Lack of approved mental health practitioner for assessment
Birmingham and Solihull Mental Health NHS Foundation Trust received 3 coroners' reports about this hazard between 15 Mar 2017 and 4 Mar 2025.
They came from 1 coroner. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed.”
Original on judiciary.uk ↗ No published response from Birmingham and Solihull Mental Health NHS Foundation Trust was found for this report.
- 2 years 4 months laterIdentical hazardConfidence 0.90 · high
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18. I was told this was an ongoing problem and was delaying assessments.”
Original on judiciary.uk ↗ Repeated from the earlier report:approvedMentalHealthassessment
Birmingham and Solihull Mental Health NHS Foundation Trust responded.Response (PDF) ↗Response (PDF) ↗
- 5 years 7 months laterClosely relatedConfidence 0.90 · high
“The inquest heard evidence that there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing.”
Original on judiciary.uk ↗ Repeated from the earlier report:Mentalhealth
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.
2017 → 2019Richard Carlon2 years 4 months after Leah Ratheram · same coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a shortage or non‑involvement of approved mental health practitioners needed to conduct Mental Health Act assessments, which compromises assessment quality and patient safety.
Leah Ratheram · 15 Mar 2017
“The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed.”
Original on judiciary.uk ↗ Richard Carlon · 22 Jul 2019
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18. I was told this was an ongoing problem and was delaying assessments.”
Original on judiciary.uk ↗ 2019 → 2025Matthew Lynch5 years 7 months after Richard Carlon · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the availability or willingness of Approved Mental Health Professionals to conduct Mental Health Act assessments. The earlier report notes an ongoing shortage causing delays, while the later report describes resistance, administrative and resourcing barriers to using S2 and S3 of the Act.
Richard Carlon · 22 Jul 2019
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18.”
Original on judiciary.uk ↗ Matthew Lynch · 4 Mar 2025
“The inquest heard evidence that there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing.”
Original on judiciary.uk ↗
No published response from Birmingham and Solihull Mental Health NHS Foundation Trust was found for this report.
No specific action could be extracted with a verified quote.
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 |
|---|---|---|---|---|
| 2017 → 2019 | 0.74 | 0.19 | Identical · 0.90 | same |
| 2019 → 2025 | 0.67 | 0.11 | Closely related · 0.90 | same |
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
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.