Matthew Lynch
4 Mar 2025 · Coroner Louise Hunt · Birmingham and Solihull
This report repeats 4 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of medication monitoring after clinic visit
“internal investigation did not address how and whether the offender's use of medication should have been monitored after the clinic visit on 12/05/23”
2. incorrect MHA assessments
“barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing”
3. inadequate information sharing with landlords
“Landlords have to rely on the information given to them by the residents and do not have access to other key information held by other agencies”
4. insufficient support worker training
“support workers need more focussed training on mental health conditions and how to manage and help residents with enduring mental health conditions”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The Mental Health Act assessment process was followed in this case was unclear. An approved social worked declined to be involved until the assessment had been completed.”
This report
“there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing.”
Closely relatedConfidence 0.90 · high
Earlier report
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18.”
This report
“The inquest heard evidence that there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing.”
Closely relatedConfidence 0.92 · high
Earlier report
“When Mr [name redacted] was admitted to hospital on 15/03/19 he was placed on S2 of the Mental Health Act when his clinical team had specifically recommended he be placed on S3.”
This report
“Mental Health assessments: The inquest heard evidence that there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“the deceased went without his medication. The deceased's GP had to contact the community mental health team directly notwithstanding the psychiatric liaison nurse's involvement.”
This report
“Internal investigation: The internal investigation did not address how and whether the offender's use of medication should have been monitored after the clinic visit on 12/05/23.”
Responses
2025-0119-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
Stated action
“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”
2025-0119-Response-from-Birmingham-City-Council.pdf ↗· Birmingham City Council
Use-of-Sections-2-and-3-of-the-MHA-Matthew-Lynch-2025-0119.pdf ↗· Birmingham City Council