Birmingham and Solihull
Coroner Area
Reports: 192
Earliest: Sep 2013
Latest: 14 Apr 2026
88% response rate (above 63% average).
Peter Harte
All Responded
2021-0283
24 Aug 2021
Bromford Lane Nursing Home
Care Home Health related deaths
Concerns summary (AI summary)
Proper skin inspections and monitoring were not consistently carried out or adequately recorded, indicating a possible systemic issue with record-keeping that could pose a risk to frail and vulnerable residents.
Action Taken
(AI summary)
Bromford Lane Care Centre reports that all staff have been spoken to and have received feedback and support to improve the service provided. Following this review, they have had an external auditor come and audit their body maps to ensure that they are being completed accurately.
Leonard Pritchard
All Responded
2021-0207
17 Jun 2021
NHS England
University Hospitals Birmingham NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The emergency department has an inadequate supply of mobility aids for patient assessments, posing a significant risk, and the procurement process for these essential aids is unmanaged and delayed.
Noted
(AI summary)
NHS England notes that the Trust has responded adequately at a local level and that the matters of concern have been dealt with, and has shared the Regulation 28 Report and both responses with the Regional NHSE/I teams. Immediately following the inquest, the hospital sourced 10 zimmer frames and made them available in the ED; a process for procurement, storage, labeling and auditing of walking frames was fully implemented in early July.
Stephen MAGUIRE
All Responded
2021-0138
5 May 2021
Options for Care Ltd
Care Home Health related deaths
Concerns summary (AI summary)
A personal alarm failed due to not being charged, indicating a flaw in the alarm charging and checking system for staff, which poses a significant risk if alarms are unusable during emergencies.
Action Taken
(AI summary)
Dartmouth House has introduced a 'security lead' role to check PIT alarms at the beginning of each shift and ensure they are working correctly. They will reinforce training through supervision sessions and staff meetings, and agency staff will receive training on PIT alarm use.
Raymond Powell
All Responded
2021-0089
29 Mar 2021
Cole Valley Care Ltd
Care Home Health related deaths
Concerns summary (AI summary)
The nursing home failed to investigate a resident's fall, did not record a preceding fall or update the falls risk assessment, and provided misleading observation records, indicating systemic safety failures.
Action Taken
(AI summary)
The nursing home has implemented a new post falls protocol folder, a new manager’s report/handover for nurses, and a Daily Walkabout Form. They have also promoted an RGN to Deputy Manager and implemented a new daily task folder for nurses to complete audits.
Azra Hussain
All Responded
2021-0082
25 Mar 2021
Birmingham and Solihull Mental Health N…
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.
Noted
(AI summary)
The Trust has taken steps to reduce risk from ligatures, including installing pressure sensor alarms on en-suite bathroom doors, removing door furniture, and establishing a rolling capital programme for ligature works. They are also reviewing therapeutic observational practice, staffing levels, and care plans. HSE states that the safety of the environment for patients, including management of ligature points, falls within the remit of CQC, not HSE, according to a Memorandum of Understanding. NHS Birmingham and Solihull ICB provides supplementary information to the Coroner, in support of the information provided by Birmingham and Solihull Mental Health Foundation Trust, in response to the Regulation 28 Report. The CQC has asked for weekly reports on ward improvements, sought an independent review from NHS England, and will share learning from the inquest with inspectors and registered persons. They are monitoring the trust and will use enforcement powers if regulations are not met.
Pardeep Plahe
All Responded
2021-0061
4 Jan 2021
Ashfield Surgery Sutton Coldfield
Birmingham and Solihull Clinical Commis…
EMIS
+1 more
Community health care and emergency services related deaths
Concerns summary (AI summary)
A technical fault in the EMIS system caused GP consultation lists to not update, leading to a missed appointment. Reliance on manual workarounds creates a risk of further missed appointments.
Noted
(AI summary)
NHS England notes that EMIS is developing a solution, expected in September 2021, to address the intermittent EMIS system issue which resulted in a booked telephone consultation for Mr Plahe not taking place. NHS Digital will jointly review the solution with EMIS clinicians. The CCG's IT Team worked with EMIS and GP practices to address appointment refreshing issues, issuing guidance after identifying the cause. In response to reoccurring issues after the Windows 10 upgrade, the CCG communicated potential problems and resolution information to all GP practices. Ashfield Surgery updated its induction pack to highlight EMIS issues and steps to address them, shared this information with nursing staff and term locums, and cascaded to Primary Care Networks using EMIS. A Significant Event Analysis was completed and shared. EMIS investigated the reported issue of the appointment book not refreshing, advised the practice to check UDP ports, and states they are investigating potential solutions to improve functionality given the increase in remote working, but offered no concrete actions.
Ian Allen
All Responded
2020-0161
17 Aug 2020
Birmingham and Solihull Mental Health F…
Department of Health and Social Care
Alcohol, drug and medication related deaths
Care Home Health related deaths
Concerns summary (AI summary)
The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of understanding regarding its importance. National guidance is needed for monitoring frequency and practitioner education on clozapine.
Action Taken
(AI summary)
Birmingham and Solihull Mental Health Trust has provided pharmacists with additional training on Clozapine, will build further education into the Post Graduate Medical Education programme and is drafting a safety alert to all clinicians; also reviewing and updating Trust Clozapine guidelines to reflect updated MHRA guidance in August 2020, to be approved in November 2020. The Department of Health and Social Care notes that Birmingham and Solihull Mental Health NHS Foundation Trust has responded to the report by undertaking a review and update of its guidance on the use of clozapine, and have taken additional measures such as additional training and education and an audit of patients.
Francis Cooney
All Responded
2020-0154
10 Aug 2020
University Hospitals Birmingham NHS Fou…
Community health care and emergency services related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing confusion. A lack of clear policy and systemic investigation into this communication breakdown risks future harm to vulnerable patients.
Action Planned
(AI summary)
The Trust will reinforce with staff the requirement to record sight of a registered LPA, review the 'Communication with Relatives Procedure', and explore options for implementing electronic flagging of patients lacking capacity.
Renee Brooks
All Responded
2020-0260
31 Jan 2020
British Association of Aesthetic & Plas…
Other related deaths
Concerns summary (AI summary)
The absence of UK guidelines for lipoedema-related liposuction means varied surgical practices and insufficient standards for procedure frequency, fluid management, and post-operative care, endangering patients.
Action Planned
(AI summary)
NICE will consider whether to update guidance on liposuction for chronic lymphoedema and whether to produce new IP guidance specifically relating to the use of liposuction in the treatment of chronic lipoedema. Their website explains that they are considering whether they need to update their guidance in response to safety concerns. BAAPS and BAPRAS have agreed to work in partnership to create guidelines for the use of liposuction in the UK, including the level of hospital support required and pre-assessment needs. A joint expert panel has been set up to produce the report within the next six months, for adoption by the wider sector and submission to the CQC.
Colin North
All Responded
2020-0003
9 Jan 2020
Incarace
ORCi
Other related deaths
Concerns summary (AI summary)
There is a severe lack of pedestrian control on race tracks immediately post-race, with active vehicles and no designated safe zones or walkways. Risk assessments are inadequate for both pedestrians and staff on the track.
Action Taken
(AI summary)
Incarace Ltd has revised its risk assessment to prohibit pedestrians on the track during race events, and now undertakes prize giving when there are no moving vehicles on the track. The company states that no staff are permitted on the track area during a race. The ORCi distributed the Regulation 28 report to all members. Interim control measures addressing pedestrian/vehicle segregation were already sent to members in November 2019, specifying procedures for recovery vehicles entering the track after pedestrians have exited, drivers remaining in cars, and a one-way system at the pit gate.
Youngson Nkhoma
All Responded
2019-0416
6 Dec 2019
Capita
MOD
Service Personnel related deaths
Concerns summary (AI summary)
Non-UK military selection candidates are not screened for sickle cell trait, posing a significant increased risk of death or collapse during military exercise.
Action Taken
(AI summary)
The Ministry of Defence outlines changes made to the Army recruitment process, including revised medical screening for Sickle Cell Trait, updated risk management processes for physical training, and clarified roles and responsibilities for training staff. They also removed previous versions of AGAI Vol 1 Ch 7 from use and circulation. The Ministry of Defence reports on actions taken, including improvements to sickle cell trait screening, mandating training for staff on exertional collapse, and implementing a joint clinical policy for exertional collapse. They also ensure Defence Medic training incorporates exertional collapse scenarios.
Kamil Iddrisu
All Responded
2019-0416-wp26929
6 Dec 2019
Capita
MOD
Service Personnel related deaths
Concerns summary (AI summary)
There is a critical need to screen all non-UK military selection candidates for sickle cell trait, both before and after selection, due to the significant risk of collapse or death during military exercise.
Noted
(AI summary)
• Following the death of two candidates, the 2000m run was suspended for all Commonwealth Candidates.
• Multidisciplinary meetings have taken place, informed by an Evidence-Based Medicine approach, to address the risk of Exertional Collapse Associated with Sickle Cell Trait (ECAST).
• Actions taken have been applied to all candidates applying to join the Army, not just non-UK candidates.
Suzanna Bull
All Responded
2019-0404
29 Nov 2019
Department for Transport
Road Haulage Association
Scania
+1 more
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A dashboard tray creates a dangerous blind spot in moving vehicles, yet there are no warnings on the product, nor general advisories to manufacturers or users, about this safety hazard.
Action Planned
(AI summary)
The DVSA will circulate information to haulage operators stating that aftermarket dashboard trays breach testing rules and should be removed when HGVs are driven and publish similar information on gov.uk. The Department for Transport will also make umbrella bodies aware of the concerns. DVSA published a Moving On blog on GOV.UK and sent a link to haulage operators reminding them to keep windscreens clear; they will highlight concerns at a Heavy Vehicle Industry Forum, and will update guidance to warn drivers against putting objects in their lorry which restrict their view.
Emma Langley
All Responded
2019-0384
18 Nov 2019
West Midlands Ambulance Service
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
The current system for recording patients' refusal of hospital admission, involving a generic summary and electronic signature on a tablet, fails to adequately ensure distressed patients/families understand they are rejecting medical advice.
Action Taken
(AI summary)
West Midlands Ambulance Service is changing its electronic patient report software to include a clearer statement about refusing treatment/transport. They have also updated their policy on refusal of care and revised the patient discharge advice leaflet.
Jamil Ahmed
All Responded
15 Nov 2019
National Highways
Road (Highways Safety) related deaths
Concerns summary (AI summary)
The use of hard shoulders as running lanes on smart motorways creates a severe risk of collisions with stationary vehicles, especially given high speeds and limited escape options on elevated stretches.
1 response
from National Highways
Joshua Hoole
All Responded
2019-0458
1 Nov 2019
MOD
Service Personnel related deaths
Concerns summary (AI summary)
A persistent failure to learn from previous heat-related deaths is evident, with commanders lacking awareness and training on critical heat illness guidance (JSP539), which itself is complex and lacks clear protocols for individual risk and new fitness tests.
Action Taken
(AI summary)
The Ministry of Defence has taken corrective action following concerns raised regarding the death of Corporal Joshua Hoole, including improved awareness of Joint Service Publication 539, updating the User Guide video for WBGT monitors, and providing refresher training for staff delivering Physical Training, whilst robust plans are in place to deliver remaining requirements.
Dev Naran
All Responded
2019-0341
14 Oct 2019
Highways England
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Motorway management lacks automatic detection for stationary vehicles in live lanes, compounded by long gaps in emergency refuge areas and confusing signage on dynamic hard shoulders, increasing the risk of fatal collisions.
Action Planned
(AI summary)
National Highways is introducing stopped vehicle detection capability, exploring other technologies to reduce risk, and running information campaigns on emergency procedures and safe driving practices from January 2020 to March 2021.
Anthony McCormack
All Responded
2019-0317
27 Sep 2019
Birmingham and Solihull Mental Health N…
NHS Birmingham and Solihull Clinical Co…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
A severe shortage of mental health beds prevented necessary inpatient treatment, while an overstretched home treatment team lacked resources for adequate patient assessment and monitoring.
Action Planned
(AI summary)
NHS Birmingham and Solihull ICB is allocating funding towards community based crisis support services run by MIND and crisis houses to complement inpatient mental health facilities. BSMHFT is also actively recruiting staff into the Home Treatment Team and other services.
Gurdeep Singh Dundhal
All Responded
2019-0294
10 Sep 2019
Birmingham City Council
Birmingham Women’s and Children’s NHS T…
Priory Group of Hospitals
+1 more
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
Systemic delays in mental health act assessments due to inter-agency confusion and resource shortages led to critical information being missed and the incorrect legal framework being applied. Walsall MBC also failed to investigate these failings.
Disputed
(AI summary)
Birmingham Women's and Children's NHS Foundation Trust redistributed the safer inter agency information sharing guidance within the urgent care team. They have also been contacted by Walsall MBC and have been invited to participate in a multi agency meeting to discuss this matter. Priory Group states that relevant information relating to Mr. Dundhal was made readily available to the assessing team and that their clinician was available for contact, disputing concerns that information was unavailable. Walsall Council conducted an investigation and review, increased the number of AMHPs, changed AMHP working practices, and opened discussions with neighboring authorities to formalize practices of asking neighboring authorities to carry out reviews within the borough of Walsall. There will also be a manager on duty or on call.
Karen Burns
All Responded
2019-0273
12 Aug 2019
Home Office
West Midlands Police
Emergency services related deaths (2019 onwards)
Suicide (from 2015)
Concerns summary (AI summary)
Police resources are critically insufficient, leading to incorrect call grading and leaving numerous P2 and P3 calls unanswered due to high demand for priority incidents.
Action Planned
(AI summary)
West Midlands Police has reviewed its call handling procedures, including providing additional training, instituting a "Log Closure Doctrine", reducing the number of logs held by each dispatcher, changing the dispatch model and shift patterns. They are also developing a new Command and Control platform to support call handlers. The Home Office will ask officials to contact West Midlands Police to identify if any remedial or additional measures need to be put in place to ensure calls are handled appropriately. The Home Office states that public safety remains the government's number one priority and cites increased police funding and plans to increase officer numbers. West Midlands Police accepted that the 101 call was incorrectly graded and has discussed this with the staff member in question, and has promised additional training for all control room staff. They have also instituted a "Log Closure Doctrine", reduced the number of logs held by each dispatcher, changed the dispatch model and shift patterns, and are developing a new Command and Control platform.
Prabhaker Kapoor
All Responded
2019-0278
6 Aug 2019
University Hospitals Birmimgham NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
Essential updates to safer swallowing training and the MOODLE package were significantly delayed and lacked a completion timeline, despite being recommended in a Root Cause Analysis report.
Action Taken
(AI summary)
The Trust has updated its Moodle training package with SLT input to reflect standard operating procedures for dysphagia and 'nil by mouth' patients, reviewed standard operating procedures, developed 'preventing harm' study days, and disseminated a practice update on managing patients with swallowing difficulties.
Nigel Abbott
All Responded
2019-0284
31 Jul 2019
Birmingham and Solihull Mental Health N…
Birmingham City Council
Department of Health and Social Care
+3 more
Community health care and emergency services related deaths
Emergency services related deaths (2019 onwards)
Mental Health related deaths
Concerns summary (AI summary)
A critical misunderstanding exists between agencies regarding the urgent execution of Mental Health Act warrants, leading to ineffective inter-agency cooperation and a failure to learn from incidents, risking public safety.
Action Taken
(AI summary)
The Home Treatment Team Operational Procedure has been revised and approved, to ensure that it fully corresponds with the safeguards for fully assessed and initially assessed patients waiting for a bed.
Richard Carlon
All Responded
2019-0287
22 Jul 2019
Birmingham and Solihull Mental Health N…
Birmingham City Council
West Midlands Police
Alcohol, drug and medication related deaths
Mental Health related deaths
Suicide (from 2015)
Concerns summary (AI summary)
The unavailability of Approved Mental Health Practitioners delayed critical assessments, and poor inter-agency communication led to mental health services missing opportunities to re-engage with a patient.
Action Planned
(AI summary)
Birmingham City Council is implementing a 60-point improvement plan for AMHP services, including commissioning urgent beds, developing urgent care pathways, and improving information sharing. A workshop will be held to improve joint working between the Mental Health Trust and the AMHP service, with monthly project board meetings to oversee improvements. West Midlands Police will provide further guidance to call handlers on managing calls and incident grading related to missing persons, and will ensure callers are updated when a missing person is located. Full implementation is expected by November 2019.
David Jukes
All Responded
2019-0329
12 Jul 2019
Birmingham and Solihull Clinical Commis…
Birmingham and Solihull Mental Health N…
Black Country Partnership NHS Foundatio…
+2 more
Hospital Death (Clinical Procedures and medical management) related deaths
Mental Health related deaths
Concerns summary (AI summary)
Critical information was withheld from mental health assessors in custody, and communication breakdowns meant existing mental health teams failed to assess the patient, despite being notified, creating significant risk.
Disputed
(AI summary)
NHS England and NHS Improvement will hold a national event by the end of March 2020 to discuss information sharing issues with liaison and diversion practitioners, NHS Commissioners, and police representatives. They are also working with West Midland Police regarding their new IT system. Staffordshire Police argues that adequate information *was* available on the custody record and that the Liaison and Diversion practitioner could have requested further information from custody staff, therefore no action is required. Birmingham and Solihull Mental Health NHS Trust has increased resources to all Home Treatment Teams, launched two Quality Improvement Projects and is recruiting additional staff to improve services. Black Country Partnership NHS Trust has taken several actions, including reviewing the L&D process, providing additional training to staff, and improving access to mental health databases, including rolling out staff access to the Spine. NHS Birmingham and Solihull CCG highlights increased investment into mental health services including crisis cafes and crisis houses to improve accessibility and experience of those in crisis and reduce the impact of crisis on other agencies across the region.
Allan Davies
All Responded
2019-0291
9 Jul 2019
NHS Digital
NHS England
Alcohol, drug and medication related deaths
Emergency services related deaths (2019 onwards)
Concerns summary (AI summary)
The NHS Pathways triage system for overdose patients is too generic, failing to assess specific drug risks for sudden collapse, potentially categorizing high-risk cases incorrectly and endangering lives.
Action Taken
(AI summary)
NHS England highlighted the issue of triaging overdose cases to ambulance services and asked them to ensure robust clinical oversight is in place for self-harm and suicidal patients. A new diagnostic code (Dx0124) is being introduced in 'NHS Pathways Release 18' to raise visibility to clinicians, with widespread deployment planned for October 2019 after beta testing. NHS Digital (NHS Pathways) is deploying Release 18 which includes a new disposition code (Dx0124) to highlight potential overdose/suicide cases. They also reference a letter from NHS England to Ambulance Services about oversight of self-harm patients.