. The evidence given to me was that a 'task and finish group' has been set up to address the issue, which expects to have concluded by early next year, i.e. 2024, and that this group will be addressing matters as they are found rather than waiting until the final stage of its existence early next year. The evidence was that this group is at an early stage, with meetings considering the terms of reference and also, recently, the most appropriate persons to contribute to the group. 4. In the circumstances I am concerned that currently there is an extant issue within the Trust about the completion of risk assessments being, on a number of occasions, unsatisfactory. The task and finish group is at an early stage and I do not know what it is going to do, or when. I therefore cannot be reassured that the issues around risk recording which that group is going to examine have, at this point in time, been addressed. It seems to me that they continue to exist, because there has been no evidence to tell me otherwise. ”

Is this part of a recurring concern?

Yes — Failure to update risk assessments after material changes or safety events; Unreliable documentation of safety risk assessments.

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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

Monitor risk-assessment completion through monthly local clinical governance committees and the trust-wide performance delivery group.

Verbatim wording from the response

“To ensure we continue to support staff in maintaining these levels of completion we will be monitoring via our monthly local CMHT clinical governance committee and trust wide performance delivery group.”

Source location

Response from Birmingham and Solihull Mental Health
Page 2 · response
Published 6 October 2023

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Complete the review of the risk management policy.

Verbatim wording from the response

“The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .”

Source location

Response from Birmingham and Solihull Mental Health
Page 2 · response
Published 6 October 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Operate a project group reviewing the risk assessment process, outpatient clinics and documentation for care support patients.

Verbatim wording from the response

“The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .”

Source location

Response from Birmingham and Solihull Mental Health
Page 2 · response
Published 6 October 2023

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

Ratify the revised risk management policy.

Verbatim wording from the response

“The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .”

Source location

Response from Birmingham and Solihull Mental Health
Page 2 · response
Published 6 October 2023

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 protected dedicated staff time to update risk assessment documentation.

Verbatim wording from the response

“The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .”

Source location

Response from Birmingham and Solihull Mental Health
Page 2 · response
Published 6 October 2023

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 failing to update risk assessment information already recorded would create a risk of death or meet the PFD threshold.

Verbatim wording from the response

“I understand that during evidence presented at the inquest you concluded that the failure to update the risk assessment did not contribute to the death and accepted that the information was recorded within the records for staff to access. Your report sets out your belief that the risk assessment should be updated ‘so that a professional looking quickly can absorb it; this is all the more important where professionals are under time pressure.’ This aspect of your report is not based on evidence heard at the inquest and the Trust does not accept that failing to update the Risk Assessment section of the medical notes, when the information is already within the records, would result in death. Even in times of pressure, clinicians would review all the necessary pertinent information prior to reviewing a patient.”

Source location

Response from Birmingham and Solihull Mental Health
Page 1 · response
Published 6 October 2023

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