Dear Mr Bennett,

Re: Prevention of Future deaths Philip Malone

Thank you for your Prevention of Future Death’s report (PFD) dated 23 November 2023. I am sorry that you have felt it necessary to issue this against the Trust. I attach a copy of the previous two responses for similar PFD’s, highlighting the work that is being carried out by the Trust along with the ICB to try and ensure that patients are allocated a bed as soon as possible, when this is required.

I would like to take this opportunity to explain that whilst many steps are being taken to address the matter of bed availability, the solution is very much reliant on our system partners as well. We are continuing to work closely with them . As you state within your PFD Report; this is a national problem. The Trust is therefore taking all available steps, within its power, in order to minimise and reduce the risks associated with this issue. I understand that in making the decision around the PFD at inquest you expressed that you took into account that multiple PFDs reports have already been issued, but in your view the volume of reports and repetition of issuing further reports is tangible and the fact that another report is being issued may contribute. I would like to express that the issuing of PFDs has not directly influenced the on going work the Trust has been undertaking for some time on this matter and we remain committed to do all we can to develop capacity and pathways that enable us to meet the needs of our population within the resources we have available to us.

However, in order to offer further assurances I would like to update you on some of the work referred to in our previous attached letters. Since then we have made significant progress in providing timely access for patients who require an inpatinet admission and have outlined the processes taken since April.

Birmingham and Solihull NHS Foundation Trust commissioned the services of Grant Thornton Consultancy to work with us on a specific 12-month project to address the issue of local bed shortages

2 and the over-reliance on referring patients to private out of area hospital beds that are scattered across the country. The three main drivers to enable overall progress in accessing local timely beds has been:
1. Managing demand and admissions
2. Improving patient flow (by reducing length of stay and delayed transfers of care)
3. Increasing bed base capacity locally. The programme concluded in the summer of 2023 with the recommendation that two core workstreams are developed and delivered to improve bed capacity, namely:

1. Locality model working Throughout autumn 2023 we have had a dedicated project group leading the locality model work. This model described linking specific local hospital mental health beds to dedicated local home treatment teams, community mental health teams and local communities. It means that instead of patients being placed onto a generic bed waiting list, there is a local home treatment team and local hospital ward team working together to support prioritisation of admission to hospital based upon clinical risk and need.

2. Gatekeeping National mental health policy has for many years advocated home treatment teams leading on the gatekeeping function of acute mental health admissions. This process had been less rigidly adhered to in recent years for a variety of reasons. In response to the recommendations from the Grant Thornton project work, alongside the locality working we have developed processes to improve gatekeeping of acute admissions. Within core hours this is now a routine part of clinical decision making for admission. Overnight and at weekends it is not currently operationally possible, however processes have been developed and are currently being agreed to support how routine acute admissions will come through home treatment teams and urgent admissions out of hours will remain with on-call and urgent care services for the time being. Additional processes are also in place however, such as the 5-point plan framework which requires a level of clinical scrutiny when ensuring that admissions are appropriate and clinically necessary.

Progress to date The Trust has been tracking clinical activity as part of the project and we have been able to demonstrate the following:
i. We have been able to place less patients into “inappropriate out of area” beds situated across the country. This results in care closer to home with a better patient experience and greater continuity on the care pathway (See appendix 1)
ii. The percentage of admissions gatekept through home treatment have increased through daily locality management of patient admissions. The detail of this is current subject to an audit process to be reported in February 2024.
iii. The overall numbers of patients receiving increased unput and monitoring and as such may require inpatient admission have decreased from a peak of 67 in September to a low of 23 in December 2023 (See appendix 1)
iv. The percentage of delayed transfers of care (DTOC) patients has continued to be challenging. As timely clinical discharges are optimised, the DTOCs will inevitably become more apparent. The Trust is working with our local authorities to improve the social care support to patients on our inpatient wards with an aim to provide speedier and safer discharges and thus create more capacity within our bed stock (See appendix 1)

Governance and assurance There is a weekly out of area steering group: This system wide group meets weekly to monitor progress against agreed trajectories and ensure that action plans are delivered on. This group is supported by dedicated project management office support. Dedicated workstreams accountable to the out of area steering group: The workstreams have dedicated leads, meeting and support. They report weekly into the steering group.

A clinical oversight group (COG) now meets regularly with all acute wards to support clinically appropriate discharges and enable escalation of discharge delays that occur as a result of non-clinical issues (appendix 2).

3 Assurance to the ICB in regard to clinical and operational safety oversight: The Trust have provided assurance to the medical director at the ICB that governance process are in place to support escalation and decision making around risk management of patients across the urgent and acute pathways (including acute care admissions). A copy of the process is available in appendix 3.

Additional workstreams Highcroft redevelopment project: The Trust is currently leading on a business case to secure funding to build new acute hospital capacity on the Highcroft hospital site in North Birmingham. The long term plan is to replace all of the aging bed stock on the site. The medium term plan is to realise two new additional wards. Based on our acute bed case for need, these are currently proposed to be an 18-bedded acute ward and a 12-bedded acute intensive care ward (PICU). Business case submissions are scheduled to be submitted in early Spring 2024. However, even if the case is approved, this is only the first step and it would be at least a few years before it is likely to be completed.

Strategic bed procurement steering group: This group is led by ICB with BSMHFT and FTB input. It is looking at how additional contracted beds can be contracted closer to Birmingham as an interim measure while the Highcroft programme is in development.

We hope that we have been able to offer you further insights into the work that is being undertaken. You will note there is considerable work ongoing to try and reduce the number of people waiting for a mental health bed in the Birmingham and Solihull area. The Trust will continue to work above and beyond to achieve this within the scope and abilities we are able to fulfil. If you require any further information, please do contact us.

Dear Mr Bennett

Re: Prevention of Future Deaths - Philip Laurence Justin Malone

I am writing in response to your Prevention of Future Deaths report dated 23rd November 2023, in relation to the recent investigation into the circumstances surrounding the death of Philip Laurence Justin Malone. We note the response to you from Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) dated 10th January 2024.

Firstly, may I apologise for the delay in our response; we have now been able to review a business case prepared by BSMHFT to increase their bed capacity with a proposed new build at the Highcroft site at the Birmingham and Solihull ICS System Investment Committee.

Alongside the improvements BSMHFT set out in their response to you, in relation to managing demand and admission and improving overall patient flow, we are working collaboratively with BSMHFT to increase the mental health inpatient bed capacity. In March 2023, to increase capacity, an additional 20 mental health beds were commissioned in the independent sector within the Birmingham and Solihull geographic area. As per the response by BSMHFT, we continue to work with the Birmingham and Solihull Mental Health Provider Collaborative, with BSMHFT as the lead provider, to commission more local independent sector provision.

The business case for additional mental health inpatient bed capacity has been supported in principle by the Investment Committee and we are working alongside BSMHFT to ensure that the case addresses actions raised by the Committee to allow it to progress to full support. We are, however, concerned as to whether the system will be able to raise the necessary capital to facilitate delivery because of the constraints placed upon NHS capital availability.

Dear Mr Bennett,

Thank you for your Regulation 28 report to prevent future deaths dated 23/11/23 about the death of Philip Malone. I am replying as Minister with responsibility for Mental Health.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Malone’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

Please accept my sincere apologies for the significant delay in responding to this matter.

The report raises concerns over the available psychiatric bed capacity in Birmingham and Solihull.

In preparing this response, I have noted the responses received from the organisations to which you issued your report, Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham and Solihull Integrated Care Board.

My officials have informed me that the Trust remains committed to developing capacity and pathways to ensure they are able to meet the needs of the population. The Trust initiated a 12- month project with Grant Thornton Consultancy to address local bed shortages and reduce reliance on out-of-area hospital beds. The trust has made progress in developing bed capacity by implementing a locality model linking hospital beds to local mental health teams, enhancing gatekeeping processes, and tracking clinical activity to reduce inappropriate admissions.

Birmingham and Solihull NHS Foundation Trust and Birmingham and Solihull Integrated Care Board are working collaboratively to increase mental health inpatient bed capacity.

At a national level, through the NHS Long Term Plan we have provided record levels of investment to expand and transform NHS mental health services and increase the workforce. The long-term aim set out within the Plan is to improve community support for those with serious mental illness to avoid the need for an inpatient admission where possible. We are set to reach nearly £1 billion additional funding invested by 2023/24 (compared to 2018/19) to transform community mental health services. However, we recognise that community-based care will not always be appropriate for those with more complex needs. Major expansion in funding for community mental health services commenced in all areas in 2021/22, which has been key to managing pressures on inpatient beds.

I hope this response is helpful. Thank you for bringing these concerns to my attention.