Patricia Cleghorn
25 Jul 2016 · Coroner Louise Hunt · Birmingham and Solihull
A similar concern from this report was raised again 4 times later. See the linked reports.
The coroner's concerns
1. lack of acute mental health beds
“availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care”
2. risk of overdose
“The deceased had repeatedly stated that she would end her life by taking an overdose”
3. lack of risk assessment
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her”
Linked reports
Identical hazardConfidence 0.92 · high
This report
“The deceased could not be admitted to hospital as there were no inpatient beds available.”
Later report
“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.”
Closely relatedConfidence 0.85 · high
This report
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her.”
Later report
“(c) no risk assessment was carried out prior to making the decision to return his call bell.”
Identical hazardConfidence 0.85 · high
This report
“availability of acute mental health beds means the most vulnerable people are being cared for in the community with limited resources and care.”
Later report
“a bed could not be found for the Deceased even though he had been assessed and fit for detention. The absence of a bed meant that Mr [name redacted] was not adequately assessed and appropriate treatment could not be given.”
Closely relatedConfidence 0.90 · high
This report
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her”
Later report
“When Mr [name redacted] was first reported as missing no risk assessment was undertaken about his level of risk to himself”
Responses
2016-0270-Response-by-Birmingham-and-Solihull-NHS-Trust.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
Stated action · 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”
Stated action · 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”
Stated action · 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.”
2016-0270-Response-by-Care-Quality-Commission.pdf ↗· Care Quality Commission
Stated action · December 2016
“We will be meeting with the Trust again in December 2016 to review the impact of their action plans.”
2016-0270-Response-by-Department-of-Health.pdf ↗· NHS England: Department of Health
2016-0270-Response-by-NHS-England.pdf ↗· Care Quality Commission
Stated action · 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.”