Birmingham Council Background This response is provided by Birmingham Council (BCC) in response to the regulation 28 report to Prevent Future Deaths, dated the 22nd July 2019, made by Louise Hunt; Senior Coroner for Birmingham and Solihull areas, under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations
2013. This report was made following an Inquest touching upon the death of. Mr Richard Patrick Carlon: BCC was not an Interested Person and took no part in the Inquest: Mr Carlon died on the 14th December 2018. The conclusion of the Inquest on 22nd July 2019 was Suicide_ At the outset of this response, the Local Authority expresses its deepest condolences to the family of Mr Carlon: The matter of concern relating to BCC was that no Approved Mental Health Professional (AMHP) was available to make the requested Mental Health Act Assessment (MHAA) of Mr Carlon in the early hours of the 14th November 2018, the Coroner having been told that this was an ongoing problem and was delaying assessments. It is understood that in delivering her findings of fact; the Coroner stated in the inquest that had the MHAA taken place it would not have changed the outcome for Mr Carlon_ AMHP resources and decisions made on the 14th November 2018 At 00.17am on the November 2018 a referral was received, by BCC's Emergency Duty Team, requesting MHAA be undertaken in respect of Mr Carlon, who was at the time awaiting assessment in the Accident and Emergency (A&E) department at the Heartlands Hospital. There was at the time no completed Medical Recommendation' nor an available psychiatric bed MHAA is usually initiated with the provision of a first medical recommendation confirming that the patient is suffering from a mental disorder of a nature or degree which' either 'warrants the detention of the patient in hospital for assessment" (Section 2) or 'makes it appropriate for the patient to receive medical treatment in hospital' (Section 3). (The Mental Health Act 1983: Criteria for detention Royal College of Psychiatrists 22.01.2018) To provide some context on the management criteria in cases such as this: All MHAA referrals are screened and prioritised and as Mr Carlon was in hospital setting therefore deemed to be in place of safety. In situations like this where the service is in receipt of multiple referrals the priority would always be those in the community or those individuals in police custody presenting a risk to themselves and the public. Where an individual may appear to be under the influence of alcohol or decision to defer assessment is always made (as per Mental Health Act 1983) until the person is no longer under influence of substances. The reason is that the influence of the substances affects the outcome of the assessments_ The Out of Hours AMHP service is part of BCCs Emergency Duty cover: Mr Carlon was not an emergency due to being in a place of safety and hence a decision was made to pass the referral to the day time AMHP service. This was communicated to the Heartlands_ City" City 14th drugs, the

Birmingham Council On the 14t November 2018 at
10.51 AM, when the time service contacted the Heartlands hospital Mr Carlon was cooperating with Mental Health Service and a MHAA was not required_ There was a further MHAA referral on the night of the 14th November 2018, a MHAA was undertaken by a BCC AMHP, and an application for admission under the Mental Health Act (MHA) was not required as Mr Carlon agreed to an informal admission. The MHA requires the 'Least Restrictive' option to be undertaken; this was deemed to be an informal admission on this occasion: Mr Carlon left the hospital on the 15th November 2018, there was no request received for a MHAA following this_ Mr Carlon subsequently stepped in front of a motor vehicle on the 16th November 2018 and died from his injuries on the 14lh December 2018. AMHP availability In response to the ongoing issue of AMHP availability leading to delays in assessments, below is brief synopsis of the process adopted and the work currently being undertaken by BCC to about improvements around the availability of the AMHP service. If Local Social Services have reason to think that an application for admission to hospital or guardianship application may need to be made in respect of patient within their area_ shall make arrangements for an approved mental health professional to consider the patient's case on their behalf (Mental Health Act 1983, Section 13). If the AMHP then determines that MHAA is needed will coordinate and undertake the MHAA. This should be done in a timely manner: The coordination role involves the AMHP being multi agency dependant It is this that will often impact on time scales for MHAAs being completed rather than availability of AMHPs who may well be coordinating MHAAs and chasing up partner agencies_ The availability of partner agency resources as opposed to AMHP prioritisation decisions by AMHPs and partners, can involve people undergoing more than one MHAA before resources become available to allow a suitable outcome_ The consideration and coordination will involve prioritisation of cases The AMHP has the responsibility to coordinate the MHAA, including partner resources, but does not have the authority to prioritise partner resources The current model of AMHP service delivery is reviewed by BCC. Attached to this response is a statement that provides detailed information on the steps that will be taken to improve the service_ The to the successful delivery of this plan with be joint working with all partners_ project board meeting which serves as governance body for the improvement work around the AMHP service in Birmingham was held on 11th September 2019. The board reviewed the plan providing solutions to system wide issues impacting the work of the AMHPs_ It should be reiterated that the review identified a total of 60 areas for improvement and 20 of these were related to whole systems partnership working: City" day bring they they being key

Birmingham Council In the main these consisted of strategic level actions that addressed the longer-term issues needed to bring about sustainable improvements to the system: Some of the actions were linked to commissioning of'urgent beds for both Adults and Children and Young People and developing a clear urgent care pathway for Birmingham: From an operational perspective the board considered adopting an information sharing system developed by Birmingham Council for Voluntary Services to help manage the cohort of indivviduals who frequently present with multiple and complex needs The idea would be that any service that the individual comes into work with will have the ability to access history and records for the individual including information about homelessness and access to services such as drug and alcohol, make referrals to other services and review outcomes and risks. The other area that was agreed on was workshop being held to agree improved joint working between the Mental Health Trust and the AMHP service This workshop will be set up very shortly: The board has agreed to meet on monthly basis and will become the vehicle for overseeing the improvement work There is a commitment to drive forward the improvements that have been identified as vital, to ensuring a better whole system, improved partnership working and preventing tragedies such as this occurring in the future_ Signed: Title: Dnecicrei Eeshcodo (on bzhuly % EbeceFve ) Date; 214 |2614 City " key Eke Nesh

Dear Sir or Madam, Mr Richard Carlon Please accept our apologies for the delayed response_ In response to paragraph 5.2 of the report; West Midlands Police has reviewed the practical application of the new 'Missing Persons Authorised Professional Practice' , implemented in May 2019 As part of this review, it has been agreed that WMP Call Handlers will receive further guidance on the management of calls, and the subsequent procedures involved in incident grading and management: As part of this it has been agreed that West Midlands Police will ensure any caller is updated when missing person has been located to allow further contact between parties This may not always mean full details of whereabouts are disclosed (as individual cases may prevent this from being appropriate) however , the reasons for this will be recorded and explained in each case. Notwithstanding the above, West Midlands Police will ensure the caller is updated in each case. Timescales for full implementation are by November 2019. We apologise again for the delayed response and hope the above assists however, please do not hesitate to contact us should the Coroner have any queries whatsoever.