Birmingham and Solihull

Coroner Area
Reports: 192 Earliest: Sep 2013 Latest: 14 Apr 2026

88% response rate (above 63% average).

Response Status
Responded 169 Historic 22 Pending 1
AI Classification
Action Taken 44%
Action Planned 33%
Noted 22%
Disputed 1%
Based on 299 classified responses
Top Categories
Hospital Death (Clinical Procedure… (69) Mental Health related deaths (29) Suicide (from 2015) (27) Care Home Health related deaths (23) Other related deaths (20)
Quarterly Trend
Category Breakdown
How does this area compare?
vs West Midlands average: +118 reports · +24pp response rate
vs national average: +108 reports · +25pp response rate
192 results
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.
Marcus McGuire
All Responded
2019-0209 23 Jun 2019
HMP Birmingham, MOJ, G45
Mental Health related deaths State Custody related deaths
Concerns summary (AI 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.
Noted (AI summary) HMP Birmingham has trained additional case managers, monitors compliance with the single case manager model daily, reviews it monthly, and has introduced further quality assurance of every ACCT document. G4S states that actions at HMP Birmingham are not within its remit as the prison is now operated and managed by HMPPS, but they reflect on every death in custody and consider lessons learned to inform best practice across their establishments.
Aram Mustafa
All Responded
2019-0508 19 Jun 2019
G4S Home Office Urban Housing Services
Suicide (from 2015)
Concerns summary (AI 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.
Action Planned (AI summary) G4S now alerts its subcontractor UHS immediately of safeguarding concerns raised in Service Commission Forms from UKVI so that such cases can be raised with the Senior Safeguarding working group. Significant improvements have been made in relation to such cases, in particular, with the information conveyed by UKVI to G4S/UHS. Urban Housing Services has reviewed procedures and interactions with other agencies, including flagging incomplete safeguarding information with UKVI and G4S, directly notifying hospital visits to Attwood Green Medical Centre, updating out-of-hours guidance, and recording additional information in staff handover books. The Home Office is reviewing processes to ensure sufficient information is provided on Service Commission Forms, balancing this with data protection requirements. The Home Office will also share learning from this incident widely.
Ronald Lowe
All Responded
2019-0113 3 Apr 2019
University Hospitals Birmingham NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The Trust conducted a review of outpatient CTPA studies, created a central register for radiographer training across multiple sites, and reviews staff training during annual appraisals.
Nora Bruton
All Responded
2019-0090 25 Mar 2019
Birmingham & Solihull Mental Heath NHS …
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI 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.
Action Taken (AI summary) Birmingham and Solihull Mental Health NHS Trust has developed a dedicated crisis email address for Home Treatment Teams with dedicated support to manage the system. They have also increased the capacity of the out of hours service by putting a senior clinician (Band 7) on duty each evening and have increased the capacity of their Home Treatment Teams and are now ‘over-recruited’ to medical positions.
Anthony Watson
All Responded
2019-0044 12 Feb 2019
Birmingham and Solihull Clinical Commis… NHS England
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary (AI 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.
Noted (AI summary) By 2023/24, anyone experiencing a mental health crisis will be able to call NHS 111 and access 24/7 age-appropriate mental health community support. By 2020/21 no acute hospital will be without a mental health liaison service for all ages in A&E departments and inpatient wards. The CCG acknowledges the coroner's concerns, noting that there appear to have been failings in care delivery which impacted on the ability for a bed to be located for Mr Watson, which BSMHFT have identified and taken actions to rectify.
Jean Cutler
All Responded
2019-0040 8 Feb 2019
Cole Valley Care Limited
Care Home Health related deaths
Concerns summary (AI 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.
Action Taken (AI summary) New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed, considering internal and external risk factors. A new competent, experienced and dynamic manager who will provide strong leadership and governance is to commence employment at the Home before the end of April 2019.
Stephen Kennedy
All Responded
2019-0039 7 Feb 2019
Birmingham and Solihull Mental Health N… Birmingham Cross City Clinical Commissi… Department of Health and Social Care
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide (from 2015)
Concerns summary (AI 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.
Noted (AI summary) The Department of Health and Social Care highlights national initiatives to improve mental health services, including expanding CRHTTs, integrating primary and secondary care, and establishing a national single point of contact for mental health crises. They also reaffirm commitment to suicide prevention and will continue measures through the existing suicide reduction programme. The Trust is developing training and guidance for staff on Personality Disorder and patients with Personality Disorder, to be mandated for all staff working within our Home Treatment Teams during 2019/20. A Personality Disorders Strategy which includes clinical standards to be met for patients with a diagnosis of Personality Disorder is being led by the Trust's Chief Psychologist. The CCG acknowledges the coroner's concerns and is unable to identify any correlation between funding and this death, but has recognised the need to continually improve its quality monitoring function and to also improve processes for learning from deaths at the earliest opportunity.
Stephen Harte
All Responded
2019-0077 1 Feb 2019
Birmingham and Solihull Clinical Commis… Care Quality Commission
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI 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.
Noted (AI summary) The trust is developing a drug strategy to address illicit substance use in the medium secure unit including risk assessments, educational sessions, opiate replacement consideration and potentially making Naloxone available on discharge; it is anticipated to be in place from January 2020. The CQC clarifies its role in inspections, stating they did not ask the trust to relax rules on takeaways, but did ask for review of blanket restrictions and active risk assessment for patients returning from leave. They review actions taken by organisations if informed of drug problems.
Andrew Carr
Historic (No Identified Response)
2019-0038 31 Jan 2019
G4S HM Prisons and Probation MOJ
Alcohol, drug and medication related deaths State Custody related deaths
Concerns summary (AI 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.
Ann Swoffer
All Responded
2019-0026 22 Jan 2019
University Hospitals Birmingham NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
Action Taken (AI summary) The Trust found the guidelines are recognized and used at Good Hope Hospital, and a gastroenterology consultant now attends weekend ward rounds. A unified operational structure will be established by May 2019, with alignment of protocols and guidelines across sites as a short-term goal.
Neil Black
All Responded
2019-0024 21 Jan 2019
Birmingham Community Healthcare NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.
Action Taken (AI summary) A new protocol clarifies physical observations for prisoners, and IDTS nurses now complete the National Early Warning Score (NEWS). Healthcare staff were reminded on February 13, 2019, to ensure appropriate observations are carried out during physical examinations.
Ricardo Holgate
Partially Responded
2019-0012 11 Jan 2019
G4S HM Prisons and Probation Service MOJ
State Custody related deaths
Concerns summary (AI 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.
Noted (AI summary) G4S states that HMP Birmingham is currently being managed by HMPPS and decisions regarding actions/equipment are not within their remit, but they agree with the need for CCTV and airport-style scanners and state that the governor's appointment has been extended.
John Delahaye
Partially Responded
2018-0388 18 Dec 2018
Birmingham and Solihull Mental Health N… Birmingham Community NHS Trust G4S +2 more
State Custody related deaths Suicide (from 2015)
Concerns summary (AI 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.
Action Planned (AI summary) NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems; and SNOMED CT has been introduced as an alternative coding system into the prison general practice electronic medical records; SystmOne since 14 January 2019.
Jacqueline Oakes
Partially Responded
2018-0419 16 Oct 2018
Home Office MOJ
Other related deaths
Concerns summary (AI summary) There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, preventing effective risk management.
Noted (AI summary) HM Prison and Probation Service describes existing arrangements for sharing risk information with partner agencies when a high-risk offender is released, including MAPPA and MASH. Guidance on activity required at the termination of sentence is currently being written.
Simon Graham
Partially Responded
2018-0418 4 Oct 2018
Birmingham Clinical Commissioning Group Future Care & Social Care Association NHS England
Mental Health related deaths
Concerns summary (AI 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.
Action Planned (AI summary) NHS England will ensure services are commissioned and provided to ensure risk assessments are available 24/7, and the CCG will meet with the local authority to address differences in opinion regarding prevention services for alcohol, drug misuse and homelessness; the Intensive Support Team (IST) will provide support in December 2018. The CCG provided funding to Forward Thinking Birmingham (FTB) for a personality disorder pathway and clinical lead, and invested in BSMHFT to appoint a clinical lead for personality disorder; they also invested in a primary care liaison model and increased staffing in 'step up step down' provision.
William Edge
All Responded
2018-0417 4 Oct 2018
Birmingham Clinical Commissioning Group NHS England
Mental Health related deaths
Concerns summary (AI 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.
Action Planned (AI summary) Birmingham and Solihull CCG has already invested in various mental health services, including a new pathway for personality disorders, increased community provision, and staffing for 'step up step down' services. NHS England acknowledges concerns about mental health service demands and funding. They state that providers will make more robust plans to contact patients who do not attend appointments, and will ensure risk assessments are available 24/7; the CCG will meet with the local authority to address prevention services.