Richard Carlon
22 Jul 2019 · Coroner Louise Hunt · Birmingham and Solihull
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of approved mental health practitioner for assessment
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18. I was told this was an ongoing problem and was delaying assessments.”
2. failure to notify mental health team after safe check
“When Mr [name redacted] was found safe and well at home WMP did not advise BSMHT. This was a missed opportunity for Mental health to re‐engage with Mr [name redacted] and make a further assessment of his condition. Consideration need to be given to how agencies can improve communication.”
Linked reports
Identical hazardConfidence 0.90 · 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
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18. I was told this was an ongoing problem and was delaying assessments.”
Closely relatedConfidence 0.90 · high
This report
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18. I was told this was an ongoing problem and was delaying assessments.”
Later report
“During the course of the inquest, I heard evidence Mr [name redacted] was deemed to be suffering from behavioural issues rather than a mental health crisis and no full Mental Health Act assessment took place either at New Cross Hospital or whilst in custody at Oldbury Police station.”
Closely relatedConfidence 0.90 · high
This report
“No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr [name redacted] on 14/11/18.”
Later 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.”
Responses
2019-0287-Response-by-Birmingham-City-Council.pdf ↗· Birmingham City Council
Stated action · 11 September 2019
“The board has agreed to meet on a monthly basis and will become the vehicle for overseeirig the improvement work”
2019-0287-Response-by-Staffordshire-and-West-Midlands-Police.pdf ↗· West Midlands Police
Stated action · by November 2019
“West Midlands Police will ensure any caller is updated when a missing person has been located to allow further contact between parties. This may not always mean full details of whereabouts are disclosed (as individual cases may prevent this from being appropriate) however, the reasons for this will be recorded and explained in each case.”