Spencer Barr
13 May 2022 · Coroner Adam Hodson · Birmingham and Solihull
The coroner's concerns
1. lack of inter-agency information sharing
“In the months prior to his death, [the deceased] had been under the care of multiple agencies, including Referral Management Team (RMC) (part of Birmingham Women's and Children's NHS Foundation Trust), as well as the addiction service Change Grow Live (CGL); the Young Adults Central Team of the Probation Service; and Forward Thinking Birmingham”
2. inconsistent inter-agency cooperation
“I heard evidence that Birmingham Women's and Children's NHS Foundation Trust are now taking steps to improve intra-agency co-operation in an attempt to mitigate against the risk of further deaths in the future. However, I heard evidence that other agencies may not be aware of their own limitations when it comes to inter-agency co-operation. For instance, CGL gave evidence that they had no concerns regarding their co-operation with other services, but Birmingham Women's and Children's NHS Foundation”
3. absence of central points of contact
“Additionally, I am concerned that there appear to be no central points of contact for agencies to facilitate that co-operation. I heard evidence that CGL has no central point of contact for referrals being made/to allow sharing of information - instead relying on information being conveyed via specific individuals”
4. restrictive referral practices
“Furthermore, I heard evidence that certain organisations do not accept direct referrals or share information between agencies. For instance, I heard that CGL solely depend on referrals from GP practices and do not allow referrals direct from other agencies”