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
Stephen Jackson
All Responded
2018-0416 4 Oct 2018
Birmingham Clinical Commissioning Group NHS England
Community health care and emergency services related deaths Suicide (from 2015)
Concerns summary (AI 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.
Action Planned (AI summary) The CCG will be meeting the local authority to address differences in opinion regarding provision of services for alcohol, drug and substance misuse and homelessness. The Clinical network is currently providing support to review and plan services and the IST will be asked to provide support in December 2018. 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.
Michael Wheeler
All Responded
2018-0414 4 Oct 2018
Birmingham Clinical Commissioning Group NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI 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.
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.
Bradley Morgan
All Responded
2018-0412 4 Oct 2018
Birmingham Clinical Commissioning Group NHS England
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI 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.
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.
Michael Cooper
All Responded
2018-0413 4 Oct 2018
Birmingham Clinical Commissioning Group NHS England
Mental Health related deaths Suicide (from 2015)
Concerns summary (AI 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.
Noted (AI summary) The CCG will be meeting the local authority to address differences in opinion regarding provision of services for alcohol, drug and substance misuse and homelessness. The Clinical network is currently providing support to review and plan services and the IST will be asked to provide support in December 2018. The CCG provides background and context on mental health commissioning, including funding increases, but does not explicitly state actions taken or planned in direct response to the concerns raised in the report.
Paul Price
All Responded
19 Sep 2018
Birmingham and Solihull Mental Health T…
Community health care and emergency services related deaths
Concerns summary (AI summary) Critical delays in information sharing between mental health services and GPs, due to incompatible IT systems and communication failures, risk patient care and medication management.
2 responses from Paul Price Response2, Paul Price
Sufia Begum
All Responded
19 Sep 2018
Clinical Commission Group NHS England
Community health care and emergency services related deaths
Concerns summary (AI summary) Many doctors are unaware of the BNF mobile app, a crucial tool for identifying potential drug interactions, risking preventable deaths from unknown medication interactions.
2 responses from Sufia Begum Response2, Sufia Begum
Paul Ryley
All Responded
2018-0284 14 Sep 2018
Toxbase
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial treatment for liver toxicity.
Action Taken (AI summary) The NPIS has added a statement to the paracetamol index in TOXBASE guidance: "If the patient re-presents following assessment and discharge, manage as per a new presentation."
Daniel Collins
Historic (No Identified Response)
2018-0283 14 Sep 2018
Birmingham and Solihull Clinical Commis… Birmingham Women’s and Children’s NHS T…
Hospital Death (Clinical Procedures and medical management) related deaths Suicide (from 2015)
Concerns summary (AI summary) A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.
Kiarah Allen
Partially Responded
2018-0253 21 Aug 2018
Birmingham Woman’s and Children NHS Tru… CRG Lead Commissioner
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Unsafe nursing and clinical staffing levels result from funding models based on 85% occupancy, leaving insufficient personnel when the unit is full and caring for very sick babies.
Action Taken (AI summary) The Trust is working to improve commissioning and funding arrangements for the Neonatal Intensive Care Unit (NICU) with NHS England. Several actions have already been implemented to improve the NICU, including ordering additional labels and standardizing practices.
Darren Neilson
All Responded
2018-0231 18 Jul 2018
BAE Systems Ltd MOD
Service Personnel related deaths
Concerns summary (AI summary) The tank was able to fire without the BVA assembly being present, a hazard not adequately considered during production and manufacture. There was also no written process to check for the BVA assembly's presence or confirm when it should be removed and stored.
Action Taken (AI summary) Following the accident, a ban on all 120mm training ammunition natures was ordered and an Extraordinary Safety and Environmental Management Panel (SEMP) was convened. Three systemic issues relating to safety have been identified across DE&S and will be resolved. Following the incident in June 2017 the MoD and BAE Systems are developing a design solution to eliminate the risk of this happening again and to bring the current Challenger 2 gun up to date with the Standard. Progress on four solutions will be reviewed by the MoD Challenger 2 Safety and Environmental Management Panel in October 2018.
Matthew Hatfield
All Responded
2018-0231-wp26293 18 Jul 2018
BAE Systems Ltd MOD
Service Personnel related deaths
Concerns summary (AI summary) Soldiers lacked clarity on gun safety drills, and the officer in charge lacked critical information on tank status. Risk assessments also failed to identify a design flaw allowing guns to fire without a vital safety assembly.
Disputed (AI summary) • Immediately following the tragic accident; ban on all 12Omm training ammunition natures was ordered by Defence General Munitions ("DGM"). • Once all live fire training on Challenger 2 ("CR2") tanks was halted, an Extraordinary Safety and Environmental Management Panel ("SEMP") was convened. • The SEMP held a series of four extraordinary meetings (20 June, 12 July, 24 July and August 2017) to investigate the incident.
Kathleen Allen
All Responded
2018-0213 4 Jul 2018
University Hospitals Birmingham NHS Tru…
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a risk of inconsistent patient monitoring and delayed escalation.
Action Taken (AI summary) The Trust has deployed an ED-specific MEWS Observation Chart for use in the BHH and Good Hope EDs, and the Solihull Minor Injuries Unit; the ED directorate has circulated an email to Divisional Directors across HGS sites disseminating the ED MEWS SOP; the nurse responsible for the care of Mrs Allen has received a period of supervised practice and completed targeted objectives.
Keiron Bould
Partially Responded
2018-0178 13 Jun 2018
National Police Chiefs' Council Warwickshire Police West Midlands Police
Police related deaths
Concerns summary (AI summary) Lack of clear communication protocols between police forces regarding incident primacy and case transfers led to significant delays in handling a missing person report.
Action Taken (AI summary) Warwickshire Police has updated its working practice guidance to require call handlers to follow up a transfer of a missing person report to another force with a telephone call to confirm receipt of information. They have also re-circulated College of Policing guidance on ownership of missing persons.
Imtiaz Mohammed
Partially Responded
2018-0170 1 Jun 2018
Birmingham City Council Sandwell Borough Council
Road (Highways Safety) related deaths
Concerns summary (AI summary) Excessive speed, defective tyres, driving under the influence of cannabis, and non-use of seatbelts resulted in a fatal multi-vehicle collision.
Noted (AI summary) The Department for Transport has no current plans to introduce mandatory drug screening for professional drivers. The coroner's report has been shared with policy officials dealing with drug driving.
Francis Beech
Partially Responded
2017-0367 12 Dec 2017
Heart of England NHS Trust St Giles Care Home
Care Home Health related deaths Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital lacked clear guidelines for high-risk fracture management, leading to poor continuity of care and inadequate discharge planning. The nursing home also failed to implement cast care plans, monitor for infection, or train staff.
Action Taken (AI summary) The care home has implemented a care of plaster cast policy and procedure, a care of plaster cast care plan, supervision and training with staff, and the National Early Warning score.
Mildred Griffiths
All Responded
2017-0400 17 Nov 2017
St Giles Nursing Home
Care Home Health related deaths
Concerns summary (AI summary) The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing lesions and uses an inverse scoring method.
Noted (AI summary) Avery Health Group states they will continue to use the Braden pressure ulcer risk tool but will keep this under ongoing review considering national guidance and standards.
Conall Gould
All Responded
2017-0458 28 Sep 2017
Northern Health and Social Care Trust
Mental Health related deaths
Concerns summary (AI summary) The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust lacked a policy requiring written confirmation. This created a significant risk of missed appointments and inadequate care review.
Action Taken (AI summary) The Northern Health and Social Care Trust has introduced a requirement for written confirmation of follow-up appointments and contact numbers to be provided to patients and, with consent, their relatives/concerned others upon discharge from hospital, documented in the Integrated Care Protocol.
Mohammad Ashraf
All Responded
2017-0243 1 Sep 2017
Al Hijrah School Birmingham City Council Birmingham Community Healthcare NHS Tru… +1 more
Child Death (from 2015) Community health care and emergency services related deaths Other related deaths
Concerns summary (AI summary) Inaccurate and delayed care plans, poor communication between the school and catering service, and a failure to disseminate critical safety recommendations by the local authority resulted in inadequate allergy management for pupils.
Noted (AI summary) The Trust confirms that it has worked with Al-Hijrah school to provide a full response, and that its comments have been incorporated into the school's letter. This response is not classifiable as it appears to be a scan of a coversheet only. The content is unreadable and does not contain any meaningful information about actions taken or planned.
James Harris
All Responded
2017-0334 21 Jul 2017
Care First Class UK Limited Care Quality Commission
Care Home Health related deaths
Concerns summary (AI summary) Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an absent registered manager.
Noted (AI summary) Care First Class UK has implemented read and sign sheets for care plans, provided a falls protocol to all staff, maintained records of nightly checks, and addressed pain management procedures; management staff are also monitoring records to address any issues arising. CQC acknowledges the concerns raised regarding Cherry Lodge Care Home, details actions taken by the provider, and explains its regulatory role and monitoring of the situation, including the need for a registered manager and ongoing assessments.
David Sheppard
Partially Responded
2017-0153 8 May 2017
Boldmere Court Care Home Care Quality Commission Department of Health and Social Care
Care Home Health related deaths
Concerns summary (AI summary) Communication breakdowns due to poor English language skills among care staff, inadequate first aid training, poor record-keeping, and substandard post-event investigation hindered effective emergency response and learning.
Noted (AI summary) The Department of Health acknowledges the concerns and outlines the responsibilities of care providers and the CQC. They clarify the role of the NMC and the requirements for language testing for non-regulated workers, noting the Care Certificate covers communication.
Ahsiyah Bibi
Historic (No Identified Response)
2017-0142 30 Apr 2017
Heart of England NHS Trust
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Critical blood gas results were lost, delaying treatment. A significant insulin prescribing error occurred due to clinicians confusing doses, exacerbated by inadequate dose checking and lack of Trust-wide learning from errors.
Johan Pambou
All Responded
2017-0125 20 Apr 2017
NHS England
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also raised about the availability of essential vaccines and GPs' knowledge of how to access them.
Action Planned (AI summary) NHS England has established a serious incident group to address issues at the GP practice, including systems for monitoring letters and vaccine availability. They are developing a letter to GPs reinforcing responsibilities, and a Performance Advisory Group will consider regulatory action for the GP.
Leah Ratheram
Historic (No Identified Response)
2017-0081 15 Mar 2017
Birmingham and Solihull Mental Health T… Birmingham Children’s Hospital NHS Trust Birmingham City Council +2 more
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Fragmented mental health services for young adults, with separate organizations and incompatible record systems, led to uncoordinated care, poor information sharing, and unclear responsibility during patient transfers in crisis.
Frederick Bevan
Historic (No Identified Response)
2017-0060 9 Mar 2017
Bondcare Limited
Care Home Health related deaths
Concerns summary (AI summary) A poor handover practice led to paramedics receiving an inaccurate incident history from a non-witnessing nurse instead of the witnessing carer, risking detrimental effects on treatment.
Roger Tombs
Partially Responded
2017-0027 13 Feb 2017
Care Quality Commission Solihull Falls Team Sunrise Senior Living
Care Home Health related deaths
Concerns summary (AI summary) Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.
Noted (AI summary) Sunrise Senior Living acknowledges the report but states it is leaving the Home's management and registration with CQC on 1 March 2017. It invites dialogue and can describe immediate actions taken after the inquest but not future measures. The Falls Team reviewed its practices after the PFD report and found them consistent and accurate. A guidance document outlining good practice in sensor mat use was developed and sent to the local council for circulation to care homes in the borough.