Insufficient treatment capacity for serious mental illness
NHS England received 2 coroners' reports about this hazard between 9 Aug 2019 and 14 Jul 2023.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 4 specific actions.
The story, report by report
Spacing grows with the time between reports.
“There are no resources and no system of treatment for people who present with serious mental ilIness and aicohol or drug misuse histories.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“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”
Stated timescale: 2023/24
- 3 years 11 months laterIdentical hazardConfidence 0.90 · higha different coroner
“There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull.”
Original on judiciary.uk ↗ NHS England responded, stating 3 specific actions.Response (PDF) ↗
“The NHS is working to further improve this capability to enable information to be automatically added into the GP [name redacted] record as appropriate.”
“medication. The dispensing notification used by pharmacies is for payment purposes and does not link back to the prescribing system. It is not used consistently by pharmacies as some use the notification system for when an item has been dispensed and is ready for collection, meaning the patient has not yet collected the medication and in fact may not collect it. Therefore, the system would not be a reliable way for the GP to check the patient's compliance with medication as there is no confirmation on”
1 more stated action in the Promises tab.
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2019 → 2023Peter Fleming3 years 11 months after Reece Lapina-Amarelle · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight a chronic lack of resources and systems to treat people with serious mental illness. They describe the same underlying hazard of insufficient treatment capacity leading to unsafe outcomes.
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.”
Original on judiciary.uk ↗ Peter Fleming · 14 Jul 2023
“There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull.”
Original on judiciary.uk ↗
Stated action · 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”
Stated action
“The NHS is working to further improve this capability to enable information to be automatically added into the GP [name redacted] record as appropriate.”
Stated action
“medication. The dispensing notification used by pharmacies is for payment purposes and does not link back to the prescribing system. It is not used consistently by pharmacies as some use the notification system for when an item has been dispensed and is ready for collection, meaning the patient has not yet collected the medication and in fact may not collect it. Therefore, the system would not be a reliable way for the GP to check the patient's compliance with medication as there is no confirmation on”
Stated action · timescale: June this year
“In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2019 → 2023 | 0.74 | 0.15 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.