Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Patricia Cleghorn · 25 Jul 2016 · Louise Hunt, Birmingham and Solihull
“The deceased could not be admitted to hospital as there were no inpatient beds available.”
What was promised
Stated action 1 · response to Patricia Cleghorn (25 Jul 2016) · stated 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”
judiciary.uk/…/2016-0270-Response-by-Birmingham-and-Solihull-NH…
Stated action 2 · response to Patricia Cleghorn (25 Jul 2016) · stated 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”
judiciary.uk/…/2016-0270-Response-by-Birmingham-and-Solihull-NH…
Stated action 3 · response to Patricia Cleghorn (25 Jul 2016) · stated 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.”
judiciary.uk/…/2016-0270-Response-by-Birmingham-and-Solihull-NH…
4 further stated actions are listed on the full chain page.
What recurred
- 7 Feb 2019 · Stephen Kennedy · Louise Hunt · Identical hazard · confidence 0.92 (high)
- 27 Sept 2019 · Anthony McCormack · Emma Brown · Identical hazard · confidence 0.90 (high)
- 11 Jan 2023 · Leroy Hamilton · Louise Hunt · Closely related · confidence 0.85 (high)
- 23 Nov 2023 · Philip Malone · James Bennett · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Patricia Cleghorn · 25 Jul 2016
“The deceased could not be admitted to hospital as there were no inpatient beds available.”
Later · Stephen Kennedy · 7 Feb 2019
“In August 2018 the deceased required inpatient treatment. There were no beds available and as a result he had further episodes of self-harm and suicide attempts.”
What happened next
No evidence found either way · stated action 1
“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”
Urgent care · bsmhft.nhs.uk/our-services/urgent-care
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“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.”
Birmingham and Solihull Mental Health NHS Foundation ... · cqc.org.uk/provider/RXT/inspection-summary
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Welcome to Birmingham and Solihull Mental Health NHS Foundation Trust Excellent care, empowered people, thriving communities”
Welcome - Birmingham and Solihull Mental Health NHS Foundation Trust · bsmhft.nhs.uk
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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.”
“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”
OLD PROBLEMS, NEW SOLUTIONS: · rcpsych.ac.uk/…/policy-old-problems-new-solutions-caapc-report-…
“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................................................................................................................”
Mental Health – Adult Crisis and Acute Care · gettingitrightfirsttime.co.uk/…/Mental-Health-Sept21i.pdf
“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 ..................................”
Extended Acute Care (EAC) Services · cbhphilly.org/wp-content/uploads/2022/10/CBH_CPS_EAC_2026-03.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “From September 2019, subject to recruitment, we anticipate to be in a position whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist within their team”
“Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) is proud to provide inpatient, community and specialist mental health care for over 80,000 people across Birmingham and Solihull and the West Midlands.”
Birmingham and Solihull Mental Health NHS Foundation Trust · linkedin.com/…/birmingham-and-solihull-mental-health-nhs-founda…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The CCG has recently provided a comprehensive report to the HM Senior Coroner for Birmingham and Solihull on mental health services in the area, in response to a Regulation 28 report to prevent future deaths.”
“The investigation concluded at the end of the inquest. The conclusion of the inquest was; Killed unlawfully”
Birmingham and Solihull Mental Health NHS Found · hundredfamilies.org/…/PFD-Matthew-Lynch-Jul-23-.pdf
“I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.”
Birmingham and Solihull Mental Health NHS Found · hundredfamilies.org/…/PFD-Matthew-Lynch-Jul-23-.pdf
“The investigation concluded at the end of the inquest. The conclusion of the inquest was; Killed unlawfully”
Birmingham and Solihull Mental Health NHS Found · hundredfamilies.org/…/PFD-Matthew-Lynch-Jul-23-.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The CCG has been working closely with both local mental health service providers and the third sector, with the aim of improving the service offer for people experiencing a mental health crisis. Stakeholders are working on designing community based services, which will increase accessibility for those in crisis and their families, to deliver the most appropriate support at the earliest opportunity.”
“Welcome to Birmingham and Solihull Mental Health NHS Foundation Trust Excellent care, empowered people, thriving communities”
Welcome - Birmingham and Solihull Mental Health NHS Foundation Trust · bsmhft.nhs.uk
No evidence found does not mean the action did not happen.