Michael Cooper
4 Oct 2018 · Coroner Emma Brown · Birmingham and Solihull
A similar concern from this report was raised again 5 times later. See the linked reports.
The coroner's concerns
1. delayed follow up appointment
“An appointment following referral onto the Care Programme Approach on the 18th April 2018 was outside the two week timeframe specified in the Care Programme Approach Policy”
2. excessive caseload
“Care Co-ordinators within Birmingham and Solihull Mental Health Trust are currently carrying a caseload of more than 30 patients”
3. insufficient funding
“Despite a detailed root cause analysis investigation with a comprehensive action plan arising from Mr. [name redacted] case, without increased funding similar circumstances could arise again”
4. system strain
“The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust”
5. lack of clear accountability
“letters are enclosed from the Medical Directors of both Trusts setting out their concerns”
Linked reports
Identical hazardConfidence 0.92 · high
This report
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
Later report
“Although she had been accepted for such a placement a bed did not become available before she died. Evidence heard at the Inquest indicated that there was a national shortage of placements/beds and this was putting individuals at risk of serious harm and possible death.”
Identical hazardConfidence 0.90 · high
This report
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
Later report
“at the time of [the deceased] ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient”
Identical hazardConfidence 0.90 · high
This report
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
Later report
“I heard that a bed on the mental health ward should have been available for Mr [name redacted] when he was discharged from the medical wards but that there is a chronic shortage of mental health beds and not just in London but nationally.”
Closely relatedConfidence 0.80 · moderate
This report
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust”
Later report
“There is a lack of inpatient beds leading to unacceptable wait times in A&E for those suffering with their mental health who are awaiting beds”
Identical hazardConfidence 0.90 · high
This report
“The lack of inpatient beds is a known resource issue within the Birmingham and Solihull Mental Health NHS Foundation Trust, which the Trust is currently working to address through numerous new initiatives.”
Later report
“The lack of inpatient beds leading to the unacceptable wait time in A&E for those suffering with their mental health who are awaiting a psychiatric beds.”
Responses
Birmingham-and-Solihull-CCG-Response.pdf ↗· NHS England
Stated action
“The CCG has taken the opportunity, as part of this investigation, to review its broader quality assurance processes and identify any learning outside the scope of the Regulation 28 reports.”
NHS-England-Response.pdf ↗· NHS England
Stated action · November 14 2018
“the CCG will lead the establishment of an oversight group which involved all stakeholders . The oversight group will work on the delivery of actions from this meeting and will meet on a monthly basis.”