Birmingham and Solihull

Noted (AI summary) NHS England explains the NHS Pathways triage system and how it handles repeat calls, noting that ambulance services have local procedures for managing duplicate callers, including a geofence and other differentiating factors. They also highlight the use of the 'what3words' function to support location identification. West Midlands Ambulance Service explains their call taking protocols, addressing how they manage duplicate/repeat calls and clarifies the circumstances surrounding the delayed ambulance response, attributing it to significant hospital handover delays. They state the ambulance crew initially went to the kidney treatment center because they were unaware Mr. Fray had returned home.

Noted (AI summary) NHS England will issue guidance to health systems on reviewing Serious Incident investigations to ensure lessons are learned and changes agreed upon. A national oversight group has been set up to review concerns and issues with RCRP, and this group feeds into a ministerial working group. West Midlands Police (WMP) has provided additional RCRP training to call handlers and officers and produced an exhibit detailing the escalation point of contact for partner agencies to West Midlands Police. WMP has also emphasised the need for officers to gather information from all sources and record the rationale for decisions made, particularly regarding vulnerable people. This is an appendix to the BSMHFT response, specifically the Trust's Missing Patient Policy. It outlines the actions to be taken when a patient is missing or AWOL, relating to Informal inpatients, Detained patients who are AWOL and patients in the community, read in line with National Partnership Agreement: Right Care, Right Person (RCRP). The National Police Chiefs' Council clarifies the aims of Right Care Right Person (RCRP) and states that it appears the situation concerning Mr. Bari was treated as a missing person case from the outset by West Midlands Police, and therefore RCRP principles would not apply. BSMHFT has updated their Missing Persons Policy in line with Right Care Right Person (RCRP) changes, incorporating feedback from the inquest, and a new Executive Director of Quality and Safety/Chief Nursing Officer will be accountable for the policy. The updated policy includes a revised Appendix C form focusing on the reasoning for critical concern and requires formal notification from the police with their decision and reasoning if they have decided not to deploy immediately. The APCC provides background on its role and the role of PCCs in local policing, noting that it has developed guidance for members on the Right Care, Right Person approach. It states that the NPCC is reviewing the report to identify relevant national learning. The Department of Health and Social Care acknowledges the concerns raised, noting that local policies should align with the Mental Health Act Code of Practice and that local partners should reassess joint processes on risk assessment, communication, and escalation. They emphasise the importance of collaboration between policing and health partners. The College of Policing is undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process. They are also working to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. The Home Office outlines the rationale and purpose of the National Partnership Agreement (NPA) and notes that decisions on implementation of Right Care Right Person (RCRP) are for individual Chief Constables. They state that missing persons cases are outside the scope of RCRP and existing police procedures should continue to operate.

Noted (AI summary) NHS England outlines key actions from their Delivery plan for recovering urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity, improving hospital flow, speeding up discharges, and expanding community services. They also mention the Regulation 28 Working Group which shares learnings from preventable deaths across the NHS. The DHSC acknowledges concerns about ambulance response times and hospital handover delays, directing the coroner to NHS England and Birmingham Integrated Care Board for specific actions. They highlight the 'Delivery plan for recovering urgent and emergency care services' and funding allocated to boost ambulance capacity and improve patient flow. NHS Birmingham and Solihull outline several actions to address ambulance delays, including the implementation of a medical push model, improvement activities to reduce length of stay, and a single transfer of care hub. These measures aim to improve patient flow out of acute hospitals.

Noted (AI summary) West Midlands Police have updated their systems with prompts to improve the identification of those at increased risk and will work with MAPPA partners to ensure the coordinator role and new policy are understood and cascaded to relevant staff. HMP & YOI Parc has provided notice to offender managers to notify the relevant Community Offender Manager when a prisoner is being released at sentence end date and will be of no fixed abode, including providing information relating to a prisoner’s intentions in terms of where they are going on the day of release. G4S will continue to streamline its own data recording, to ensure as much information as possible is shared through the primary national prisons IT system, DPS. BSMHFT will develop a sustainable engagement strategy with MAPPA, review the Prison Discharge Coordinator's role, and explore amendments to the Systemone interface in HMP Birmingham to record community mental health team involvement, anticipating a decision within a month. The health board acknowledges the concerns raised in the report but states that it has no jurisdiction/power over the actions required for some of the concerns. However, it has alerted the MAPPA Coordinator to the concern regarding release of high-risk prisoners and will participate in Strategic Management Board discussions. West Midlands Probation Service is working with NHS-England Reconnect Service to ensure Probation Practitioners are aware of how to refer into this service in Prison for support “through the gate”, the transition period from prison into the community. West Midlands Probation Service will work with the Health Trust to support any Guidance revisions undertaken by the Health Trust to ensure that the Guidance is clear and enables effective information sharing and can be embedded within and understood by all in the Probation Service.

Noted (AI summary) BCC has conducted staff engagement sessions and provided a template for recording multi-disciplinary decision making. The ICB is leading on developing procedures around 1 to 1 support in P2 beds, stating that it can only be removed following an MDT decision. Connaught House states they assessed Sylvia required 1:1 supervision and communicated this, but that funding for 1:1 observations is a wider issue. They claim the Regulation 28 order is unfair and not factual against them. Connaught House has cascaded information about a new ICB process for removing 1:1 support to their staff and placed posters in each nursing station to ensure awareness.

Noted (AI summary) NHS England highlights national initiatives to improve digital systems, workforce, and mental health services, including the Long Term Workforce Plan and the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme. All reports received are discussed by the Regulation 28 Working Group. BSMHFT is working jointly with the Integrated Care System and highlights other areas to assist with lack of resources, including 3 Places of Safety available. The Shared Care Platform has been enhanced allowing different organisations to access different clinical information across the system. NHS Birmingham and Solihull ICB clarifies that GPs are not contractually required to monitor the collection status of medicines that they have prescribed. Birmingham City Council is working with NHS partners on a new Memorandum of Understanding to increase AMHP capacity and will fund AMHP training for NHS staff. They also trained 8 AMHPs in 2022 with funding from Skills For Care and aim to train 5 per year. The Department of Health and Social Care acknowledges the concerns, highlights existing investment in mental health services and workforce, and points to integration of services through integrated care systems and the Major Conditions Strategy.