Michael Cooper
PFD Report
All Responded
Ref: 2018-0413
All 2 responses received
· Deadline: 29 Nov 2018
Response Status
Responses
2 of 2
56-Day Deadline
29 Nov 2018
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
_ The Home Treatment Team advised on the 13th March 2018 that Mr: Cooper should be admitted for inpatient mental health treatment: However , this could not happen on the as there was no bed available. lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust; which the Trust is currently working to address through numerous new initiatives In the absence of an inpatient bed, Mr. Cooper was managed with medication and home treatment team visiting twice a day. Whilst awaiting admission; he was offered an out-of-area bed on the 16th March 2018 but he declined as he felt it would be detrimental to him to be so far from his wife and family: The Coroner is aware, although this was not an issue that came out in evidence in this case, that placing patients in out ofarea beds not only causes difficulty for maintaining the patient's support and visits from family and friends which can be prejudicial to their mental health, but also affects their continuity of care thus creating a risk to life_ An appointment following referral onto the Care Programme Approach on the 18th April 2018 was outside the two week timeframe specified in the Care Programme Approach Policy This was due to capacity issues within the team and was not an isolated occurrence: Consequently a patient requiring follow up within 2 weeks may be left unsupported which creates a risk to life When Mr: Cooper was established on the Care Programme Approach, his Care Co-ordinator did not have the capacity to review his notes prior to her first visit and therefore did not have a clear understanding of his complex history: Care Co-ordinators within Birmingham and Solihull Mental Health Trust are currently carrying a caseload of more than 30 patients: The NICE guidelines for the Care Programme Approach advises that a Care Coordinator should have and May will May day The this caseload of 15 patients. Without the time to familiarise themselves with their patients' histories Care Co-ordinators cannot make informed assessments of their risk which puts lives at risk Despite a detailed root cause analysis investigation with a comprehensive action plan arising from Mr: Cooper'$ case, without increased funding similar circumstances could arise again due to the pressures placed on staff and resources arising from demand for the service: The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent to the Birmingham and Solihull Coroners in recent months: Consequently this report to prevent future death is being made in conjunction with reports to prevent future deaths arising from 6 other investigations into deaths between and August 2018 that demonstrate a risk that future deaths will occur as a result of under-funding: In addition to this report, letters are enclosed from the Medical Directors of both Trusts setting out their concerns_
Responses
Response received
View full response
Dear Mrs Hunt; Re: Regulation 28 Reports to Prevent Future Deaths cases and funding concerns Thank you for your Regulation 28 Report dated October 4 2018 concerning linked deaths identified by Birmingham and Solihull coroners with commensurate concerns about demands on NHS providers of mental health services and chronic underfunding of mental health services_ also thank you for forwarding letters from the Medical Directors of the 2 trusts providing services which support your concerns_ Thank you for forwarding the 7 regulation 28 reports Firstly , would like to express my deep condolences to the family of each of these individuals would also like to add that NHS England regards the concerns raised as a matter of great import and has carefully considered the response below: The regulation 28 reports conclude series of concerns which will summarise as follows_ High quality care for all, now and for future generations
Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding the above issues_ On November 12th 2018 NHS England received correspondence from the Birmingham and Solihull Clinical Commissioning Group (CCG) following a review of Regulation 28 letters and Provider responses_ The CCG noted that FTB had communicated a view that demand and funding were significant underlying issues; The view of BSHMFT also highlighted demand related issues but did not overtly articulate funding as an issue. The CCG commissions mental health services at Tier 1, 2 3 and 4 for adults and for Children and Young people (0-25 years of age), tiers 1,2 and 3 (with Tier commissioned by Specialised commissioners at NHS England): These services are commissioned from FTB and BSMHFT NHS England directly commissions specialised tier four inpatient mental health services for children and young people, specialised mental health services (e.g: eating disorders and services for the deaf), adult medium High quality care for all, now and for future generations the being
and high secure services, perinatal mental health, services for prisoners and services for the military and military veterans_ The CCG: Undertakes monthly contract review of its providers Since February 2018_ following an 'inadequate' rating by the Care Quality Commission of FTB, the CCG has led the development of a Quality Improvement Board to oversee and provide assurance on CQC improvement Action Plan and System Improvement Plan. Is confident in its quality assurance processes 3 Participates in strategic planning as part of the Sustainability and transformation partnership which has at its core an ambition to provide comprehensive and timely services, including a zero suicide ambition Proactively manages demand with series of initiatives to reduce unnecessary admissions and avoid delayed transfers of care, such that capacity can be optimally managed; 5_ Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to €4,611,000 for BSMHFT (3.7% increase) and E6,235,000 for FTB (22.6% increase) In 2018/19 the CCG provided additional investment in BSMHFT amounting to €3,117,000 (2.4% increase) and FTB amounting to E2,881,000 (9.3% increase): Further funding discussions are ongoing but at present the CCG is unable to validate a link between funding and the deaths presented. However, the CCG continuously monitors this position and demand in order to ensure it is responsive to any increase in demand where funding would be either the sole, or contributory solution: Undertakes mortality and incident review seriously and in line with national policy_ The coroners' letters have prompted comprehensive review of mortality and incident governance which will result in improved care quality and learning from incidents_ On November 14" 2018, all stakeholders involved in the commissioning, provision and regulatory oversight of mental health services in Birmingham and Solihull were convened at a 'deep dive' meeting: The summary of outcomes from this meeting are as follows - Oversight of strategic and operational issues: the CCG will lead the establishment of an oversight group which involved all stakeholders The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis. 2 Information sharing: it is clear that commissioners and providers are not always sharing or reviewing the same data and intelligence The CCG has established a governance framework which will enable more proactive management of quality and in particular, learning from significant events and mortality _ This will enable issues to escalate to the wider system more expeditiously_ A review of trends showed that there is not an observed increase in suicides compared with national figures which is reassuring, but all stakeholders agreed in the need to support a zero suicide ambition across health and social care although many individuals do not come into contact with mental health services prior to death; Strategic planning: It is clear that funding is not the sole issue responsible for the failures highlighted in the cases reviewed although funding for an extra 32 mental health beds has been made available by the CCG There are several areas of High quality care for all, now and for future generations
strategic planning which require attention_ Data sharing and more effective communication across commissioners and providers, and between providers is one area of concern: Secondly, there is significant workforce challenge here and now; not unique to Birmingham and Solihull; which needs articulating and planning for. Thirdly, whilst there is debate about whether there is sufficient capacity in the system, it is indisputable that pressure exists at times which results in acutely ill patients not having access to acute mental health beds_ Funding alone is not the issue but there is agreement that in order to answer the question of the likely attribution of funding constraint on risk within services all stakeholders need to be party to a shared demand analysis (with an extended invitation to partners from health and Justice, local authorities and schools) and a 'Suicide prevention strategy: The Demand analysis will be led by the CCG and the Suicide prevention strategy will be led by the Director of Public Health: Transformation: whilst we determine what is required to make services 'safe' in line with a shared definition of what 'safe' means, it was clear that the system has further ambition to excel. Work will be undertaken in the following areas Primary mental healthcare services (Le: services delivered in primary care under the auspices of a General Practitioner): it is clear there is limited access to mental health services in primary care and this will require assessment, Secondary mental healthcare (i.e_ that delivered in hospitals or specialised centres): planning for future demand and capacity_ Specialist mental health service support in acute physical illness: we agree that this needs to improve in order to support patients who end up in our Emergency Departments or downstream acute inpatient hospital beds Commissioning: collaboration between specialised and CCG commissioned services needs to improve in order to enable patients to see a seamless pathway of care There is now a commitment from the CCG and Specialised commissioning team to collaborate in services each commissions_ This will commence with meetings scheduled in December 2018_ Upstream interventions (i.e. prevention of risk factors which predispose to mental iIl-health): The West Midlands Combined Authority has ambition to address social determinants of health and has mental health strategy which needs to fully resonate with the NHS Delivery of mental health services: the cases reviewed demonstrate that at times, services are neither integrated nor responsive and it was accepted that this needs to improve with work in the following areas - Pathways of care, in particular for crisis care , early intervention in psychosis (EIP) and for children and young people, need to be clearly defined s0 that services are available, accessible and acquired. Where patients do not acquire services i.e_ failure to attend appointments, NHS providers will make more robust plans to ensure contact is made_ review of EIP services in Birmingham and Solihull by the national clinical lead in the past month has determined that services are safe at present; Risk assessment: this needs to be available and of high quality 24 hours day, 7 days a week We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care. Provider and the CCG identify any cases where risk assessment has not been provided in a timely manner for patients and also investigate where the outcome of that risk assessment is inadequate_ This will be undertaken by the CCG and providers at established monthly quality review meetings. High quality care for all, now and for future generations will
Access to prevention services: there is a difference in opinion between the NHS and local authorities in what is deemed adequate provision of services for alcohol, drug and substance misuse and homelessness The CCG will be meeting the local authority to address this; External support to the system: stakeholders welcomed the support of the national Intensive Support team (IST) for mental health, mental health clinical networks and the West Midlands Clinical Senate_ These offers of support have already been made The Clinical network is currently providing support to review and plan services and the IST will be asked to provide support in December 2018, am therefore satisfied that all stakeholders in the provision and oversight of mental health services have taken the concerns you articulate seriously. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information_
Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding the above issues_ On November 12th 2018 NHS England received correspondence from the Birmingham and Solihull Clinical Commissioning Group (CCG) following a review of Regulation 28 letters and Provider responses_ The CCG noted that FTB had communicated a view that demand and funding were significant underlying issues; The view of BSHMFT also highlighted demand related issues but did not overtly articulate funding as an issue. The CCG commissions mental health services at Tier 1, 2 3 and 4 for adults and for Children and Young people (0-25 years of age), tiers 1,2 and 3 (with Tier commissioned by Specialised commissioners at NHS England): These services are commissioned from FTB and BSMHFT NHS England directly commissions specialised tier four inpatient mental health services for children and young people, specialised mental health services (e.g: eating disorders and services for the deaf), adult medium High quality care for all, now and for future generations the being
and high secure services, perinatal mental health, services for prisoners and services for the military and military veterans_ The CCG: Undertakes monthly contract review of its providers Since February 2018_ following an 'inadequate' rating by the Care Quality Commission of FTB, the CCG has led the development of a Quality Improvement Board to oversee and provide assurance on CQC improvement Action Plan and System Improvement Plan. Is confident in its quality assurance processes 3 Participates in strategic planning as part of the Sustainability and transformation partnership which has at its core an ambition to provide comprehensive and timely services, including a zero suicide ambition Proactively manages demand with series of initiatives to reduce unnecessary admissions and avoid delayed transfers of care, such that capacity can be optimally managed; 5_ Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to €4,611,000 for BSMHFT (3.7% increase) and E6,235,000 for FTB (22.6% increase) In 2018/19 the CCG provided additional investment in BSMHFT amounting to €3,117,000 (2.4% increase) and FTB amounting to E2,881,000 (9.3% increase): Further funding discussions are ongoing but at present the CCG is unable to validate a link between funding and the deaths presented. However, the CCG continuously monitors this position and demand in order to ensure it is responsive to any increase in demand where funding would be either the sole, or contributory solution: Undertakes mortality and incident review seriously and in line with national policy_ The coroners' letters have prompted comprehensive review of mortality and incident governance which will result in improved care quality and learning from incidents_ On November 14" 2018, all stakeholders involved in the commissioning, provision and regulatory oversight of mental health services in Birmingham and Solihull were convened at a 'deep dive' meeting: The summary of outcomes from this meeting are as follows - Oversight of strategic and operational issues: the CCG will lead the establishment of an oversight group which involved all stakeholders The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis. 2 Information sharing: it is clear that commissioners and providers are not always sharing or reviewing the same data and intelligence The CCG has established a governance framework which will enable more proactive management of quality and in particular, learning from significant events and mortality _ This will enable issues to escalate to the wider system more expeditiously_ A review of trends showed that there is not an observed increase in suicides compared with national figures which is reassuring, but all stakeholders agreed in the need to support a zero suicide ambition across health and social care although many individuals do not come into contact with mental health services prior to death; Strategic planning: It is clear that funding is not the sole issue responsible for the failures highlighted in the cases reviewed although funding for an extra 32 mental health beds has been made available by the CCG There are several areas of High quality care for all, now and for future generations
strategic planning which require attention_ Data sharing and more effective communication across commissioners and providers, and between providers is one area of concern: Secondly, there is significant workforce challenge here and now; not unique to Birmingham and Solihull; which needs articulating and planning for. Thirdly, whilst there is debate about whether there is sufficient capacity in the system, it is indisputable that pressure exists at times which results in acutely ill patients not having access to acute mental health beds_ Funding alone is not the issue but there is agreement that in order to answer the question of the likely attribution of funding constraint on risk within services all stakeholders need to be party to a shared demand analysis (with an extended invitation to partners from health and Justice, local authorities and schools) and a 'Suicide prevention strategy: The Demand analysis will be led by the CCG and the Suicide prevention strategy will be led by the Director of Public Health: Transformation: whilst we determine what is required to make services 'safe' in line with a shared definition of what 'safe' means, it was clear that the system has further ambition to excel. Work will be undertaken in the following areas Primary mental healthcare services (Le: services delivered in primary care under the auspices of a General Practitioner): it is clear there is limited access to mental health services in primary care and this will require assessment, Secondary mental healthcare (i.e_ that delivered in hospitals or specialised centres): planning for future demand and capacity_ Specialist mental health service support in acute physical illness: we agree that this needs to improve in order to support patients who end up in our Emergency Departments or downstream acute inpatient hospital beds Commissioning: collaboration between specialised and CCG commissioned services needs to improve in order to enable patients to see a seamless pathway of care There is now a commitment from the CCG and Specialised commissioning team to collaborate in services each commissions_ This will commence with meetings scheduled in December 2018_ Upstream interventions (i.e. prevention of risk factors which predispose to mental iIl-health): The West Midlands Combined Authority has ambition to address social determinants of health and has mental health strategy which needs to fully resonate with the NHS Delivery of mental health services: the cases reviewed demonstrate that at times, services are neither integrated nor responsive and it was accepted that this needs to improve with work in the following areas - Pathways of care, in particular for crisis care , early intervention in psychosis (EIP) and for children and young people, need to be clearly defined s0 that services are available, accessible and acquired. Where patients do not acquire services i.e_ failure to attend appointments, NHS providers will make more robust plans to ensure contact is made_ review of EIP services in Birmingham and Solihull by the national clinical lead in the past month has determined that services are safe at present; Risk assessment: this needs to be available and of high quality 24 hours day, 7 days a week We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care. Provider and the CCG identify any cases where risk assessment has not been provided in a timely manner for patients and also investigate where the outcome of that risk assessment is inadequate_ This will be undertaken by the CCG and providers at established monthly quality review meetings. High quality care for all, now and for future generations will
Access to prevention services: there is a difference in opinion between the NHS and local authorities in what is deemed adequate provision of services for alcohol, drug and substance misuse and homelessness The CCG will be meeting the local authority to address this; External support to the system: stakeholders welcomed the support of the national Intensive Support team (IST) for mental health, mental health clinical networks and the West Midlands Clinical Senate_ These offers of support have already been made The Clinical network is currently providing support to review and plan services and the IST will be asked to provide support in December 2018, am therefore satisfied that all stakeholders in the provision and oversight of mental health services have taken the concerns you articulate seriously. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information_
Response received
View full response
NHS Birmingham and Solihull Clinical Commissioning Group NHS Birmingham and Solihull CCG: Response to the Birmingham and Solihull Coroner's Regulation 28 reports to prevent future deaths Introduction
1.1 This report provides a response to the Birmingham and Solihull Coroner; in respect of the seven Regulation 28 reports issued to NHS Birmingham and Solihull Clinical Commissioning Group (the CCG): These reports relate to the deaths of: 3 12 The CCG has taken the opportunity, as part of this investigation, to review its broader quality assurance processes identify any learning outside the scope of the Regulation 28 reports. The CCG is aware that there are a number of other unexplained deathslpotential suicides, since the reports were received from the Coroner; which will be included into our analysis and further recommendations for action but which are excluded from this report 2 Background and context
2.1 On 05 October 2018, the CCG received seven Regulation 28 Reports to Prevent Future Deaths from the Birmingham and Solihull Coroner These deaths occurred over a four month period, between and August 2018. One of the deceased had been under the care of services provided by Forward Thinking Birmingham (FTB) at the time of their death, with the other six being under the care of services provided by Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT).
2.2 The Regulation 28 reports were accompanied by letters from the medical directors of BSMHFT and Birmingham Women's and Children's NHS Foundation Trust on behalf of FTB The letter from FTB highlighted pressures in mental health services, which they felt were caused by demand for services, coupled with a lack of funding: However, the letter from BSMHFT was explicit that they did not feel that funding was a contributing factor in these incidents_ and May
2.3 The CCG commissions a range of health services for the population of Birmingham and Solihull: For mental health, this includes tiers one, two and three mental health services for children and young people aged under 25, and tiers one, two, three and four for adults_
2.4 The CCG commissions mental health services from both FTB and BSMHFT. FTB provides mental health services for people aged under 25 years old through a consortium of providers, with the CCG holding a contract with Birmingham Women's and Children's NHS Foundation Trust as the main provider of these services_ BSMHFT provides mental health services for people aged 25 years old and over.
2.5 NHS England directly commissions specialised tier four inpatient mental health services for children and young people, specialised mental health services (e.g: eating disorders and services for the deaf) , adult medium and high secure . services, perinatal mental health; services for prisoners and services for the military and military veterans'_ 3 Contract management
3.1 The CCG commissions services from FTB and BSMHFT through NHS standard contracts. The standard contract sets out the required operational standards, as well as national and Iocal quality requirements_ Contracts and provider performance are monitored by the CCG through a range of reports and meetings which include:
3.1.1 Monthly contract review meetings, which include oversight of performance , activity and quality.
3.1.2 A range of contractual performance indicators and monthly andlor quarterly reports, which include data relating to patient experience, patient safety and clinical effectiveness_
3.1.3 In accordance with the NHS England Serious Incident Reporting Framework (2015), the reporting of serious incidents to the CCG within two days of the provider becoming aware that a serious incident has occurred:
3.1.44 Quarterly reporting from providers regarding their systems and processes for learning from deaths, as set out in the National Quality Board Publication: National Guidance on Learning from Deaths (2017)_ https:Iiwww england nhs uklcommissioninglwho-commissions-nhs-serviceslnhs-england/ key
3.1.5 In response to a Care Quality Commission (CQC) inspection report in February 2018 which found the FTB service to be inadequate? _ Quality Improvement Board was established to oversee and provide assurance on the delivery of their CQC Improvement Action Plan and also the System Improvement Plan
4. Quality monitoring
4.1 The CCG's approach to the management of quality is set in the Birmingham and Solihull Quality Strategy 2017-2018, which was approved in July
2017.
4.2 Serious incidents that are reported to the CCG are collated into a weekly report which is reviewed for trends issues that require escalation_ Matters that need to be addressed are raised through the monthly contract review meetings; thereafter any urgent concerns are raised with the relevant provider, as a matter of priority, at a senior level_
4.3 In addition to the direct monitoring of contracts, the CCG reports on the contract meetings through Quality and Safety Committee and Finance and Performance Committee, both of which are sub-committees of the CCG Governing Body and have Governing Body membership: The Quality and Safety Committee routinely receives a quality and safety integrated report This report analyses a number of quality indicators, including serious incidents, and highlights any areas of concern for discussion escalation if required:
4.,4 The CCG is a member of the NHS England West Midlands Quality Surveillance Group, covering Birmingham and the Black Country. The Group brings together different health and care partners, including the Care Quality Commission; NHS Improvement and Healthwatch: NHS England also operate a mortality leads meeting; which is attended by a representative of the CCG.
4.5 The CCG's independent internal auditors undertook a review of quality assurance mechanisms; which they reported in January 2018. This audit specifically reviewed the provider quality and performance review meetings in order to provide assurance that there were effective mechanisms in place to share recommendations, lessons learned and to monitor trends. The review concluded that there was 'significant assurance' that the mechanisms were appropriate and working effectively 5 Understanding and responding to capacity and demand
5.1 Since 2016, the CCG (both in the current form and as three former CCGs, prior to the Birmingham and Solihull CCG merger on 01 April 2018) has taken a Available at https JLwWW_cqc orguklproviderIRQ3inspection-summarylmhchildrenandyoung out and and
number of steps, with partner organisations, to understand and respond to concerns about capacity and demand within the local mental health system _
5.22 The CCG is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment: Part of this approach involves the CCG being an active partner in the Birmingham and Solihull Sustainability and Transformation Partnership (the STP), and the Mental Health Programme Delivery Board, The ambition of STP is to achieve sustainability, through a strong focus on prevention and recovery:
5.3 The Mental Health Programme Delivery Board's plan of action includes a range of initiatives to deliver measurable changes for mental health services. This includes reducing the number of patients being placed in inpatient units that are out of the local area to zero by 2021. The plan is jointly owned by the CCG, Birmingham Women's and Children's NHS Foundation Trust, BSMHFT , Solihull Metropolitan Borough Council and Birmingham City Council. A 'zero suicide' ambition has been committed to, which is led by the local authorities' respective public health teams. This ambition will be supported by evidence based, preventative action and high- quality crisis support, as well as reducing stigma around mental health and improving access through early intervention services_
5.4 To date; the CCG's response to the increase in demand for mental health services has included:
5.4.1 An independent system simulation modelling exercise; which was jointly commissioned with FTB and BSMHFT to develop an informed response on the best solutions to address the demand and where investment should be prioritised. This followed a sharp increase in demand for inpatient beds in 2016.
5.4.2 An independent review of patients' journeys into and out of inpatient mental health beds was commissioned by the STP. The review considered whether alternatives to admission have been used and whether patients stayed in hospital longer than necessary. The review found that in both cases; improvements could be made to help avoid unnecessary admissions and reduce the time taken to discharge patients_
5.4.3 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_
5.4.4 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. the could
5.4.5 Continuing to support the use of admissions to other NHS mental health trusts within the MERIT Vanguard? and to independent hospitals, where no locally commissioned beds are available, and an admission is deemed necessary:
5.4.6 evidence and data analysis to inform investment and approach.
5.4.7 Recognising that capacity is impacted by a wide range of factors and encouraging action at all levels across the mental health care pathway
5.4.8 In 2017/18 providing additional investment in mental health services above the contract value amounting to €4,611,000 for BSMHFT (3.7% increase) and 26,235,000 for FTB (22.6% increase) _
5.4.9 In 2018/19 providing additional investment in BSMHFT amounting to_ E3,117,000 (2.4% increase) and FTB amounting to E2,881,000 (9.3% increase)
5.4.10 This reflects growth of 3.03% in core mental health budgets, in accordance with the CCG s investment standard, which is above the national growth standard of 2.85%_ See annexes one and two for further information_
5.5 There are many further initiatives underway, which are underpinned by performance monitoring, to make real improvements to local services. These include:
5.,5.1 A number of discussions have taken place at contract level with FTB, regarding pressures on services and more patients accessing the service, and specifically the effect that this has had on inpatient care. As a result; there has been investment in the service over-and-above the contracted level, as detailed above_
5.5.1 The issue of funding was formally raised by FTB when they issued an activity query notice4 on 14 September 2018, after the initial €1.4million that was invested by the CCG at the start of the year had been spent This notice set out concerns about demand and capacity, in community (+10%) and inpatients (+1%) . This resulted in a meeting taking place on 20 September 2018 and an action plan being jointly developed. The MERIT Vanguard was supported Ihrough the Deparlment of Heallh New Models of Care Programme It is # partnership belween four NHS mental health providers in the Midlands (Birmingham and Solihull Mental Health NHS Foundation Trusk; Black Country Partnership NHS Foundalion Trust; Dudley and Walsall Menlal Heallh Partnership NHS Trust Coventry and Warvickshire Parlnership NHS Trust, The Vanguard has sought to improve crisis care through more Ilexible use of bed stock across ihe region and by seeking lo embed 'recovery princlples' in practice. This is a formal contractual clause in the NHS contract that is used when there are significant changes to activity planning and managerent processes, which require either party to alert the other if there have been unusual changes in activity or referrals and allow for either party to issue an activity query notice, leading to a joint activity review, activity management plan or utilisation review Using and
5.5.2 It is acknowledged; through contract review meetings; there have been informal decisions with BSMHFT about funding and capacity. However, this has not been raised formally with the CCG.
5.5.3 In October 2018 BSMHFT developed a proposal for funding, via the Solihull Local Transformation Plan fund; for additional investment in the Solihull Early Intervention Team: This is currently being progressed: 6_ Response to serious incident management
6.1 Serious incidents are managed in accordance with NHS England"'s serious incident reporting framework and are reported to the CCG by all providers, including FTB and BSMHFT, in accordance with the framework and their contractual requirements_
6.2 Reports are shared with key CCG staff, in real time, and considered through the CCGs Serious Incidents Group: Following the initial notification; the CCG can request an update at 72 hours on the immediate actions taken by the provider; and will be this for all reported deaths in the future:
6.3 Following initial management of the incident; the provider is required to submit a full root cause analysis (RCA) investigation report of the incident within 60 working days Each RCA is quality assured by the CCG, through a multidisciplinary panel review, before being signed off. To improve the quality of RCAs and learning from adverse events the CCG will convene a second tier panel, with specialist clinical input, for review of serious incidents requiring clinical expertise.
6.4 To further strengthen the process for managing RCAs the CCG will produce a weekly serious incident report, which will be circulated to a wider group of nominated CCG clinicians and senior staff. 6,5 The CCG was aware of all of the seven deaths highlighted by the Coroner AlI had been reported as serious incidents by FTB or BSMHFT_ To date, the CCG has received four RCAs, which were received within the required timescales_ However two of the RCAs have been referred back to the provider for additional work to be carried out; as the CCG was not satistied thal all of the learning opportunities had been identified to prevent a recurrence_ The remaining RCA reports are scheduled to be received by the CCG in November 2018, and will go through the same quality assurance process 6,6 On 25 September 2018, the CCG's Quality and Safety Committee received the integrated quality and safety report, as part of its regular oversight of provider performance_ The Committee identified there were & number of unexplained deathslpotential suicides, prior to receipt of the Coroners letter and Regulation 28 reports. The Committee raised questions as to whether BSMHFT was an outlier in the region: The Committee will continue to monitor the situation and make recommendations, as appropriate, in response to any quality issues or concerns_ doing
Should the investigation of these deaths reveal either a theme that needs to be addressed, Or safety issues arising from the individual investigations, the Committee will consider the specific problem and identify any required actions
6.7 In addition to the deaths that are the subject of the Regulation 28 reports; the CCG has become aware of a number of additional unexplained deathslpotential suicides; which are subject to current investigation; In response to this, the CCG's Medical Director and Chief Nurse held a meeting with the Medical Director of BSMHFT on 05 November 2018 to discuss BSMHFT's understanding of this and to also Iearn more about their oversight of risk assessments and care planning for patients who are not detained under the Mental Health Act: Conclusion
7.1 The CCG aspires to there being no avoidable deaths in Birmingham and Solihull and takes every reported unexplained death seriously. The CCG is continuously working with providers to improve the quality and safety of services, as well as looking at new and innovative ways to improve ali mental health services
7.2 The CCG has taken this opportunity to review the processes for managing serious incidents; but to also consider whether a shortage of funding may have contributed to these untimely deaths. The CCG has been unable to identify any correlation between funding and these deaths, 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_
7.3 The CCG recognises the need to take a multiagency approach to the prevention of deaths, including creating robust partnerships with mental health support services e.g: substance abuse services, community intervention and crisis management; The CCG must also ensure that inpatient beds are maximised and available for those who need them.
7.4 There is a system wide recognition of the need to improve access to early intervention in mental health services to prevent mental health difficulties escalating; to reduce pressure on crisis services and to improve flow through the system thereby freeing up capacity. Equally; there needs to be improvement in the mechanisms for transfer of patients from crisis care to community support and care.
7.5 The system wide mental health commissioning strategy should be revisited and updated to ensure that resources are focussed on early intervention and support, as well as supporting those transferred to or being treated within community services_
7.6 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_
7.7 The CCG will analyse the outstanding RCAs that will be received in the near future, in relation to these deaths, to ensure that all necessary actions are implemented: very
7.8 It is noted from the Coroner's letter and the Regulation 28 reports that under funding may be a contributing factor to these deaths: The CCG is still awaiting detailed investigation reports into all of the deaths However , at this stage there is no evidence that a lack of funding contributed to the deaths of the individuals concerned This has been confirmed by BSMHFT in their letter to the Coroner, dated 28 September 2018
7.9 Notwithstanding this, the CCG recognises that there has been increased demand for mental health services since 2016, and has responded to this additional pressure with increased funding and through working with the FTB, BSMHFT and the STP to look at different ways of working throughout system: The CCG will monitor the situation to ensure that all partnership working across Birmingham and Solihull is focussed on improving access and the quality of care_
7.10 The CCG has processes in place for monitoring and responding to individual serious incidents, as well as emerging trends and themes; which might indicate an underlying issue_ It is recognised; however; that there is always a need to continually Tearn and improve. As & result of this investigation the CCG has made a number of recommendations in relation to its monitoring systems, which are detailed in section eight:
7.11 The CCG has identitied a number of reported unexpected deathslpotential suicides in the period since the Regulation 28 reports have been issued, is actively working with FTB and BSMHFT to understand the root causes of these deaths and any contributory factors. In addition, the CCG will work to improve the broader understanding of the local area's position,_in terms of performance against comparable organisations, allowing for early identification of emerging changes in performance
7.12 As part of this review into the seven Regulation 28 reports, the CCG has identified a number of areas where processes can be improved and these have been incorporated into the recommendations below: These recommendations incorporate system wide improvements, beyond the immediate situation and reports, and are consistent with our aims for improving the quality and safety of services
7.13 The recommendations in this response should form part of the system'$ immediate response and longer term planning: 8 Recommendations
8.1 We intend to improve our learning from all mortality by implementing the following recommendations:
8.1.1 comprehensive review of the CCG's serious incident reporting policy; including how the CCG manages serious incidents from reporting through to the close down of actions_ This is to ensure that all actions to bring about improvements are implemented and there are clear early warning signs for director-led intervention. the and
8.1.2 Increasing primary care (general practice) reporting with clear guidance on when there should be escalation through the CCG's serious incident process _ This is to ensure that any deaths that occur outside of mental health services form part of the learning and review processes.
8.1.3 Undertaking an urgent review of the CCG's operational processes to ensure that appropriate and robust quality assurance mechanisms are in place:
8.1.4 Continuing to work with all providers, to address any deficiencies in RCA reports.
8.1.3 Improved scrutiny and challenge of learning from provider deaths processes_
8.1.5 Quantifying and understanding trends in mortality data ensuring that there is a system in place for early identification of significant variation; which can be reported through the CCG's quality reports_
8.1,6 Ongoing monitoring of statistical data, which allows comparison with other similar organisations, in order to identify outliers
8.1.7 Triangulation, with qualitative reviews, of mortality undertaken by individual organisations.
8.1.8 Improving communication and information sharing with oversight and regulatory bodies, to ensure that all relevant sources of information are used for early identification of emerging issues. This will include closer working with the Coroner; NHS England; Care Quality Commission, NHS Improvement and Health Education England.
8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced:
8.1.10 Updating the system wide mental health commissioning strategy, including developing plans to reduce fragmentation of services and to ensure care is delivered in the most appropriate setting:
8.1.11 Working with our Local Authorities to ensure a suicide prevention strategy and plan is approved and implemented.
8.1.12 Ensuring action plans relating to learning from deaths and improvement plans tor managing demand and capacily are incorporated into contracts as service delivery improvement plans_
8.1.13 The CCG, BSMHFT and FTB will work with the National Mental Health Support Team to undertake a diagnostic review of early help and intervention services, and thereafter develop a plan to address any issues raised: and
Annex 1: Key milestones July 2016 to October 2018 July 2016 Paper discussed at Mental Health System Strategy Board- this set out the issues in relation to capacity in the mental health system and proposed the joint commissioning an independent system simulation modelling exercise, to develop an informed response on the best solutions to address the demand and where investment should be prioritised. Oct 2016 Mental Health Strategies are commissioned to undertake the system simulation modelling exercise. Feb 2017 Interim report produced by Mental Health Strategies. E420,000 investment in community based personality disorder service , provided by BSMHFT. 2017 Final report produced by Mental Health Strategies, including key recommendations May 2017 Programme of work initiated, in response to recommendations: July 2017 Additional inpatient bed capacity commissioned (investment of E2.44million BSMHFT and E2.56million FTB) Nov 2017 Additional 32 bed capacity is mobilised via BSMHFT , for adults aged 18+ Dec 2017 Changes to the Code of Practice to reduce detention under Section 136 of the Mental Health Act from 72 to 24 hours_ Jan 2018 E312,000 per annum recurrent investment in FTB to fund new pathway for people with a diagnosis of personality disorder and included funding for a clinical lead for personality disorder: Feb 2018 CQC report published on FTB. April 2018 Additional €700,000 invested in FTB community provision and further €1.4million investment above contract value in 2018/19 E60,000 invested recurrently in BSMHFT , to appoint a clinical lead for personality disorder . E110,000 non-recurrent investment across BSMHFT and FTB to test a model of primary care liaison to reduce referrals into secondary care June 2018 BSMHFT raise concerns about capacity verbally at Contract Review Group meeting (CRG): No further action taken by BSMHFT. Sept 2018 CCG identify funds to increase staffing ratio in 'step up step down' provision with Servol (voluntary care service) to accept a wider range of patients_ 10 May
Sept 2018 Report to Programme Delivery Board detailing limited progress in relation to some key recommendations of system simulation report: Sept 2018 FTB Issue Activity Query Notice (AQN}: CCG meet with FTB to discuss AQN. Oct 2018 BSMHFT submit request for additional investment of 2325,000 in Solihull Early Intervention Service per annum , via CRG meeting on 26 October 2018_ 11
Annex 2 Increase in funding for BSMHFT BSMHFT EOOO's Increase Baseline 2017-18 (inc CQUIN) 124,885 Inpatient Capacity 2,119 7% Other Investments 2,492
2.0% Total Investment 2017-18 129,496
3.7% Baseline 2018-19 (inc CQUIN) 128,654 Inpatient Capacity 1,633
1.3% Other Investments 1,484 1,2% Total Investment 2018-19 131,771
2.4% Increase in funding for FTB FTB E000's Increase Baseline 2017-18 (inc CQUIN) 27,586 Inpatient Capacity 4,254
15.4% Other Investments 1,981
7.2% Total Investment 2017-18 33,821
22.6% FTB EO0O's Increase Baseline 2018-19 (inc CQUIN) 30,889 Inpatient Capacity
0.0% Other Investments 2,881
9.3% Total Investment 2017-18 33,770
9.3% 12
1.1 This report provides a response to the Birmingham and Solihull Coroner; in respect of the seven Regulation 28 reports issued to NHS Birmingham and Solihull Clinical Commissioning Group (the CCG): These reports relate to the deaths of: 3 12 The CCG has taken the opportunity, as part of this investigation, to review its broader quality assurance processes identify any learning outside the scope of the Regulation 28 reports. The CCG is aware that there are a number of other unexplained deathslpotential suicides, since the reports were received from the Coroner; which will be included into our analysis and further recommendations for action but which are excluded from this report 2 Background and context
2.1 On 05 October 2018, the CCG received seven Regulation 28 Reports to Prevent Future Deaths from the Birmingham and Solihull Coroner These deaths occurred over a four month period, between and August 2018. One of the deceased had been under the care of services provided by Forward Thinking Birmingham (FTB) at the time of their death, with the other six being under the care of services provided by Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT).
2.2 The Regulation 28 reports were accompanied by letters from the medical directors of BSMHFT and Birmingham Women's and Children's NHS Foundation Trust on behalf of FTB The letter from FTB highlighted pressures in mental health services, which they felt were caused by demand for services, coupled with a lack of funding: However, the letter from BSMHFT was explicit that they did not feel that funding was a contributing factor in these incidents_ and May
2.3 The CCG commissions a range of health services for the population of Birmingham and Solihull: For mental health, this includes tiers one, two and three mental health services for children and young people aged under 25, and tiers one, two, three and four for adults_
2.4 The CCG commissions mental health services from both FTB and BSMHFT. FTB provides mental health services for people aged under 25 years old through a consortium of providers, with the CCG holding a contract with Birmingham Women's and Children's NHS Foundation Trust as the main provider of these services_ BSMHFT provides mental health services for people aged 25 years old and over.
2.5 NHS England directly commissions specialised tier four inpatient mental health services for children and young people, specialised mental health services (e.g: eating disorders and services for the deaf) , adult medium and high secure . services, perinatal mental health; services for prisoners and services for the military and military veterans'_ 3 Contract management
3.1 The CCG commissions services from FTB and BSMHFT through NHS standard contracts. The standard contract sets out the required operational standards, as well as national and Iocal quality requirements_ Contracts and provider performance are monitored by the CCG through a range of reports and meetings which include:
3.1.1 Monthly contract review meetings, which include oversight of performance , activity and quality.
3.1.2 A range of contractual performance indicators and monthly andlor quarterly reports, which include data relating to patient experience, patient safety and clinical effectiveness_
3.1.3 In accordance with the NHS England Serious Incident Reporting Framework (2015), the reporting of serious incidents to the CCG within two days of the provider becoming aware that a serious incident has occurred:
3.1.44 Quarterly reporting from providers regarding their systems and processes for learning from deaths, as set out in the National Quality Board Publication: National Guidance on Learning from Deaths (2017)_ https:Iiwww england nhs uklcommissioninglwho-commissions-nhs-serviceslnhs-england/ key
3.1.5 In response to a Care Quality Commission (CQC) inspection report in February 2018 which found the FTB service to be inadequate? _ Quality Improvement Board was established to oversee and provide assurance on the delivery of their CQC Improvement Action Plan and also the System Improvement Plan
4. Quality monitoring
4.1 The CCG's approach to the management of quality is set in the Birmingham and Solihull Quality Strategy 2017-2018, which was approved in July
2017.
4.2 Serious incidents that are reported to the CCG are collated into a weekly report which is reviewed for trends issues that require escalation_ Matters that need to be addressed are raised through the monthly contract review meetings; thereafter any urgent concerns are raised with the relevant provider, as a matter of priority, at a senior level_
4.3 In addition to the direct monitoring of contracts, the CCG reports on the contract meetings through Quality and Safety Committee and Finance and Performance Committee, both of which are sub-committees of the CCG Governing Body and have Governing Body membership: The Quality and Safety Committee routinely receives a quality and safety integrated report This report analyses a number of quality indicators, including serious incidents, and highlights any areas of concern for discussion escalation if required:
4.,4 The CCG is a member of the NHS England West Midlands Quality Surveillance Group, covering Birmingham and the Black Country. The Group brings together different health and care partners, including the Care Quality Commission; NHS Improvement and Healthwatch: NHS England also operate a mortality leads meeting; which is attended by a representative of the CCG.
4.5 The CCG's independent internal auditors undertook a review of quality assurance mechanisms; which they reported in January 2018. This audit specifically reviewed the provider quality and performance review meetings in order to provide assurance that there were effective mechanisms in place to share recommendations, lessons learned and to monitor trends. The review concluded that there was 'significant assurance' that the mechanisms were appropriate and working effectively 5 Understanding and responding to capacity and demand
5.1 Since 2016, the CCG (both in the current form and as three former CCGs, prior to the Birmingham and Solihull CCG merger on 01 April 2018) has taken a Available at https JLwWW_cqc orguklproviderIRQ3inspection-summarylmhchildrenandyoung out and and
number of steps, with partner organisations, to understand and respond to concerns about capacity and demand within the local mental health system _
5.22 The CCG is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment: Part of this approach involves the CCG being an active partner in the Birmingham and Solihull Sustainability and Transformation Partnership (the STP), and the Mental Health Programme Delivery Board, The ambition of STP is to achieve sustainability, through a strong focus on prevention and recovery:
5.3 The Mental Health Programme Delivery Board's plan of action includes a range of initiatives to deliver measurable changes for mental health services. This includes reducing the number of patients being placed in inpatient units that are out of the local area to zero by 2021. The plan is jointly owned by the CCG, Birmingham Women's and Children's NHS Foundation Trust, BSMHFT , Solihull Metropolitan Borough Council and Birmingham City Council. A 'zero suicide' ambition has been committed to, which is led by the local authorities' respective public health teams. This ambition will be supported by evidence based, preventative action and high- quality crisis support, as well as reducing stigma around mental health and improving access through early intervention services_
5.4 To date; the CCG's response to the increase in demand for mental health services has included:
5.4.1 An independent system simulation modelling exercise; which was jointly commissioned with FTB and BSMHFT to develop an informed response on the best solutions to address the demand and where investment should be prioritised. This followed a sharp increase in demand for inpatient beds in 2016.
5.4.2 An independent review of patients' journeys into and out of inpatient mental health beds was commissioned by the STP. The review considered whether alternatives to admission have been used and whether patients stayed in hospital longer than necessary. The review found that in both cases; improvements could be made to help avoid unnecessary admissions and reduce the time taken to discharge patients_
5.4.3 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_
5.4.4 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. the could
5.4.5 Continuing to support the use of admissions to other NHS mental health trusts within the MERIT Vanguard? and to independent hospitals, where no locally commissioned beds are available, and an admission is deemed necessary:
5.4.6 evidence and data analysis to inform investment and approach.
5.4.7 Recognising that capacity is impacted by a wide range of factors and encouraging action at all levels across the mental health care pathway
5.4.8 In 2017/18 providing additional investment in mental health services above the contract value amounting to €4,611,000 for BSMHFT (3.7% increase) and 26,235,000 for FTB (22.6% increase) _
5.4.9 In 2018/19 providing additional investment in BSMHFT amounting to_ E3,117,000 (2.4% increase) and FTB amounting to E2,881,000 (9.3% increase)
5.4.10 This reflects growth of 3.03% in core mental health budgets, in accordance with the CCG s investment standard, which is above the national growth standard of 2.85%_ See annexes one and two for further information_
5.5 There are many further initiatives underway, which are underpinned by performance monitoring, to make real improvements to local services. These include:
5.,5.1 A number of discussions have taken place at contract level with FTB, regarding pressures on services and more patients accessing the service, and specifically the effect that this has had on inpatient care. As a result; there has been investment in the service over-and-above the contracted level, as detailed above_
5.5.1 The issue of funding was formally raised by FTB when they issued an activity query notice4 on 14 September 2018, after the initial €1.4million that was invested by the CCG at the start of the year had been spent This notice set out concerns about demand and capacity, in community (+10%) and inpatients (+1%) . This resulted in a meeting taking place on 20 September 2018 and an action plan being jointly developed. The MERIT Vanguard was supported Ihrough the Deparlment of Heallh New Models of Care Programme It is # partnership belween four NHS mental health providers in the Midlands (Birmingham and Solihull Mental Health NHS Foundation Trusk; Black Country Partnership NHS Foundalion Trust; Dudley and Walsall Menlal Heallh Partnership NHS Trust Coventry and Warvickshire Parlnership NHS Trust, The Vanguard has sought to improve crisis care through more Ilexible use of bed stock across ihe region and by seeking lo embed 'recovery princlples' in practice. This is a formal contractual clause in the NHS contract that is used when there are significant changes to activity planning and managerent processes, which require either party to alert the other if there have been unusual changes in activity or referrals and allow for either party to issue an activity query notice, leading to a joint activity review, activity management plan or utilisation review Using and
5.5.2 It is acknowledged; through contract review meetings; there have been informal decisions with BSMHFT about funding and capacity. However, this has not been raised formally with the CCG.
5.5.3 In October 2018 BSMHFT developed a proposal for funding, via the Solihull Local Transformation Plan fund; for additional investment in the Solihull Early Intervention Team: This is currently being progressed: 6_ Response to serious incident management
6.1 Serious incidents are managed in accordance with NHS England"'s serious incident reporting framework and are reported to the CCG by all providers, including FTB and BSMHFT, in accordance with the framework and their contractual requirements_
6.2 Reports are shared with key CCG staff, in real time, and considered through the CCGs Serious Incidents Group: Following the initial notification; the CCG can request an update at 72 hours on the immediate actions taken by the provider; and will be this for all reported deaths in the future:
6.3 Following initial management of the incident; the provider is required to submit a full root cause analysis (RCA) investigation report of the incident within 60 working days Each RCA is quality assured by the CCG, through a multidisciplinary panel review, before being signed off. To improve the quality of RCAs and learning from adverse events the CCG will convene a second tier panel, with specialist clinical input, for review of serious incidents requiring clinical expertise.
6.4 To further strengthen the process for managing RCAs the CCG will produce a weekly serious incident report, which will be circulated to a wider group of nominated CCG clinicians and senior staff. 6,5 The CCG was aware of all of the seven deaths highlighted by the Coroner AlI had been reported as serious incidents by FTB or BSMHFT_ To date, the CCG has received four RCAs, which were received within the required timescales_ However two of the RCAs have been referred back to the provider for additional work to be carried out; as the CCG was not satistied thal all of the learning opportunities had been identified to prevent a recurrence_ The remaining RCA reports are scheduled to be received by the CCG in November 2018, and will go through the same quality assurance process 6,6 On 25 September 2018, the CCG's Quality and Safety Committee received the integrated quality and safety report, as part of its regular oversight of provider performance_ The Committee identified there were & number of unexplained deathslpotential suicides, prior to receipt of the Coroners letter and Regulation 28 reports. The Committee raised questions as to whether BSMHFT was an outlier in the region: The Committee will continue to monitor the situation and make recommendations, as appropriate, in response to any quality issues or concerns_ doing
Should the investigation of these deaths reveal either a theme that needs to be addressed, Or safety issues arising from the individual investigations, the Committee will consider the specific problem and identify any required actions
6.7 In addition to the deaths that are the subject of the Regulation 28 reports; the CCG has become aware of a number of additional unexplained deathslpotential suicides; which are subject to current investigation; In response to this, the CCG's Medical Director and Chief Nurse held a meeting with the Medical Director of BSMHFT on 05 November 2018 to discuss BSMHFT's understanding of this and to also Iearn more about their oversight of risk assessments and care planning for patients who are not detained under the Mental Health Act: Conclusion
7.1 The CCG aspires to there being no avoidable deaths in Birmingham and Solihull and takes every reported unexplained death seriously. The CCG is continuously working with providers to improve the quality and safety of services, as well as looking at new and innovative ways to improve ali mental health services
7.2 The CCG has taken this opportunity to review the processes for managing serious incidents; but to also consider whether a shortage of funding may have contributed to these untimely deaths. The CCG has been unable to identify any correlation between funding and these deaths, 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_
7.3 The CCG recognises the need to take a multiagency approach to the prevention of deaths, including creating robust partnerships with mental health support services e.g: substance abuse services, community intervention and crisis management; The CCG must also ensure that inpatient beds are maximised and available for those who need them.
7.4 There is a system wide recognition of the need to improve access to early intervention in mental health services to prevent mental health difficulties escalating; to reduce pressure on crisis services and to improve flow through the system thereby freeing up capacity. Equally; there needs to be improvement in the mechanisms for transfer of patients from crisis care to community support and care.
7.5 The system wide mental health commissioning strategy should be revisited and updated to ensure that resources are focussed on early intervention and support, as well as supporting those transferred to or being treated within community services_
7.6 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_
7.7 The CCG will analyse the outstanding RCAs that will be received in the near future, in relation to these deaths, to ensure that all necessary actions are implemented: very
7.8 It is noted from the Coroner's letter and the Regulation 28 reports that under funding may be a contributing factor to these deaths: The CCG is still awaiting detailed investigation reports into all of the deaths However , at this stage there is no evidence that a lack of funding contributed to the deaths of the individuals concerned This has been confirmed by BSMHFT in their letter to the Coroner, dated 28 September 2018
7.9 Notwithstanding this, the CCG recognises that there has been increased demand for mental health services since 2016, and has responded to this additional pressure with increased funding and through working with the FTB, BSMHFT and the STP to look at different ways of working throughout system: The CCG will monitor the situation to ensure that all partnership working across Birmingham and Solihull is focussed on improving access and the quality of care_
7.10 The CCG has processes in place for monitoring and responding to individual serious incidents, as well as emerging trends and themes; which might indicate an underlying issue_ It is recognised; however; that there is always a need to continually Tearn and improve. As & result of this investigation the CCG has made a number of recommendations in relation to its monitoring systems, which are detailed in section eight:
7.11 The CCG has identitied a number of reported unexpected deathslpotential suicides in the period since the Regulation 28 reports have been issued, is actively working with FTB and BSMHFT to understand the root causes of these deaths and any contributory factors. In addition, the CCG will work to improve the broader understanding of the local area's position,_in terms of performance against comparable organisations, allowing for early identification of emerging changes in performance
7.12 As part of this review into the seven Regulation 28 reports, the CCG has identified a number of areas where processes can be improved and these have been incorporated into the recommendations below: These recommendations incorporate system wide improvements, beyond the immediate situation and reports, and are consistent with our aims for improving the quality and safety of services
7.13 The recommendations in this response should form part of the system'$ immediate response and longer term planning: 8 Recommendations
8.1 We intend to improve our learning from all mortality by implementing the following recommendations:
8.1.1 comprehensive review of the CCG's serious incident reporting policy; including how the CCG manages serious incidents from reporting through to the close down of actions_ This is to ensure that all actions to bring about improvements are implemented and there are clear early warning signs for director-led intervention. the and
8.1.2 Increasing primary care (general practice) reporting with clear guidance on when there should be escalation through the CCG's serious incident process _ This is to ensure that any deaths that occur outside of mental health services form part of the learning and review processes.
8.1.3 Undertaking an urgent review of the CCG's operational processes to ensure that appropriate and robust quality assurance mechanisms are in place:
8.1.4 Continuing to work with all providers, to address any deficiencies in RCA reports.
8.1.3 Improved scrutiny and challenge of learning from provider deaths processes_
8.1.5 Quantifying and understanding trends in mortality data ensuring that there is a system in place for early identification of significant variation; which can be reported through the CCG's quality reports_
8.1,6 Ongoing monitoring of statistical data, which allows comparison with other similar organisations, in order to identify outliers
8.1.7 Triangulation, with qualitative reviews, of mortality undertaken by individual organisations.
8.1.8 Improving communication and information sharing with oversight and regulatory bodies, to ensure that all relevant sources of information are used for early identification of emerging issues. This will include closer working with the Coroner; NHS England; Care Quality Commission, NHS Improvement and Health Education England.
8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced:
8.1.10 Updating the system wide mental health commissioning strategy, including developing plans to reduce fragmentation of services and to ensure care is delivered in the most appropriate setting:
8.1.11 Working with our Local Authorities to ensure a suicide prevention strategy and plan is approved and implemented.
8.1.12 Ensuring action plans relating to learning from deaths and improvement plans tor managing demand and capacily are incorporated into contracts as service delivery improvement plans_
8.1.13 The CCG, BSMHFT and FTB will work with the National Mental Health Support Team to undertake a diagnostic review of early help and intervention services, and thereafter develop a plan to address any issues raised: and
Annex 1: Key milestones July 2016 to October 2018 July 2016 Paper discussed at Mental Health System Strategy Board- this set out the issues in relation to capacity in the mental health system and proposed the joint commissioning an independent system simulation modelling exercise, to develop an informed response on the best solutions to address the demand and where investment should be prioritised. Oct 2016 Mental Health Strategies are commissioned to undertake the system simulation modelling exercise. Feb 2017 Interim report produced by Mental Health Strategies. E420,000 investment in community based personality disorder service , provided by BSMHFT. 2017 Final report produced by Mental Health Strategies, including key recommendations May 2017 Programme of work initiated, in response to recommendations: July 2017 Additional inpatient bed capacity commissioned (investment of E2.44million BSMHFT and E2.56million FTB) Nov 2017 Additional 32 bed capacity is mobilised via BSMHFT , for adults aged 18+ Dec 2017 Changes to the Code of Practice to reduce detention under Section 136 of the Mental Health Act from 72 to 24 hours_ Jan 2018 E312,000 per annum recurrent investment in FTB to fund new pathway for people with a diagnosis of personality disorder and included funding for a clinical lead for personality disorder: Feb 2018 CQC report published on FTB. April 2018 Additional €700,000 invested in FTB community provision and further €1.4million investment above contract value in 2018/19 E60,000 invested recurrently in BSMHFT , to appoint a clinical lead for personality disorder . E110,000 non-recurrent investment across BSMHFT and FTB to test a model of primary care liaison to reduce referrals into secondary care June 2018 BSMHFT raise concerns about capacity verbally at Contract Review Group meeting (CRG): No further action taken by BSMHFT. Sept 2018 CCG identify funds to increase staffing ratio in 'step up step down' provision with Servol (voluntary care service) to accept a wider range of patients_ 10 May
Sept 2018 Report to Programme Delivery Board detailing limited progress in relation to some key recommendations of system simulation report: Sept 2018 FTB Issue Activity Query Notice (AQN}: CCG meet with FTB to discuss AQN. Oct 2018 BSMHFT submit request for additional investment of 2325,000 in Solihull Early Intervention Service per annum , via CRG meeting on 26 October 2018_ 11
Annex 2 Increase in funding for BSMHFT BSMHFT EOOO's Increase Baseline 2017-18 (inc CQUIN) 124,885 Inpatient Capacity 2,119 7% Other Investments 2,492
2.0% Total Investment 2017-18 129,496
3.7% Baseline 2018-19 (inc CQUIN) 128,654 Inpatient Capacity 1,633
1.3% Other Investments 1,484 1,2% Total Investment 2018-19 131,771
2.4% Increase in funding for FTB FTB E000's Increase Baseline 2017-18 (inc CQUIN) 27,586 Inpatient Capacity 4,254
15.4% Other Investments 1,981
7.2% Total Investment 2017-18 33,821
22.6% FTB EO0O's Increase Baseline 2018-19 (inc CQUIN) 30,889 Inpatient Capacity
0.0% Other Investments 2,881
9.3% Total Investment 2017-18 33,770
9.3% 12
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
Report Sections
Investigation and Inquest
On 28/06/2018 commenced an investigation into the death of Michael William Cooper: The investigation concluded at the end of an inquest on 26th September 2018. The conclusion of the inquest was Suicide contributed to by neglect:
Circumstances of the Death
The Deceased was found dead as result ofa ligature around the neck at his home address on the 22nd June 2018. He had been assessed by a psychiatrist on the 22nd 2018 when it was evident he was at high risk of suicide and a plan was made for close follow up but he was not reviewed face to face thereafter despite a medication change: He had telephone contact with his care coordinator on the 7th June when his comments and situation indicated a high risk of suicide and no immediate action was taken: The absence of continued support and monitoring after the Z2nd have caused a deterioration in Mr: Cooper's mental health contributing to his suicide Following a post mortem the medical cause of death was determined to be: a) CONSTRICTION BY LIGATURE AROUND THE NECK
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