Birmingham and Solihull

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.

Concerns summary Critical details regarding urgent medical needs and safeguarding concerns were not sufficiently shared between immigration and accommodation providers. Furthermore, safeguarding matters were not logged when individuals were subject to deportation.

Concerns summary A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the risk of dangerous practice due to incorrect understanding of duties.

Concerns summary Inadequate dissemination of substance abuse risk assessment training and a failed review of crisis call communication protocols led to safety gaps. The protracted review of the Home Treatment Team model also raises concerns.

Concerns summary A critically ill mental health patient could not access immediate inpatient treatment due to a severe lack of local beds and distant, unappealing out-of-area options, exacerbated by age-segregated units.

Concerns summary The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic issues and incomplete risk assessments.

Concerns summary A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute inpatient mental health beds led to further self-harm and suicide attempts.

Concerns summary Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of residents returning from leave, and staff not being searched upon entry.

Concerns summary Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed through the plumbing system, and contraband mobile phones exacerbated substance misuse.

Concerns summary Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff absence, and a lack of integrated protocols across trust sites created inconsistent care standards.

Concerns summary Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.

Concerns summary Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and airport-style scanners at entry points.

Concerns summary National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.

Concerns summary There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, preventing effective risk management.

Concerns summary Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator caseloads, causing delayed follow-ups and inadequate risk assessments.

Concerns summary Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of timely patient follow-up, which created a risk to life.

Concerns summary Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia and inpatient bed shortages, overstretching Home Treatment Teams.

Concerns summary Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP referral, leaving the patient unsupported due to underfunding.

Concerns summary A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite an urgent family request, due to critical bed shortages and underfunding.

Concerns summary Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and unqualified staff conducting suicide risk assessments without training.