Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Patricia Cleghorn · 25 Jul 2016 · Louise Hunt, Birmingham and Solihull
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her”
What was promised
Stated action 1 · response to Patricia Cleghorn (25 Jul 2016) · stated timescale: 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”
judiciary.uk/…/2016-0270-Response-by-Birmingham-and-Solihull-NH…
Stated action 2 · response to Patricia Cleghorn (25 Jul 2016) · stated timescale: 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”
judiciary.uk/…/2016-0270-Response-by-Birmingham-and-Solihull-NH…
Stated action 3 · response to Patricia Cleghorn (25 Jul 2016) · stated timescale: 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.”
judiciary.uk/…/2016-0270-Response-by-Birmingham-and-Solihull-NH…
1 further stated action is listed on the full chain page.
What recurred
- 11 Jan 2023 · Leroy Hamilton · Louise Hunt · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Patricia Cleghorn · 25 Jul 2016
“No formal risk assessment was undertaken and staff failed to appreciate what drugs she had available to her”
Later · Leroy Hamilton · 11 Jan 2023
“When Mr [name redacted] was first reported as missing no risk assessment was undertaken about his level of risk to himself”
What happened next
No evidence found either way · stated action 1
“Birmingham and Solihull Mental Health NHS Foundation Trust has an urgent care pathway which has been developed to improve patients' access to urgent mental health assessment. This pathway involves partnerships with the acute hospitals in Birmingham and Solihull, plus the Police, West Midlands Ambulance Service and third sector organisations. At the core of the work is the delivery of the crisis”
Urgent care · bsmhft.nhs.uk/our-services/urgent-care
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“Birmingham and Solihull Mental Health NHS Foundation Trust provides mental health services for people of Birmingham and Solihull, and to communities in the West Midlands and beyond.”
Birmingham and Solihull Mental Health NHS Foundation ... · cqc.org.uk/provider/RXT/inspection-summary
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Welcome to Birmingham and Solihull Mental Health NHS Foundation Trust Excellent care, empowered people, thriving communities”
Welcome - Birmingham and Solihull Mental Health NHS Foundation Trust · bsmhft.nhs.uk
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “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.”
“The Commission to review the provision of acute inpatient psychiatric care for adults FEBRUARY 2016 OLD PROBLEMS, NEW SOLUTIONS: Improving acute psychiatric care for adults in England FINAL REPORT Old Problems, New Solutions: Improving Acute Psychiatric Care for Adults in England Published: February 2016 The independent Commission on Acute Adult Psychiatric Care was set up by the Royal College of”
OLD PROBLEMS, NEW SOLUTIONS: · rcpsych.ac.uk/…/policy-old-problems-new-solutions-caapc-report-…
“Mental Health - Adult Crisis and Acute Care GIRFT Programme National Specialty Report By Dr [name redacted] GIRFT Clinical Lead April 2021 GIRFT is delivered in partnership with the Royal National Orthopaedic Hospital NHS Trust, NHS England and NHS Improvement 2 Contents Foreword................................................................................................................”
Mental Health – Adult Crisis and Acute Care · gettingitrightfirsttime.co.uk/…/Mental-Health-Sept21i.pdf
“CLINICAL PERFORMANCE STANDARDS Extended Acute Care (EAC) Services Updated March 2026 CPS: EXTENDED ACUTE CARE (EAC) SERVICES Updated March 2026 2 TABLE OF CONTENTS 1. Purpose ......................................................................................................................................................... 3 2. Scope of Services ..................................”
Extended Acute Care (EAC) Services · cbhphilly.org/wp-content/uploads/2022/10/CBH_CPS_EAC_2026-03.pdf
No evidence found does not mean the action did not happen.