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recurance

Andrew Bowles

31 Jan 2023 · Coroner Ana Samuel · Birmingham and Solihull

The coroner's concerns

  1. 1. extensive mental health history with incidents of self-harm and suicidal intent

    “Mr [name redacted] had an extensive mental health history with incidents of self-harm and suicidal intent.”
  2. 2. hearing voices that were telling him to hurt himself and others

    “On 15th May 2023 Mr [name redacted] had told attending paramedics and the triage nurse at Birmingham City hospital that over the last 24 hours he had been hearing voices that were telling him to hurt himself and others.”
  3. 3. lack of access to City Hospital records

    “I am concerned that the mental health liaison nurse undertook her assessment without having access to City Hospital records, which contained essential information that would have impacted on her assessment.”
  4. 4. risk to the life of some patients

    “I am concerned that there may still be a risk to the life of some patients if the mental health liaison team and Birmingham City Hospital are not ensuring that essential patient records are being appropriately shared and read prior to diagnosis and treatment.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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