Dear Mr Bennet,

Re: Regulation 28 Report to Prevent Future Deaths – Mr Peter Fleming who died on 10 November 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 14 July 2023 concerning the death of Mr Peter Fleming on 10 November 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Peter’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Peter’s care have been listened to and reflected upon.

This letter responds to the concerns raised in your report relevant to NHS England. It is not within NHS England’s remit to respond to many of the concerns raised, particularly relating to Birmingham and Solihull Mental Health Trust (BSMHFT). NHS England has asked to be sighted on the responses from BSMHFT and Birmingham and Solihull Integrated Care Board (ICB) and will give due consideration to their responses.

Digital systems

In your Report you raised the concern that different health organisations use different digital systems that do not communicate with each other, and that GPs often do not get important patient updates from other primary care organisations.

Current GP systems are designed to be interoperable before being allowed to be used for patient care and as such are accredited under the Digital Care Services Catalogue which requires suppliers to meet relevant standards, including interoperability with other systems, which is a pre-requisite of being included on the catalogue. This has enabled almost all GPs (99%) to have the digital capability to share and receive medical information from a variety of care providers within the NHS. This quick and efficient way of relaying and transmitting information between clinicians should address the sharing of important clinical information. The NHS is working to further improve this capability to enable information to be automatically added into the GP Patient record as appropriate.

In addition, NHS England is also undertaking a programme of work that will enable the safe and secure sharing of an individual’s health and care information as they move between different parts of the NHS and social care. A shared care record joins up National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

8 September 2023

information based on an individual rather than an organisation, and is a safe and secure way of bringing an individual’s separate records from different health and care organisations together. We are currently working on the interoperability of shared care records, to ensure that where systems are used, they can connect with each other.

GP checks on prescribed medication

You also raised a concern over the lack of resources at a national level for GPs to check that patients are collecting prescribed medication.

The dispensing notification used by pharmacies is for payment purposes and does not link back to the prescribing system. It is not used consistently by pharmacies as some use the notification system for when an item has been dispensed and is ready for collection, meaning the patient has not yet collected the medication and in fact may not collect it. Therefore, the system would not be a reliable way for the GP to check the patient’s compliance with medication as there is no confirmation on the system that the patient is taking the medication as prescribed. Some prescribing systems may display compliance figures, but this is also dependent on accurately adding the medication to the patient record so that a daily dose can be calculated.

Resourcing

Your Report raised resourcing concerns, both at BSMHFT and of GP services. It is acknowledged that resourcing remains an issue across the NHS, with local services reporting over 112,000 vacancies.

In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care. The plan sets out three core priorities; to improve training and education, ensure that we retain more staff, and to reform. The plan is underpinned by the biggest recruitment drive in NHS history.

Transformation of mental health services

In 2022, NHS England also established a new Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme. The programme’s aim is to support cultural change and a reimagined model of care for the future across all NHS- funded mental health, learning disability and autism inpatient settings. It is underpinned by £36 million investment over three years and focuses on the following four themes:
1. Localising and realigning inpatient services, harnessing the potential of people and communities.
2. Improving culture and supporting staff
3. Supporting systems and providers facing immediate challenges
4. Making oversight and support arrangements fit for the sector.

I would like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings

and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.

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.

Dear Mr Bennett,

RE: Prevention of Future Deaths Report for Mr Peter Fleming (deceased)

Further to the Prevention of Future Deaths Report dated 14th July 2023, the Trust has now had an opportunity to review the Matters of Concern you have raised within the same. I would first like to begin by offering my sincere condolences to the Family of Mr Fleming for his very sad loss. As a Trust we have taken your concerns very seriously and have aim to act on these issues as quickly as possible to ensure lessons are learned to benefit other patients in the future. I will respond to each issue in turn;

1. A continuing lack of resources to treat seriously mentally ill patients in Birmingham and Solihull

As you will be aware, the Trust received a previous Prevention of Future Deaths report into this matter by Mrs Louise Hunt, which was responded to in April 2023. I attach a copy of this to set out the joint work that is currently being carried out alongside the Integrated Care System.

In addition to this we can highlight other areas where we are trying to assist with this as follows:

I. Places of Safety Whilst it is best practice that a service user presenting with a mental health concerns is taken to a mental health Place of Safety, this could not be achieved on the particular day in question as all the mental health Places of Safety within the Trust were taken. However, Mr Fleming was conveyed to the Accident & Emergency Department at Heartlands Hospital which is an appropriate Place of Safety and indeed there are a number of A&E departments across the Birmimgham and Solihull area where service users can be taken too as Places of Safety. In terms of its own provision the Trust has three Places of Safety available across the organisation. The pressure on these facilities is multi-factorial. Work is ongoing in this area with the Police to streamline the s.136 process.

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II. Care Coordinators The Care Programme Approach (CPA) has had a central role in the planning and delivery of secondary care mental health services for the past 30 years. There is a recognition that principles were sound when initially introduced and implemented. It was associated with resource allocation, clinical care delivery and planning whilst being closely associated with risk management. The two main aspects of a CPA package of care involved allocation of a care coordinator and development of a care plan. It was also used as an overarching framework to join up health and social care assessments. The CPA has been superseded by The Community Mental Health Framework (2019) which proposed replacing the CPA for community mental health services while retaining the sound theoretical principles of good care coordination and high-quality care planning. The focus is on shifting away from generic care coordination to a more meaningful intervention-based care. For there to be a named key worker with a clearer Multi Disciplinary Team approach, with a high quality co-produced, holistic personalised care and support planning. The Framework also focuses on better support for and involvement of carers and a more accessible, responsive and flexible system. The use of a Dialog Plus Care Planning tool will be the foundational component of the framework to ensure the holistic identification of needs with allocation of the appropriate clinician within teams to support those needs to be met, to liaise with other professionals who need to input into care and to ensure the Action Plan is reviewed in a timely manner.

From March 2023 to April 2024 the Trust is in a transition phase of implementing the new Dialog Plus Care planning tool. Once this is completed, the required/recommended changes to the CPA Framework, will be reviewed (with learning from other organisations as part of the process) in line with NHS England Guidance and implementation.

The Local Authority will be addressing separately the point around Approved Mental Health Professionals.

2. Communication between specialist mental health teams is not effective and this caused delays

In preparation for our transition to the Patient Safety Incident Response Framework we have undertaken an analysis of data from various sources, with aim of looking for opportunities for improvement, areas where gaps in care and treatment/or incident types remain a concerns. As part of our Incident Response Plan we are proposing that fragmented working and poor communication is a safety priority for the organisation. It is anticipated that the Response Plan will be approved in October 2023. By way of a general update on the Trust’s management of PFDs going forward, the Associate Director of Nursing and Governance is currently undertaking a deep dive review of the last 2 years of Regulation 28 Reports. This will facilitate a detailed thematic review and learning exercise. This work will subsequently feed into an overarching piece of work the Trust has already commenced pulling a variety of patient safety data sources together including SIs, Safeguarding Reviews, Complaints, Legal Claims, CQC, and Local Investigation information. This rich dataset will be formed into themes, and a QI approach taken to addressing the bigger and most impactful areas of required improvement. Anticipated timelines for this work are below:

• The thematic review of PFDs will be completed in 8 weeks.
• The overarching review of multiple patient safety datasets and subsequent forming into themes and trends will be completed in 16 weeks.
• Formulation of the major QI workstreams will commence in 18 weeks’ time.

3. Carbamazepine management indicating a problem with process and systems

A review of the RiO notes and discussions with the SI review lead and others highlighted that the patient has not been under a shared care arrangement and was discharged by BSMHFT back to their GP following non-attendance in 2012. The specialist advised the GP to prescribe carbamazepine in line with locally agreed practice, a letter was sent to the GP and acknowledged as received, but the GP stopped prescribing carbamazepine for reasons unknown. BSMHFT Home Treatment team re-started prescribing carbamazepine when the patient was admitted into their service. Carbamazepine is on the Birmingham and Solihull IMOC formulary as an AMBER medicine, meaning that once a specialist has advised initiation of this medicine, any prescriber can prescribe it. There is no requirement for a shared care agreement for carbamazepine and there has never been a template for one. Communication is evidenced via clinical correspondence.
4. Communication between different health organisations is not as effective as it could be causing important information to be missed and delay in treatment occurring

Following the introduction of the shared electronic system across Birmingham, Sandwell and Solihull areas through Your Care Connected some years ago, the Trust could access some clinical information from primary care services. However, in the last 12 months this has been enhanced, and is now known as the Shared Care Platform. This allows a number of different organisations to access different clinical information across the system, including investigation results, thus improving the exchange of clinical information and thus improving patient care.

5. GP’s are not able to proactively check patients are collecting prescribed medication due to excessive patient lists as a consequence of a lack of resources at a national level

The Trust cannot respond to this point and will leave this to others to respond to. If a patient is open to BSMHFT, our staff will regularly speak to the patient about all aspects of their care, including medication.

Dear Mr Bennett

Prevention of Future Deaths Report for Mr Peter Fleming (deceased)

Following the recent submission of the response to the above Prevention of Future Deaths report on 4 September 2023 by BSMHFT, we would like to make a further response in relation to item 6. A system wide discussion has taken place regarding this particular item, which was led by our Chief Medical Officer, , and we can clarify the below:

6. GP’s are not able to proactively check patients are collecting prescribed medication due to excessive patient lists as a consequence of a lack of resources at a national level

GPs do not, and are not contractually required to, monitor the collection status of medicines that they have prescribed. The national Electronic Prescription Service has a limited facility to allow a GP practice to determine whether an electronic prescription has been downloaded from the spine to an individual pharmacy. This is provided to allow a practice to check the status of a prescription in case of an enquiry by the patient – this eliminates the need for re-issues / reprints of prescriptions and is the purpose of the EPS function.

There is no facility to determine whether a patient has collected a medication or not as the pharmacy does not log a prescription out upon collection. The medicines may be dispensed ready for collection without having been collected.

I hope this is clear, if you do have any further questions around this particular point then please do noy hesitate to contact

Dear Mr Bennett,

Background This response is provided by Birmingham City Council (BCC) in response to the regulation 28 report to Prevent Future Deaths, dated the 14th July 2023, made by James Bennett Area 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 Peter Martin Aaron Fleming. BCC was not an Interested Person and took no part in the Inquest.

Mr Fleming died on the 10th November 2022. The conclusion of the Inquest on 4th July 2023 was Suicide. At the outset of this response, the local authority offers its deepest condolences to the family of Mr Fleming. The matter of concern is that Birmingham City Council could not provide an Approved Mental Health Practitioner (‘AMHP’) to attend in a 24-hour period.

OFFICIAL AMHP resources and decisions made on the 14'" and 15th October 2022

BCC had been informed by Heartlands Hospital at 18:58 hours on 14 October 2022 that Mr Fleming had been placed on a s.136 at 17:07 hours on 14th October 2022. At 22:53 hours on 14th October 2022 a call was made to Heartlands hospital to confirm the whereabouts of Mr Fleming as it had been stated in the referral that he was being moved to the Place of Safety at the Oleaster Hospital. During the call at 22:53 hours it was confirmed that the hospital were waiting to hear back from the Place of Safety regarding the transfer. There was no further update provided overnight on 14th October. On 15th October 2022 at 11:27 hours a follow up call was made to Heartlands hospital and it was confirmed that Mr Fleming was remining at the Emergency Department and Police were with him and that he remained settled. At 11:36 hours on 15th October a further call was received from Police requesting an update of 4 s136 cases the team were managing through and he reiterated this was urgent. There was a second call received from Police at 12:50 hours requesting an update on allocation of an AMHP and at 15:59 BCC were informed Peter’s s136 had now lapsed and that he had discharged himself. There are no recordings of actions taken between these escalation calls. Birmingham does have a dedicated Place of Safety namely the Oleaster Hospital, which has up to 3 spaces available at any one time. A hospital or a care home may also be used as a place of safety under the provisions of the Mental Health Act so in this instance the use of accident and emergency was an acceptable alternative to a placement being available at Oleaster.

There was a delay in allocating the assessment to an AMHP as there were multiple calls between Heartlands Hospital and the dedicated Place of Safety Oleaster to determine whether Mr Fleming would be transferred.

During the day shift of 15th October 2022 Birmingham City Council Out of Hours Team were dealing with 4 s.136 requests.

BCC were also given conflicting information regarding the actual end time of the s136 and Birmingham City Council believes Mr Fleming was released from the s136 before the 24 hour timeframe was ended.

OFFICIAL A call was made to Heartlands Hospital at 15:59 hours on 15th October 2022 to a member of the Psychiatric Liaison Team to discuss allocating an AMHP to complete the Mental Health Act Assessment. It is recorded within BCC electronic records that BCC were informed the s136 had lapsed and that Mr Fleming had discharged himself and had gone home. This was an hour and 8 minutes before the s136 would have expired assuming that the time we were given for the s136 to have commenced was at 17:07 hours.

From the staffing levels on 15th October 2022 BCC did have sufficient AMHPs on shift in which to complete the assessment before the end of the 24 hour timeframe. BCC holds an electronic diary showing that on 15th October 2022 there were three AMHPs on duty from 8 am to 7 pm which covers the time period prior to the expiry of the s136 at 17:07 hours. The BCC Out of Hours Service operates with an average of 5/6 AMHPs on Duty covering the 22 hours period from 8 am to 6 am the following day. On 15th October 2022 there were 5 AMHPs on duty over 24 hours.

AMHP Availability Birmingham City Council is actively seeking to recruit, retain and train Approved Mental Health Professionals and is maximising AMHP resources through use of Agency Workers and requiring all AMHPs to contribute to our AMHP service on a daily basis. We recognise the impartiality of the AMHP role and we reserve the right under s13 Mental Health Act 1983 to consider all requests for Mental Health Act Assessments and we encourage staff to look at alternatives to assessment where possible. BCC has seen an increase in requests for assessments which has risen by at least 20% this year suggesting that the acuity of people requiring formal admission under the Act has increased. The lack of bed availability increases the number of times we assess individuals as medical recommendations which are valid for 14 days often expire whilst the person is waiting for a bed, which also impacts on our referrals. BCC has also seen a significant increase in the use of s136 in Birmingham and in our Out of Hours Service s136 assessments account for 47% of all Mental Health Act assessments completed Out of Hours. Figures are retained by BCC detailing all requests for Mental Health Act Assessments and this includes the outcome of all assessments completed. A monthly report is usually produced giving these details. The Mental Health System in Birmingham meets as a partnership monthly at a Joint Strategic Meeting chaired by Birmingham and Solihull Mental Health Trust where s136

OFFICIAL assessments are regularly discussed and reported and figures are retained by the Trust around conversion rates.

Birmingham City Council has the responsibility under the AMHP regulations to Approve and Authorise AMHPs who work for or on behalf of the Local Authority. Birmingham City Council, Birmingham and Solihull Mental Health Foundation Trust and Birmingham Women’s and Children’s Trust are currently consulting on a new Memorandum of Understanding which will mean that AMHPs employed directly by the NHS in Birmingham will all contribute to the AMHP rota increasing the capacity by a further 14 AMHPs available to cover AMHP duties on a monthly basis. This includes a commitment from Birmingham City Council to fund AMHP training for NHS staff who meet the criteria for the course.

Within the regulation 28 report the Coroner recognises the chronic lack of resources including Care Coordinators, Mental health Inpatient beds and Approved Mental Health Professionals (AMHPs) at a local and national level. This is also recognised by the Chief Social Worker and their staff including who represents Mental Health Services at a National Level. As a Local Authority BCC is represented at the National AMHP Leads Network and we have a dedicated AMHP Lead who is promoting and actively supporting the training of AMHPs in Birmingham both within the Local Authority and with local NHS partners.

In 2022 we received funding from Skills For Care for an additional 10 AMHPs and we were successful in training 8 AMHPs in the first year – AMHP Training takes 2 years to complete with a period of supported practice following successful completion of the qualification. Birmingham City Council aims to train 5 AMHPs per year . Birmingham City Council has the responsibility under the AMHP regulations to Approve and Authorise AMHPs who work for or on behalf of the Local Authority. Birmingham City Council, Birmingham and Solihull Mental Health Foundation Trust and Birmingham Women’s and Children’s Trust are currently consulting on a new Memorandum of Understanding which will mean that AMHPs employed directly by the NHS in Birmingham will all contribute to the AMHP rota increasing the capacity by a further 14 AMHPs available to cover AMHP duties on a monthly basis. This includes a commitment from Birmingham City Council to fund AMHP training for NHS staff who meet the criteria for the course.

OFFICIAL Birmingham City Council regrets that Mr Fleming felt compelled to take his own life, however we cannot predict what the outcome of a Mental Health Act Assessment may have been if completed within the 24 hour timeframe allowed for this assessment. We attend almost 100% of s136 assessment requests within the timeframe and we would remind partners that Police can apply for an extension if they feel the risk necessitates this.

Dear Mr Bennett,

Thank you for your letter of 14 July 2023, to the Secretary of State for Health and Social Care, Steve Barclay, about the death of Peter Fleming. 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 Fleming’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

A number of the concerns you have raised in this report relate to policies and training requirements at a local level. It is for these local areas to ensure they have the processes in place to support mental health services, so that people with suspected mental health problems receive the appropriate response at all times.

In your report a concern was also raised regarding the lack of resources available at a national level which restricts patients from getting the mental health support that they require. We are investing at least £2.3 billion of additional funding a year by March 2024 to expand and transform mental health services in England so that two million more people can get the mental health support they need. We also provided a record investment of £15.9 billion in mental health across 2022/23, representing 27.7% more than in 2018/19.

The responsibility for the staffing and operations of mental health services lies with the relevant trust, however, we do recognise the wider need to increase capacity in NHS mental health services. Nationally, the mental health workforce increased by over 10,000 full-time equivalent staff in June 2023 compared to June 2022, and our aim is to grow the mental health workforce by an additional 27,000 staff by March 2024, compared to 2018/19.

A concern was also raised regarding a lack of communication between different health organisations. We are working towards better integration of services though the role of integrated care systems. As part of this, we are integrating services for serious mental illness, expanding community mental health services to reduce reliance on inpatient treatment, so that

people are supported to stay well in their communities. The Government announced in January that it would publish a Major Conditions Strategy, setting out a shift towards integrated, whole-person care. The Strategy will tackle the six conditions that contribute most to morbidity and mortality in England, including mental ill health. The Major Conditions Strategy: case for change and our strategic framework was published on 21 August.

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

MARIA CAULFIELD MP