William Edge
4 Oct 2018 · Coroner Emma Brown · Birmingham and Solihull
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. risk of suicide
“the Deceased had stated to the RAID team on the 17" August 2018 that he wanted to be admitted and if he was discharged he would kill himself.”
2. risk of suicide
“they had visited but left when no response was obtained”
3. underfunding of mental health services
“inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available”
4. risk to life
“HTTs cannot attend patients when required creates a risk to life”
5. underfunding of mental health services
“this case, along with several other cases being investigated by the Birmingham and Solihull Coroners' jurisdiction may arise from underfunding of mental health services”
6. systemic strain in mental health services
“The strain on the systems of mental health services provided by both Forward Thinking Birmingham and Birmingham and Solihull Mental Health NHS Foundation Trust has become apparent”
Linked reports
Closely relatedConfidence 0.85 · high
This report
“inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available”
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.”
Closely relatedConfidence 0.90 · high
This report
“The Coroner is aware, although not from evidence obtained in respect of Mr. [name redacted] case as the inquest is yet to take place, that inpatient beds within the BSMHFT are currently operating at 109% capacity and are often not available.”
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 is committed to establishing and maintaining a mental health system which facilitates timely access to inpatient care for those who need it, whilst ensuring that community-based provision is adequately resourced to support recovery in the most appropriate environment.”
NHS-England-Response.pdf ↗· NHS England
Stated action · February 2018
“Undertakes a monthly contract review of its providers. Since February 2018, following an 'inadequate' rating by the Care Quality Commission of FTB, the CCG has led the development of a Quality Improvement Board to oversee and provide assurance on a CQC improvement Action Plan and a System Improvement Plan.”
Stated action
“Proactively manages demand with a series of initiatives to reduce unnecessary admissions and avoid delayed transfers of care, such that capacity can be optimally managed.”
Stated action · 2017/18 and 2018/19
“Funding: In 2017/18 provided additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).In 2018/19 the CCG provided additional investment in BSMHFT amounting to £3,117,000 (2.4% increase) and FTB amounting to £2,881,000 (9.3% increase). Further”
Stated action
“Undertakes mortality and incident review seriously and in line with national policy. The coroners' letters have prompted a comprehensive review of mortality and incident governance which will result in improved care quality and learning from incidents.”
Stated action · November 14 2018
“Oversight of strategic and operational issues: 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.”
Stated action
“Risk assessment: this needs to be available and of high quality 24 hours a day, 7 days a week. We will ensure services are commissioned and provided to ensure this occurs in order to provide safe and effective care.”