Birmingham and Solihull Mental Health NHS Foundation Trust

“The review acknowledged the risk of relapse identified in May 2023 on page 14, identifying that whilst plans were made within the Multi-disciplinary Team, there was no clear process to track these actions, leading to a lack of oversight. If there had been stronger oversight, the team would have been aware of the non-compliance with medication sooner, allowing for timely intervention. This would have included tracking the perpetrator's prescription. To address this, the team has now implemented a”

“The policy describes the actions to be taken when a patient is missing or AWOL”

“The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out 'why the risk is considered to be present'. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.”

“I will respond on these points in particular”

“the APCC has developed guidance for members on the Right Care, Right Person approach. The guidance, which was launched in April 2024, strongly encourages PCC oversight of the planning and delivery of the Right Care, Right Person approach to ensure vulnerable people receive the right support from the right services.”

“We have now liaised with the staff involved in order to be able to respond to your concerns in relation to the GP referral system to secondary mental health services and communication to GPs in respect of the same. Community Mental Health Services have been undergoing significant transformation since April 2021. In line with the attached national programme of work the government committed significant investment in Community Mental Health Services to integrate the 'front door' of Mental Health”

“the Trust has now put into place an urgent learning session along with future planned training and development to ensure staff keep up to date with this and learning is refreshed, alongside other additional support systems that have previously been introduced.”

“We will continue to keep the issue of monitoring for clozapine toxicity under close review, including reviewing Yellow Card cases and we will be writing to the marketing authorisation holders to investigate further thresholds for clozapine toxicity.”

“The audit was undertaken by the Head of Nursing and Allied Health Professionals on 12 May 2022”

“In February 2019 a blood test confirmed that Mr [name redacted] had a high level of clozapine in his blood. This was not acted upon and no further blood test was taken. The clozapine dose was not adjusted as it should have been.”

“We have commenced an audit of all patients prescribed Clozapine on Dr 's caseload to ensure that there are no other patients for whom anomalous results have not been considered.”

“In addition, we are in the process of issuing a practice alert to all of our Doctors reminding them of the importance of review when anomalous results are evident.”

“There is a system in place whereby anomalous results received are escalated to the Consultant, for example, via the Multi-Disciplinary Team meeting, the administrative staff in receipt of paper results or by junior medical staff who have checked electronic investigations; however on this occasion it appears that this failed. We have therefore put in place an additional control whereby our Information Team will send a report to the pharmacy Clozapine Lead of any results >600 so that these can be”

“We have existing Multi-Disciplinary team meetings in place across our organisation and are now specifically strengthening the focus on physical health within these meetings utilising a quality improvement approach. This will provide an additional system for checking that periodic tests have taken place, ensuring that they are routinely acted upon when they are abnormal.”

“Clozapine has now been added to this project to increase awareness.”

“The CCG has been working closely with both local mental health service providers and the third sector, with the aim of improving the service offer for people experiencing a mental health crisis. Stakeholders are working on designing community based services, which will increase accessibility for those in crisis and their families, to deliver the most appropriate support at the earliest opportunity.”

“implementing a documented and recognised system within our bed management team for all such calls which includes phonetic spelling and other controls to ensure a consistent approach to this matter”

“From September 2019, subject to recruitment, we anticipate to be in a position whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist within their team”

“The CCG has recently provided a comprehensive report to the HM Senior Coroner for Birmingham and Solihull on mental health services in the area, in response to a Regulation 28 report to prevent future deaths.”

“The Head of:Healthcare.at HMP Birmingham will remind all clinical staff (including those working within BCHT) that when reviewing a patient's records for previous medical conditions that the following most be followed: ; ; "4. The clinician will check the 'summary and family history' section of System 2. The clinician will check the 'quick glance' section of System1 3, The clinician will use the 'search function' to check for the medical conditions » relevant to the. clinical intervention they”