Peter Fleming
14 Jul 2023 · Coroner James Bennett · Birmingham and Solihull
This report repeats 3 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of resources
“There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull”
2. ineffective communication between specialist teams
“communication between the specialist teams is not effective enough”
3. lack of medication management
“Carbamazepine management was proposed in 2012 to manage the deceased's mental health however this was not picked up by his GP and was only noted by a BSMHFT consultant in August 2022”
4. incompatible digital systems
“different health organisations use different digital systems that do not communicate with each other”
5. lack of resources
“current resources do not allow GPs to pro- actively check patients are collecting prescribed medication due to excessive patient lists”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process.”
This report
“different health organisations use different digital systems that do not communicate with each other.”
Identical hazardConfidence 0.90 · high
Earlier report
“There are no resources and no system of treatment for people who present with serious mental ilIness and aicohol or drug misuse histories.”
This report
“There continues to be a chronic lack of resources to treat seriously mentally ill patients in Birmingham and Solihull.”
Closely relatedConfidence 0.90 · high
Earlier report
“Different health care departments have different patient care records and the departments did not communicate with one another.”
This report
“different health organisations use different digital systems that do not communicate with each other.”
Identical hazardConfidence 0.90 · high
This report
“different health organisations use different digital systems that do not communicate with each other.”
Later report
“Their IT systems are completely separate and cannot transmit information into the others patient records easily.”
Closely relatedConfidence 0.80 · moderate
This 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.”
Later 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
2023-0244-Response-from-Birmingham-and-Solihull-Mental-Health-Foundation-Trust.pdf ↗· Birmingham and Solihull Mental Health NHS Foundation Trust
2023-0244-Response-from-Birmingham-and-Solihull.pdf ↗· Birmingham and Solihull Integrated Care Board
Stated action
“GP's are not able to proactively check patients are collecting prescribed medication due to excessive patient lists as a consequence of a lack of resources at a national level”
2023-0244-Response-from-Birmingham-City-Council.pdf ↗· Birmingham City Council
2023-0244-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · by March 2024
“We are investing at least £2.3 billion of additional funding a year by March 2024 to expand and transform mental health services in England so that two million more people can get the mental health support they need.”
2023-0244-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“The NHS is working to further improve this capability to enable information to be automatically added into the GP [name redacted] record as appropriate.”
Stated action
“medication. The dispensing notification used by pharmacies is for payment purposes and does not link back to the prescribing system. It is not used consistently by pharmacies as some use the notification system for when an item has been dispensed and is ready for collection, meaning the patient has not yet collected the medication and in fact may not collect it. Therefore, the system would not be a reliable way for the GP to check the patient's compliance with medication as there is no confirmation on”
Stated action · June this year
“In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care.”