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recurance

Mary Hoare

15 Nov 2019 · Coroner Emma Brown · Birmingham and Solihull

The coroner's concerns

  1. 1. inadequate information provision

    “In April 2019, and currently, Friendship Care and Housing Limited ('FCH'), who provide care at Pheonix House, and the Solihull Care Housing Association Limited ('SCHA'), are reliant upon information from the applicant and their family when assessing the suitability of a privately funded applicant to become a resident”
  2. 2. incomplete information

    “Due to their changing circumstances and/or health, applicants and their families are not always well placed to be realistic about what the applicant's needs and risks are. Therefore there is a risk that full and accurate information will not be provided to FCH and SCHA”
  3. 3. inadequate assessment

    “At assessment a full service users' assessment was not completed for Mrs. [name redacted] by the FCH assessor which would have been an opportunity to ask more searching questions of the applicant and her family”
  4. 4. inappropriate placement

    “As a consequence of the above, Mrs. [name redacted] became a resident of Phoenix House when she was not suitable. If information regarding her recent mental health history, ongoing management and care home residency had come to light before Mrs. [name redacted] became a resident it would not necessarily have prevented her being offered a unit at Phoenix House but it would have resulted in enquiries with the CMHT, her GP and potentially the care home she was in at the time of assessment”
  5. 5. missing care plan and risk assessments

    “Once Mrs. [name redacted] was a resident, a care plan and risk assessments were not completed”
  6. 6. risk of life-threatening placement

    “Therefore it continues to be a concern that applicants may be accepted to FCH supported living settings who have not been fully assessed and who are not suitable, putting their lives at risk”

Responses

No published response was found on judiciary.uk.

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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.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error