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Recurance · prevention of future deaths reports

Pre-inquest brief

Insufficient nighttime staffing leading to missed healthcare involvement in ACCT

Organisation: Birmingham and Solihull Mental Health NHS Foundation Trust · Generated: 27 Oct 2026

Recurance · recurance.com/chains/82eebe93f83c929b

The earlier warning

Yohannes Kidane · 3 Sept 2014 · Louise Hunt, Birmingham & Solihull

“The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards.”

judiciary.uk/prevention-of-future-death-reports/yohannes-kidane

What was promised

Stated action 1 · response to Yohannes Kidane (3 Sept 2014) · stated timescale: none stated

“The night staffing level for HMP. Birmingham was reviewed. when responsibility for its Operation was transferred to G4S, and NOMS is ste that it is acceptable. G4S has chosen to deploy a Prison Custody Officer (PCO) to patro] the healthcare centre at night, and this is beyond the public sector benchmark which would require the use. an Operational Support Grade (OSG) for this purpose. This allows extr: flexibility, as a PCO is trained and authorised to perform additional dutles, such-as to unoch”

judiciary.uk/…/2014-0392-Response-by-NOMS.pdf

What recurred

  • 18 Dec 2018 · John Delahaye · Emma Brown · Closely related · confidence 0.80 (moderate)

The clearest link, quoted from both reports:

Earlier · Yohannes Kidane · 3 Sept 2014

“The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards.”

Later · John Delahaye · 18 Dec 2018

“No member of the healthcare team was present at any of Mr. [name redacted] ACCT reviews.”

What happened next

No web check of the stated actions has been published for this chain.

Every quote is verified word for word against the original report on judiciary.uk. A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person.

Source: Courts and Tribunals Judiciary, Open Government Licence v3.0.