Birmingham and Solihull

Concerns summary An endemic problem of illicit drug use and supply within the secure mental health hospital, inadequately mitigated, poses significant risk to vulnerable patients with mental illness and compromised judgment.

Concerns summary There is a significant lack of awareness among clinicians about the seriousness of Myasthenia Gravis and dangerous medication interactions, posing a risk beyond the local Trust.

Concerns summary No specific safety issues or systemic failures were identified in the provided concerns text, which only stated that action should be taken to prevent future deaths.

Concerns summary Systemic failures in monitoring clozapine levels, communicating critical results, and implementing medication changes posed significant risks. Unaddressed previous PFD reports indicate a failure to learn and improve patient safety.

Concerns summary Children easily bypassed age and licence checks to illegally use hire e-scooters, facilitated by inadequate identity verification and payment system vulnerabilities. Limited regulation and ineffective education exacerbate this risk.

Concerns summary The hospital's multiprofessional appointment system for high-risk home births is not functioning as per guidance, resulting in fragmented communication and depriving patients of crucial collective professional perspectives, risking lives.

Concerns summary Overwhelmed hospital resources led to delayed test results, critical national guidance for consultant review of high-risk patients was not followed, and staff lacked awareness regarding CT scan requirements.

Concerns summary Mandatory training lacks enhanced supervision levels, and falls risk assessment training for new and agency staff is inadequate. Audits of falls risk assessments only check compliance, not correctness, failing to identify errors or training gaps.

Concerns summary The hospital's falls risk assessment form inadequately prompts staff to consider or document the presence and relevance of patient attachments, such as chest drains or IV infusions, in relation to falls risk.

Concerns summary Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded by the mental health team's lack of a psychiatrist and ongoing risk assessment documentation.

Concerns summary A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could risk other patients' lives.

Concerns summary Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police also failed to correctly classify and risk-assess mentally unwell individuals as high-risk missing persons.

Concerns summary Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, creating a gap in addressing non-violent injurious activity.

Concerns summary Unclear and unsafe systems hinder GPs from urgently contacting mental health teams, placing the burden of initiating contact on patients in crisis and leaving GPs unaware of proper referral protocols.

Concerns summary A worn-down kerb, mistaken for an official crossing, enabled a mobility scooter user to enter the carriageway unsafely. Highways dismissed the defect as not meeting repair levels, despite the clear hazard it poses to vulnerable road users.

Concerns summary Severe understaffing in the domestic abuse unit meant cases were not investigated, leaving high-risk victims vulnerable to ongoing violence and threats due to a lack of effective police action.

Concerns summary Unprecedented demand and severe hospital handover delays critically compromised ambulance availability, leading to delayed response times and directly creating a risk to patient lives.

Concerns summary Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose significant ongoing safety risks.

Concerns summary Inadequate inter-agency communication and a lack of universal protocols, central contact points, and direct referral systems hindered information sharing between multiple care agencies for a high-risk patient.

Concerns summary A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for other patients is facing significant, unacceptable delays.

Concerns summary Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment with an insecure courtyard fence and ligature risks. National perimeter fence guidelines are lacking.

Concerns summary A resident's fall incident was poorly documented, not investigated, lacked a formal incident report, and showed no evidence of learning to prevent future occurrences.

Concerns summary Acute Behavioural Disturbance, a medical emergency with high mortality risk, is inappropriately categorized as a Category 2 ambulance response, potentially causing dangerous delays in urgent medical care.

Concerns summary Critical mental health information from MARAC was not accurately recorded or cascaded to police, leading to officers being unaware of the deceased's EMD status. There was also confusion and a lack of coordination during CPR efforts.

Concerns summary A manual patient allocation system risks unassessed patients, and the electronic prescribing system lacks a secondary check, increasing the danger of incorrect medication being administered.