Lack of medication monitoring after clinic visit
Birmingham and Solihull Mental Health NHS Foundation Trust received 2 coroners' reports about this hazard between 14 Jul 2023 and 4 Mar 2025.
They came from 2 different coroners. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“the deceased went without his medication. The deceased's GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse's involvement.”
Original on judiciary.uk ↗ Birmingham and Solihull Mental Health NHS Foundation Trust responded.Response (PDF) ↗
- 1 year 8 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“Internal investigation: The internal investigation did not address how and whether the offender's use of medication should have been monitored after the clinic visit on 12/05/23.”
Original on judiciary.uk ↗ Birmingham and Solihull Mental Health NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗Response (PDF) ↗
“The review acknowledged the risk of relapse identified in May 2023 on page 14, identifying that whilst plans were made within the Multi-disciplinary Team, there was no clear process to track these actions, leading to a lack of oversight. If there had been stronger oversight, the team would have been aware of the non-compliance with medication sooner, allowing for timely intervention. This would have included tracking the perpetrator's prescription. To address this, the team has now implemented a”
- All reports to Birmingham and Solihull Mental Health NHS Foundation Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2023 → 2025Matthew Lynch1 year 8 months after Peter Fleming · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures in monitoring and communicating medication-related information between healthcare providers. The earlier report cites missed carbamazepine prescribing due to poor specialist‑team communication, while the later report notes inadequate post‑clinic medication monitoring and investigation.
Peter Fleming · 14 Jul 2023
“the deceased went without his medication. The deceased's GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse's involvement.”
Original on judiciary.uk ↗ Matthew Lynch · 4 Mar 2025
“Internal investigation: The internal investigation did not address how and whether the offender's use of medication should have been monitored after the clinic visit on 12/05/23.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
Stated action
“The review acknowledged the risk of relapse identified in May 2023 on page 14, identifying that whilst plans were made within the Multi-disciplinary Team, there was no clear process to track these actions, leading to a lack of oversight. If there had been stronger oversight, the team would have been aware of the non-compliance with medication sooner, allowing for timely intervention. This would have included tracking the perpetrator's prescription. To address this, the team has now implemented a”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Birmingham and Solihull Mental Health NHS Foundation Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2023 → 2025 | 0.71 | 0.08 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Birmingham and Solihull Mental Health NHS Foundation Trust
- Lack of approved mental health practitioner for assessment3 reports · 2017–2025
- Lack of acute mental health inpatient beds5 reports · 2016–2023
- Lack of risk assessment for missing persons2 reports · 2016–2023
- Insufficient nighttime staffing leading to missed healthcare involvement in ACCT2 reports · 2014–2018
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.