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Recurance · prevention of future deaths reports

Pre-inquest brief

Insufficient treatment capacity for serious mental illness

Organisation: NHS England · Generated: 26 Oct 2026

Recurance · recurance.com/chains/b72c8003e4a4aa8a

The earlier warning

Reece Lapina-Amarelle · 9 Aug 2019 · Alan Craze, East Sussex

“There are no resources and no system of treatment for people who present with serious mental ilIness and aicohol or drug misuse histories.”

judiciary.uk/…/reece-lapina-amarelle

What was promised

Stated action 1 · response to Reece Lapina-Amarelle (9 Aug 2019) · stated timescale: 2023/24

“The NHS Long Term Plan, published earlier this year, details how new and integrated models of primary and community health services will transform the delivery of mental health care for adults and older adults with SMI, including people with a 'personality disorder' and those with co-existing substance misuse. As the NHS Mental Health Implementation Plan 2019/20 - 2023/24 sets out, this new community-based offer, backed by significant investment over the next five years, will include access to psychological”

judiciary.uk/…/2019-0274-Response-by-NHS-England.pdf

What recurred

  • 14 Jul 2023 · Peter Fleming · James Bennett · Identical hazard · confidence 0.90 (high)

The clearest link, quoted from both reports:

Earlier · Reece Lapina-Amarelle · 9 Aug 2019

“There are no resources and no system of treatment for people who present with serious mental ilIness and aicohol or drug misuse histories.”

Later · Peter Fleming · 14 Jul 2023

“There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull.”

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.