PFD report

Winston Harris · Prevention of Future Deaths report

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Issued 3 Aug 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
5

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
17

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 raised5

  1. Failure to communicate absconding risk in written hospital transfer documentation
    Part of recurring concern: Unreliable healthcare patient transfer processes
  2. Failure to consider emergency DOLS for a person presenting a relevant deprivation-of-liberty risk
    Part of recurring concern: Inadequate deprivation of liberty safeguarding for people lacking capacity
  3. Delays in processing DOLS applications
    Part of recurring concern: Inadequate deprivation of liberty safeguarding for people lacking capacity
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.14

  1. Action

    Continue rolling audits of DoLS compliance among focused-care patients.

    Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2016.
  2. Action

    Include DoLS policy and procedure requirements in induction for new staff.

    Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 August 2016.
  3. Action

    Work with Birmingham and Sandwell local authorities to streamline DoLS applications and address late responses.

    Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2016.

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

  1. Position

    Existing policies, procedures and the DoLS framework remain suitable; further work should raise awareness rather than revise the process.

    Stated by Sandwell and West Birmingham Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 communicate absconding risk in written hospital transfer documentation

Wider context from the report

“(2)When Mr Harris was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding risk. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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 consider emergency DOLS for a person presenting a relevant deprivation-of-liberty risk

Wider context from the report

“(3) At no time did staff consider if Mr Harris should be subject to an emergency DOLS despite him having dementia and having tried to leave the ward on 16/03/2016. He had previously been assessed as requiring and DOLS. ”

Is this part of a recurring concern?

Yes — Inadequate deprivation of liberty safeguarding for people lacking capacity.

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 processing DOLS applications

Wider context from the report

“(4) The application for DOLS order was not processed before Mr Harris’s death. I heard evidence that it often takes many months to process a DOLS application. Given these are extremely vulnerable people applications should be processed more quickly. ”

Is this part of a recurring concern?

Yes — Inadequate deprivation of liberty safeguarding for people lacking capacity.

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 include absconding risk and previous absconding behaviour in the care plan

Wider context from the report

“(1) The care plan for Mr Harris did not deal with his risk of absconding. As a result when he was transferred to City Hospital with his care plan there were no details of his previous absconding behaviour. ”

Is this part of a recurring concern?

Yes — Failure to control risks posed by care-home residents to themselves and others; Failure to reliably develop and review risk-reduction plans.

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 provide written confirmation of DOLS applications during hospital transfer

Wider context from the report

“(2)When Mr Harris was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding risk. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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

Continue rolling audits of DoLS compliance among focused-care patients.

Verbatim wording from the response

“The Trust is a national pilot site for work on Focused Care. Very commonly such patients are in receipt of capacity assessment, which then drives their additional nursing and care needs. These patients are registered centrally via our Safeguarding system. We have audited the compliance with DOLS for such patients. That audit continues on a rolling basis and we would expect to see the volume of cases rise among that cohort.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 1 · response
Published 3 August 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

Include DoLS policy and procedure requirements in induction for new staff.

Verbatim wording from the response

“• An e-learning DoLS module is in development for nursing staff (ready by the end of November), and induction processes have been updated to include DoLS policy and procedure requirements for new staff.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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 Birmingham and Sandwell local authorities to streamline DoLS applications and address late responses.

Verbatim wording from the response

“Partnership working We are aware that both Birmingham and Sandwell Local Authorities are struggling to process the volume of DoLS requests they receive. However, we are working with them to see if there is a more streamlined approach to address the late responses to applications made by the Trust. The response periods will be centrally monitored and reported to me. Clearly as our volume of applications rises the resourcing issue will need to be faced.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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

Centrally monitor and report local-authority response periods for DoLS applications.

Verbatim wording from the response

“Partnership working We are aware that both Birmingham and Sandwell Local Authorities are struggling to process the volume of DoLS requests they receive. However, we are working with them to see if there is a more streamlined approach to address the late responses to applications made by the Trust. The response periods will be centrally monitored and reported to me. Clearly as our volume of applications rises the resourcing issue will need to be faced.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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

Strengthen Safeguarding Level 2 training with local scenarios and prioritised delivery for staff serving patients likely to need DoLS.

Verbatim wording from the response

“• Strengthening the existing Safeguarding Level 2 staff training, which already includes the Mental Capacity Act and DoLS, by using local scenarios and improving the content and prioritising current training for those who may have more patients needing a DoLS.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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 and introduce a DoLS e-learning module for nursing staff.

Verbatim wording from the response

“• An e-learning DoLS module is in development for nursing staff (ready by the end of November), and induction processes have been updated to include DoLS policy and procedure requirements for new staff.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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

Target relevant medical staff and require consultants to discuss DoLS implications and treatment impact with their teams.

Verbatim wording from the response

“• Targeting medical staff who carry out consent procedures with patients to promote earlier consideration of the potential need for critical care in the event of a complication. Also all Consultants will be required to share this with their team to understand why DoLS may need to be applied and how treatments may impact on the need for a DoLS.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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

Audit wards and units to confirm DoLS awareness and support systems for new and temporary staff.

Verbatim wording from the response

“• Structured audit with ward sisters and Unit matrons across the Trust, as the majority of the patients who may need a DoLS will be in these inpatient areas, to obtain confirmation that they have raised awareness of DoLS with all their staff and have systems in place to support new starters and temporary staff.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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

Make a recorded DoLS workshop available as an internal training resource and publicise it across the organisation.

Verbatim wording from the response

“• Videoing one of the workshops so that it can be shared both with those staff who could not attend, and as a training resource available on our Intranet. By the end of October this video will have been widely publicised inside the organisation.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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

Inspect wards and units to check whether DoLS are in place or required, and feed findings back to managers.

Verbatim wording from the response

“We will use our continuing programme of in-house inspections to check that DoLS are in place or required, feeding our findings back to the ward and unit managers. The next round of visits take place on November 1st and 2nd and are focussing on the wards. Awareness of DOLS will be a key indicator in that process.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 3 · response
Published 3 August 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

Deliver ongoing DoLS education and awareness workshops for multidisciplinary staff.

Verbatim wording from the response

“We have a well-developed training approach with staff. In recognising that the framework around DoLS is in place, the focus of attention is on the need to raise awareness, rather than revise the process. A programme of ongoing education and awareness is well advanced. To date it has included:”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 1 · response
Published 3 August 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

Introduce a staff aide-memoire prompt for identifying and applying for DoLS.

Verbatim wording from the response

“As you would expect we have the necessary policies and procedures in place. These provide both advice and instruction to staff. Having re-checked that material it remains suitable and is available to staff through our Intranet web site. What we have decided we need in order to augment that approach is an aide memoire or prompt for staff. This will be in place by the end of October.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 1 · response
Published 3 August 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

Invest resources to reduce the backlog of Deprivation of Liberty Safeguards assessments.

Verbatim wording from the response

“Following the Supreme Court judgment in P v Cheshire West and Chester County Council and Another; P and Q v Surrey County Council [2013] UKSC 19, [2014] COPLR 313, SC (referred to as Cheshire West and MIG and MEG), there was an immediate eleven-fold increase in the number of applications for Deprivation of Liberty Safeguards (DOLS) in England. Birmingham, as in every other local authority area, experienced this increase and saw its referrals for this work rise from 198 in 2013/14 to 3,278 authorised in the last 12 months. No additional resources have been made available to local authorities to meet this increase. In such circumstances, very large backlogs of assessments mounted, and in Birmingham this was the case as in all other areas.”

Source location

2016-0280-Response-by-Birmingham-City-Council
Page 2 · response
Published 3 August 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

Process future Deprivation of Liberty Safeguards applications more quickly.

Verbatim wording from the response

“In Birmingham great efforts and resources have been invested to address the problem, which is now delivering significant results, with the waiting list for assessment considerably reduced. Plans are thereafter in place to ensure that in future applications will be processed more quickly.”

Source location

2016-0280-Response-by-Birmingham-City-Council
Page 2 · response
Published 3 August 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

Existing policies, procedures and the DoLS framework remain suitable; further work should raise awareness rather than revise the process.

Verbatim wording from the response

“As you would expect we have the necessary policies and procedures in place. These provide both advice and instruction to staff. Having re-checked that material it remains suitable and is available to staff through our Intranet web site. What we have decided we need in order to augment that approach is an aide memoire or prompt for staff. This will be in place by the end of October.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 1 · response
Published 3 August 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 council could not immediately process DOLS applications faster because resources and nationally qualified assessors and advocates were insufficient.

Verbatim wording from the response

“Following the Supreme Court judgment in P v Cheshire West and Chester County Council and Another; P and Q v Surrey County Council [2013] UKSC 19, [2014] COPLR 313, SC (referred to as Cheshire West and MIG and MEG), there was an immediate eleven-fold increase in the number of applications for Deprivation of Liberty Safeguards (DOLS) in England. Birmingham, as in every other local authority area, experienced this increase and saw its referrals for this work rise from 198 in 2013/14 to 3,278 authorised in the last 12 months. No additional resources have been made available to local authorities to meet this increase. In such circumstances, very large backlogs of assessments mounted, and in Birmingham this was the case as in all other areas.”

Source location

2016-0280-Response-by-Birmingham-City-Council
Page 2 · response
Published 3 August 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

For a person's new hospital circumstances, the hospital must determine whether deprivation exists and request a fresh DOLS process.

Verbatim wording from the response

“In relation to the case of Mr Harris, his application for a DOLS had been prioritised for action on receipt in February 2016, but by the time the lengthy assessment process had been completed, he had been admitted to hospital. Since a DOLS assessment is specific to each care setting, this could not then be authorised. It was therefore the duty of the hospital to judge if his new circumstances also constituted a deprivation of liberty and request the process be started afresh. Indeed, had the DOLS been in place in the care home, this would have had no legal power or application once Mr Harris was admitted to hospital.”

Source location

2016-0280-Response-by-Birmingham-City-Council
Page 2 · response
Published 3 August 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.3

  1. 1

    Monitor DoLS programme measures, report key performance indicators through governance meetings and ward dashboards, and use findings to target further training.

    Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 August 2016.
  2. 2

    Implement an electronic patient record to improve monitoring of patients who may lack capacity and require DoLS.

    Stated by Sandwell and West Birmingham Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2016.
  3. 3

    Provide bi-monthly progress reports to the Board-level Quality and Safety Committee on delivery and improvement outcomes.

    Stated by Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 August 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

Monitor DoLS programme measures, report key performance indicators through governance meetings and ward dashboards, and use findings to target further training.

Verbatim wording from the response

“Tracking success:”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 2 · response
Published 3 August 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

Implement an electronic patient record to improve monitoring of patients who may lack capacity and require DoLS.

Verbatim wording from the response

“Work is in train to move towards an electronic patient record, due to be fully implemented by Christmas 2017, which will further improve the monitoring of patients who may lack capacity and require a DoLS application.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 3 · response
Published 3 August 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

Provide bi-monthly progress reports to the Board-level Quality and Safety Committee on delivery and improvement outcomes.

Verbatim wording from the response

“Taken together, I am satisfied that these actions will give us a strong likelihood of succeeding in improving substantially the number of patients who are appropriately placed on DoLS. Our Board-level Quality and Safety Committee will receive a bi-monthly progress report to check that the actions described above have delivered the required improvements.”

Source location

2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Page 3 · response
Published 3 August 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