Birmingham and Solihull

Noted (AI summary) • The Faculty of Intensive Care Medicine will highlight the case of Ms. Chloe Ulett in its tri-annual Safety Bulletin, which is distributed to all Fellows and Members. • The Safety Bulletin will signpost open access resources and highlight the utility of testing ammonia levels in encephalopathy of unknown cause. • The Faculty will draw attention to this being the second Regulation 28 Report in recent years stressing the need to test ammonia levels in patients who present in extremis with an unknown cause, referencing the Rohan Godhania case.

Noted (AI summary) NHS England refers to updated guidance regarding risk of harm to self, and states that secure access to fire escapes should be embedded within providers’ risk assessments. They state that they cannot comment further on the specific local risk assessment and direct the Coroner to the Birmingham and Solihull Integrated Care Service. The trust has updated the Environmental Risk Assessment to include the Fire Escape, installing metal fence panels and an eight-foot-high gate on the ground floor, as well as metal panels at the top of the fire escape platform. The ICB will share learning from this incident with all local mental health and rehabilitation providers by 17th December 2025. CQC acknowledges the concerns and notes that the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 apply to registered providers. They signpost to information regarding fire safety and environmental safety on their website but state they are not aware of specific guidelines regarding fire escapes in rehabilitation settings.

Noted (AI summary) Response from Deputy CEO and Chief Medical Officer, University Hospitals Birmingham NHS Foundation Trust, with no specific actions mentioned.

Noted (AI summary) NHS Birmingham and Solihull acknowledges the concerns raised and will work with Black Country ICB to coordinate a single response. The ICB takes the recommendations seriously and is committed to support Black Country ICB and WMAS in delivering necessary improvements. West Midlands Ambulance Service has implemented several actions, including face-to-face mandatory refresher training for breech birth in 2026-2027, resumption of the e-PROMPT course, a Trust focus on learning and improvement of obstetric emergencies, and removal of out-of-date WMAS Maternity Action Cards from all Trust Vehicles. They have also issued a clinical notice to all staff to remove and destroy the out-of-date cards. AACE acknowledges the concerns and explains its role in providing advisory guidelines (JRCALC) for ambulance services. While AACE is not responsible for training, it has shared the report with relevant networks for consideration, noting variations in paramedic training for maternity care and breech birth.

Noted (AI summary) The Home Office acknowledges the concerns and outlines government funding provided to West Midlands Police. Decisions around resourcing are the responsibility of the Police and Crime Commissioner and Chief Constable.

Noted (AI summary) The DHSC acknowledges concerns about insufficient radiologists at Good Hope Hospital and refers to the responsibility of individual NHS Trusts to determine staffing levels and the upcoming 10 Year Workforce Plan, deferring to the Trust for specific responses. The Trust reconfigured out-of-hours radiology reporting, separating ED and inpatient reporting across hospital sites starting September 1, 2024, and delivered an educational session around aortic dissection, though they maintain that the abnormality was very subtle and difficult to identify.

Noted (AI summary) The Trust will appoint a consultant haematologist with oversight over the stem cell lab and investigations and work up of patients, and are entering discussions with NHSBT to create a joint post. They are also identifying funding at UHB by job planning review across the department. The DHSC expects NHS Trusts to review their staffing levels and notes existing regulations regarding staffing. They also note that they expect a response from the named Trust and Integrated Care Service.

Noted (AI summary) NHS England expresses condolences and provides context regarding the commissioning and funding of specialised services, stating that no formal funding requests from RJAH for workforce development were rejected. They also describe internal review processes and national working groups related to PFD reports. The Trust outlines actions taken including; policy updates regarding patient observations, revised sepsis guidelines, improved communication of quality metrics and risk awareness to staff. They have also implemented e-learning and QI training for band 6 staff, integrated quality accreditation and business continuity systems and are developing business continuity awareness plans.

Noted (AI summary) HSE states it is not the appropriate regulator to address concerns about anti-choking devices in care settings, deferring to the CQC for registered providers and the MHRA for medical device regulation. The ICB commissioned training for nursing homes, including a guest speaker on choking prevention and provided free training on modified diets and choking risk. The ICB also shared resources from the RCUK, MHRA and DSI.

Noted (AI summary) Birmingham Womens and Childrens NHS Foundation Trust is reviewing the Trust’s Liver Biopsy Guidance with Microbiology colleagues regarding prophylactic antibiotics and creating an MDT of staff involved in procedures. They are also disseminating learning about haemothorax management and highlighting the importance of detailed documentation. The DHSC acknowledges the concerns raised in the report and explains the roles of NICE, NHS England and CQC in addressing them, noting that the hospital trust will respond separately to some points. It provides background on existing guidance and initiatives related to the concerns.