Lack of risk assessment for missing persons
Birmingham and Solihull Mental Health NHS Foundation Trust received 2 coroners' reports about this hazard between 25 Jul 2016 and 11 Jan 2023.
They came from 1 coroner. 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 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her”
Original on judiciary.uk ↗ Birmingham and Solihull Mental Health NHS Foundation Trust responded, stating 4 specific actions.Response (PDF) ↗Response (PDF) ↗
“Creation of an urgent care assessment team to concentrate specifically on the assessment of patients who are in crisis. This approach has been piloted and has demonstrated that having an urgent care assessment team improves outcomes for patients at this vulnerable time. The substantive team will be in place by the end of September 2016”
Stated timescale: end of September 2016
Web search (Tavily): No evidence found either way
Urgent care ↗“One consultant psychiatrist will form part of each home treatment team to ensure that all patients who are presenting high levels of risk have daily access to medical review or medical opinion. This will be in place across all of our home treatment teams by the end of October 2016”
Stated timescale: end of October 2016
Web search (Tavily): No evidence found either way
Birmingham and Solihull Mental Health NHS Foundation ... ↗2 more stated actions in the Promises tab.
- 6 years 6 months laterClosely relatedConfidence 0.90 · high
“When Mr [name redacted] was first reported as missing no risk assessment was undertaken about his level of risk to himself”
Original on judiciary.uk ↗ Repeated from the earlier report:riskassessmentundertaken
Birmingham and Solihull Mental Health NHS Foundation Trust responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 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.
2016 → 2023Leroy Hamilton6 years 6 months after Patricia Cleghorn · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a lack of proper risk assessment concerning individuals at risk of self‑harm. The earlier case involved medication availability while the later case involves missing‑person risk assessment.
Patricia Cleghorn · 25 Jul 2016
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her”
Original on judiciary.uk ↗ Leroy Hamilton · 11 Jan 2023
“When Mr [name redacted] was first reported as missing no risk assessment was undertaken about his level of risk to himself”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We will take action with regards to managing the breach of policy The Senior Nurse for Professional Standards issued a formal practice alert on 12th September 2016 to registered and unregistered clinicians in our crisis and community teams to reinforce the requirements for: Clinical Risk Assessments regarding risk of self-harm and/or suicide; Risk Assessments with regard to medicines management and self-medication; Safe administration of medication as per current Medicines Code and NMC Code.”
Stated action · timescale: end of September 2016
“Creation of an urgent care assessment team to concentrate specifically on the assessment of patients who are in crisis. This approach has been piloted and has demonstrated that having an urgent care assessment team improves outcomes for patients at this vulnerable time. The substantive team will be in place by the end of September 2016”
What happened next: No evidence found either way
The Birmingham and Solihull Mental Health NHS Foundation Trust describes an urgent care pathway and crisis services but does not specify a team to be established by the end of September 2016.
“Birmingham and Solihull Mental Health NHS Foundation Trust has an urgent care pathway which has been developed to improve patients' access to urgent mental health assessment. This pathway involves partnerships with the acute hospitals in Birmingham and Solihull, plus the Police, West Midlands Ambulance Service and third sector organisations. At the core of the work is the delivery of the crisis”
No evidence found does not mean the action did not happen.
Stated action · timescale: end of October 2016
“One consultant psychiatrist will form part of each home treatment team to ensure that all patients who are presenting high levels of risk have daily access to medical review or medical opinion. This will be in place across all of our home treatment teams by the end of October 2016”
What happened next: No evidence found either way
The trust's strategy mentions digital transformation and service development but does not specify a timeline for implementing daily medical reviews in home treatment teams.
“Birmingham and Solihull Mental Health NHS Foundation Trust provides mental health services for people of Birmingham and Solihull, and to communities in the West Midlands and beyond.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 12th September 2016
“We will take action with regards to managing the breach of policy The Senior Nurse for Professional Standards issued a formal practice alert on 12th September 2016 to registered and unregistered clinicians in our crisis and community teams to reinforce the requirements for: Clinical Risk Assessments regarding risk of self-harm and/or suicide; Risk Assessments with regard to medicines management and self-medication; Safe administration of medication as per current Medicines Code and NMC Code.”
What happened next: No evidence found either way
The Trust's public pages and policy documents describe a formal practice alert issued on 12th September 2016 reinforcing requirements for risk assessments and medication safety, but no source confirms the alert was implemented or withdrawn.
“Welcome to Birmingham and Solihull Mental Health NHS Foundation Trust Excellent care, empowered people, thriving communities”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2020/21
“NHS England recently established an adult mental health programme which is taking a whole system approach comprising crisis, acute, and community/primary care work streams. The acute care work stream has been developed in response to a number of recommendations set out by the Commission on Acute Adult Psychiatric Care and The Five Year Forward View for Mental Health, and is particularly relevant to the concerns outlined in your report.”
What happened next: No evidence found either way
The NHS England adult mental health programme was described as a whole-system initiative with an acute care work stream developed in response to recommendations, but no source confirms it was operational by 2020/21.
“The Commission to review the provision of acute inpatient psychiatric care for adults FEBRUARY 2016 OLD PROBLEMS, NEW SOLUTIONS: Improving acute psychiatric care for adults in England FINAL REPORT Old Problems, New Solutions: Improving Acute Psychiatric Care for Adults in England Published: February 2016 The independent Commission on Acute Adult Psychiatric Care was set up by the Royal College of”
“Mental Health - Adult Crisis and Acute Care GIRFT Programme National Specialty Report By Dr [name redacted] GIRFT Clinical Lead April 2021 GIRFT is delivered in partnership with the Royal National Orthopaedic Hospital NHS Trust, NHS England and NHS Improvement 2 Contents Foreword................................................................................................................”
“CLINICAL PERFORMANCE STANDARDS Extended Acute Care (EAC) Services Updated March 2026 CPS: EXTENDED ACUTE CARE (EAC) SERVICES Updated March 2026 2 TABLE OF CONTENTS 1. Purpose ......................................................................................................................................................... 3 2. Scope of Services ..................................”
No evidence found does not mean the action did not happen.
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.
- 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 |
|---|---|---|---|---|
| 2016 → 2023 | 0.71 | 0.20 | 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
- Lack of approved mental health practitioner for assessment3 reports · 2017–2025
- Lack of medication monitoring after clinic visit2 reports · 2023–2025
- Lack of acute mental health inpatient beds5 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.