Birmingham and Solihull Mental Health NHS Foundation Trust

PFD Addressee

Reports: 31 Earliest: Sep 2014 Latest: 14 Apr 2026

86% 2-year response rate (above 83% average). 38% of classified responses show concrete action taken.

Responded 6 Pending 1

Action Taken 38%

Action Planned 42%

Noted 18%

Disputed 2%

Based on 60 classified responses

PFD Reports

31 results

Greg Hutchins

Historic (No Identified Response)

2018-0129 12 Sep 2018 Warwickshire

Mental Health related deaths

Concerns summary (AI summary) Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in record-keeping and inter-area communication.

Leah Ratheram

Historic (No Identified Response)

2017-0081 15 Mar 2017 Birmingham and Solihull

Child Death 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.

Patricia Cleghorn

2016-0270 25 Jul 2016 Birmingham and Solihull

Community health care and emergency services related deaths

Concerns summary (AI summary) The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside a failure to conduct a formal risk assessment despite repeated threats of overdose.

Noted (AI summary) NHS England highlights the establishment of an adult mental health programme taking a whole system approach and reiterates the national ambition of reducing suicides, with Clinical Commissioning Groups expected to develop local multi-agency suicide prevention plans by 2017, supported by further national investment from 2018/19. The Department of Health acknowledges the concerns raised, refers to the government's mandate for accessible and high-quality crisis services, and notes that the availability of mental health beds is a matter for local commissioners, addressed by NHS England's response. The Senior Nurse for Professional Standards issued a formal practice alert regarding risk assessments, and a Clinical Risk Management Group has been established. The Head of Pharmacy will review the Medicines Code by the end of November 2016. The CQC is requiring the Trust to clarify the role of non-registered staff in the crisis team. The CQC will formally review the actions put in place by the Trust and their impact of those actions on patients at the quarterly meeting with the Trust in December 2016.

Luke Ayres

2016-0148 15 Apr 2016 Birmingham and Solihull

Mental Health related deaths State Custody related deaths Suicide

Concerns summary (AI summary) Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current patient status, and paramedics not being immediately escorted to the ward.

Action Planned (AI summary) The trust has improvement measures in place including implementation of a single anti barricade system, replacement of 70 observation panels and piloting of a new clinical handover tool. The trust will also implement a more robust approach to Environmental and ligature risk assessments and extend the simulation of medical emergencies on wards.

Doreen England

Partially Responded

2015-0291 23 Jul 2015 Birmingham and Solihull

Mental Health related deaths

Concerns summary (AI summary) The patient at high risk of pressure sores lacked a care plan, staff lacked knowledge and training in prevention, and the ward suffered from inadequate leadership and medical cover. RMN training also failed to cover pressure sores sufficiently.

Action Planned (AI summary) NHS England will oversee a specific action plan to address deficiencies in care, particularly regarding pressure sore risk assessment. The matter has been tabled for discussion in the Quality Surveillance Group.

Yohannes Kidane

2014-0392 3 Sep 2014 Birmingham & Solihull

State Custody related deaths

Concerns summary (AI summary) Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and the quality of care provided.

Noted (AI summary) NOMS reviewed the night staffing level for HMP Birmingham and found it acceptable, noting G4S's deployment of a Prison Custody Officer. They state that the Night Orderly Officer arranges cover for breaks, and additional staff are provided for prisoners under continuous supervision. The Trust has liaised with Birmingham Community Healthcare Trust and G4S to address staffing concerns and is considering options for staff breaks, including administrative duty sharing. They are engaging the commissioner regarding funding for an extra staff member and have met with G4S to discuss non-clinical duties.