Stephen Kennedy

NHS Birmingham and Solihull CCG: Response to the Birmingham and Solihull 
Coroner’s Regulation 28 report to prevent future deaths  

1. 

Introduction 

1.1  This report provides a response to the HM Coroner, in respect of the 
Regulation 28 report issued to NHS Birmingham and Solihull Clinical 
Commissioning Group (the CCG) relating to the death of Stephen Anthony 
Kennedy.  

1.2  Two issues have been raised in the Regulation 28 report, to which the CCG is 

required to respond: 

•  A delay in August 2018 in obtaining an inpatient bed 
•  The long waiting time in 2018 for accessing psychological therapy.  

1.3  The CCG has recently provided a comprehensive report to the HM Senior 

Coroner for Birmingham and Solihull on mental health services in the area, in 
response to a Regulation 28 report to prevent future deaths. Much of the 
information contained in that report is pertinent to the circumstances of this 
particular case and, therefore, we will not seek to repeat those details in this 
response.   

2.  Background and context  

2.1  On 8th February 2019, the CCG received a Regulation 28 Report to Prevent 

Future Deaths from the Birmingham and Solihull Coroner, relating to the death 
and subsequent inquest, of Stephen Anthony Kennedy who sadly passed away 
on 8th October 2018. 

2.2  Stephen had been known to mental health services in the area for many years 
and in 2018 had been both an inpatient and under the Home Treatment Team. 
His care was provided by Birmingham and Solihull Mental Health Foundation 
Trust (BSMHFT).  

2.3  Statements submitted to the inquest confirm that on 13th August 2018 Stephen 
was identified as needing admission to an informal inpatient bed. However, one 
was not immediately available and on 19th August Stephen was admitted to the 
Psychiatric Decision Unit (PDU), and transferred to the Zinnia Centre on 22nd 
August 2018 before being discharged on 11th September 2018. The CCG has 
no direct knowledge of these events.   

2.4  Stephen was identified as needing psychological therapy in early May 2018. 

The referral was escalated on 25th May but there is no evidence available to the 

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 CCG that identifies whether this service was ever accessed, nor what steps 
were taken to chase the referral. It is understood that Stephen accessed 
psychological therapies whilst an inpatient in the Zinnia Centre.  

2.5  The CCG commissions services from BSMHFT through an NHS standard 

contract. The standard contract sets out the required operational standards, as 
well as national and local quality requirements. Contracts and provider 
performance are monitored by the CCG through a range of reports and 
meetings which include: 

2.5.1  Monthly contract review meetings, which include oversight of 

performance, activity and quality.  

2.5.2  A range of contractual key performance indicators and monthly and/or 

quarterly reports, which include data relating to patient experience, 
patient safety and clinical effectiveness.  

2.5.3 

In accordance with the NHS England Serious Incident Reporting 
Framework (2015), the reporting of serious incidents to the CCG within 
two days of the provider becoming aware that a serious incident has 
occurred. 

2.5.4  Quarterly reporting from providers regarding their systems and 

processes for learning from deaths, as set out in the National Quality 
Board Publication: National Guidance on Learning from Deaths (2017). 

2.6  The CCG has quality monitoring processes which include serious incident 

reporting and reacting systems, clear reporting and monitoring requirements. 
All investigations into serious incidents are quality checked by the CCG to 
ensure that necessary actions are identified and implemented.  

3.  Understanding and responding to capacity and demand  

3.1  Since 2016, the CCG (both in the current form and as three former CCGs, prior 
to the Birmingham and Solihull CCG merger on 1st April 2018) has taken a 
number of steps, with partner organisations, to understand and respond to 
concerns about capacity and demand within the local mental health system.  

3.2  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. Part of this approach involves 
the CCG being an active partner in the Birmingham and Solihull Sustainability 
and Transformation Partnership (the STP), and the Mental Health Programme 

2 

 
 
 
 
 
 
 
 
 
 Delivery Board. The ambition of the STP is to achieve sustainability, through a 
strong focus on prevention and recovery.  

3.3  The CCG has a Mental Health Programme Delivery Board with a plan of action 

which includes a range of initiatives to deliver measurable changes for mental 
health services. This includes reducing the number of patients being placed in 
inpatient units that are out of the local area to zero by 2021. The plan is jointly 
owned by the CCG, Birmingham Women’s and Children’s NHS Foundation 
Trust, BSMHFT, Solihull Metropolitan Borough Council and Birmingham City 
Council. A ‘zero suicide’ ambition has been committed to, which is led by the 
local authorities’ respective public health teams. This ambition will be supported 
by evidence based, preventative action and high-quality crisis support, as well 
as reducing stigma around mental health and improving access through early 
intervention services.  

3.4  Psychological therapy services for people under the care of BSMHFT forms 
part of the provider’s internal pathway and as such waiting times are not 
monitored by the CCG. The CCG’s approach is to increasingly commission for 
outcomes rather than inputs. In line with this, commissioners have set out their 
intention that community-based mental health services should operate distinct 
treatment pathways for people with psychotic disorders and those with mood 
and personality disorders. Pathways will be focused on the delivery of 
treatment and support that promotes recovery alongside the proportionate 
management of risk. Providers will be expected to put in place a workforce 
model that reflects this approach and affords access to treatment options 
including psychological therapies. This change will be formalised through a 
Service Development and Improvement Plan (SDIP) which will form a part of 
the contract between the CCG and BSMHFT for 2019/20. 

3.5  The CCG has recognised and reacted to the increased demand for mental 

health services. To date, this has included: 

3.5.1   An independent system simulation modelling exercise, which was 

jointly commissioned with Forward Thinking Birmingham (FTB), the 
provider of mental health services for those aged up to 25 years, and 
BSMHFT, to develop an informed response on the best solutions to 
address demand and where investment should be prioritised. This 
followed a sharp increase in demand for inpatient beds in 2016. A key 
recommendation of the exercise was to agree a strategy for the support 
and treatment of people with a diagnosis of personality disorder. This 
strategy is now being mobilised by BSMHFT and FTB. An SDIP has 
been developed for 2019/20 which formalises the implementation of the 
strategy and the CCG has provided additional funding for the 
appointment of a Clinical Lead for Personality Disorder within BSMHFT 
who will lead this work.  

3 

 
 
 3.5.2  An independent review of patients’ journeys into and out of inpatient 

mental health beds was commissioned by the STP. The review 
considered whether alternatives to admission could have been used 
and whether patients stayed in hospital longer than necessary. The 
review found that in both cases, improvements could be made to help 
avoid unnecessary admissions and reduce the time taken to discharge 
patients.  

3.5.3  Supporting operational initiatives to reduce delayed transfers of care, 
where CCG funding of individual packages of care under Section 117 
(jointly funded packages of health and social care) are required to 
facilitate discharge from hospital. 

3.5.4  Weekly, and daily peak period, delayed discharge escalation calls with 

providers and local authority social work teams, in order to escalate any 
delays and for swift resolution. 

3.5.5  Whilst the CCG is committed to reducing the use of admissions to 

inpatient care outside the local area, commissioners continue to  
support the use of admissions to other NHS mental health trusts within 
the MERIT Vanguard1 and to independent hospitals, where no locally 
commissioned beds are available, and an admission is deemed 
necessary. BSMHFT are able to make such admissions without prior 
approval from the CCG.  

3.5.6  Working closely with BSMHFT and FTB as part of an NHS England 

collaborative to seek further ways to reduce the need to admit patients 
out of the local area. This work includes taking learning from other 
areas that have enjoyed success in achieving change. Commissioners 
are in discussion with BSMHFT to agree ways in which resource can 
be shifted internally to support this work.  

3.5.7  Using evidence and data analysis to inform investment and approach.  

3.5.8  Recognising that capacity is impacted by a wide range of factors and 

encouraging action at all levels across the mental health care pathway.  

3.5.9 

In 2017/18 providing additional investment in mental health services 
above the contract value amounting to £4,611,000 for BSMHFT (3.7% 
increase).  

3.5.10  In 2018/19 providing additional investment in BSMHFT amounting to a 

£3,117,000 (2.4% increase).   

1 The MERIT Vanguard was supported through the Department of Health New Models of Care Programme. It is a partnership 
between four NHS mental health providers in the Midlands (Birmingham and Solihull Mental Health NHS Foundation Trust, 
Black Country Partnership NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust and Coventry and 
Warwickshire Partnership NHS Trust. The Vanguard has sought to improve crisis care through a more flexible use of bed stock 
across the region and by seeking to embed ‘recovery principles’ in practice.  

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 3.5.11  This further investment reflects growth of 3.03% in core mental health 
budgets, in accordance with the CCG’s investment standard, which is 
above the national growth standard of 2.85%.   

3.6 

It is acknowledged, through contract review meetings, there have been 
discussions with BSMHFT about funding and capacity, as capacity and demand 
issues are discussed through the contract review mechanism. Contract 
negotiations for services provided in 2019/20 have focused on measures to 
improve capacity through investment and service development and 
improvement.  

4 

Conclusion 

4.1  The CCG aspires to there being no avoidable deaths in Birmingham and 

Solihull and takes every reported unexplained death very seriously. The CCG is 
continuously working with providers to improve the quality and safety of 
services, as well as looking at new and innovative ways to improve all mental 
health services.  

4.2 

In response to concerns previously raised by HM Coroner, the CCG has 
undertaken a review of the processes for managing serious incidents, but also 
whether a shortage of funding may have contributed to these untimely deaths. 
The CCG has been unable to identify any correlation between funding and this 
death, but has recognised the need to continually improve its quality monitoring 
function and to also improve processes for learning from deaths at the earliest 
opportunity.  

4.3  The CCG recognises the need to take a multiagency approach to the 

prevention of deaths, including creating robust partnerships with mental health 
support services e.g. substance abuse services, community intervention and 
crisis management. The CCG must also ensure that inpatient beds are 
maximised and available for those who need them. 

4.4    The CCG will continue to keep under review the pressures on mental health 
services and the need to develop new initiatives to manage patient flow and 
improve services. 

4.5   The CCG recognises that there has been increased demand for mental health 
services since 2016, and has responded to this additional pressure with 
increased funding and through working with FTB, BSMHFT and the STP to look 
at different ways of working throughout the system. The CCG will monitor the 
situation to ensure that all partnership working across Birmingham and Solihull 
is focussed on improving access and the quality of care. 

5

Private and Confidential 
HM Senior Coroner Mrs Hunt 
Birmingham Coroner’s Court  
50 Newton Street     
Birmingham       
B4 6NE 

5 April 2019  

Dear Mrs Hunt 

Chair & Chief Executive’s Office 
Unit 1, B1 
50 Summer Hill Road 
Ladywood 
Birmingham B1 3RB 

Tel:  0121 301 1111 

REGULATION 28 REPORT – MR S KENNEDY 

Thank you for your communication relating to the investigation into the death of Stephen 
Anthony Kennedy. I note that the investigation concluded at the end of an inquest on 7th 
February 2019 with a conclusion of Suicide.  

It is evident that the deceased suffered from emotional unstable personality disorder and 
depression. At the time of his death Stephen had been under the care of our mental health 
team for several years. His condition resulted in frequent attempts to self harm which was 
managed through hospital admissions and at home with support from the home treatment 
team. His condition deteriorated during 2018. He was seen regularly by the mental health 
team with his last admission being from 22/08/18 until 11/09/18. He was then reviewed by 
the home treatment team. Stephen presented to Good Hope Hospital on 07/10/18 with 
chest pains and low mood. He was assessed by a mental health nurse and arrangements 
were made for ongoing support from the home treatment team and to see his consultant 
on 08/10/18. Tragically, Stephen was found hanging from a door frame at his home 
address on 08/10/18 and was declared deceased at 10.07. Our serious incident 
investigation RCA report highlighted a gap in care relating to non compliance with NICE 
guidelines for psychological therapy whereby Stephen had not been in receipt of 
Psychological Therapy throughout his time on our Community caseload.  

During the course of the inquest the evidence revealed matters giving rise to concern. The 
matters of concern are noted as follows:- 

1. The deceased suffered from emotional unstable personality disorder and was in crisis 
for most of 2018. The recommended treatment for his condition was psychological 
therapy. He had not had any psychological input since 2010. The inquest heard that whilst 
he was under the care of the home treatment team there was no access to psychology 
services. He had to be under the community mental health team to be able to access 

Chair: Sue Davis, CBE 

        Chief Executive: Roisin Fallon-Williams  

Customer Relations    Mon – Fri, 8am – 8pm    Tel: 0800 953 0045    Text: 07985 883 509      
Email: bsmhft.customerrelations@nhs.net     Website: www.bsmhft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 psychological services. There were periods when he was under the care of the community 
mental health team but at this time he remained on a long waiting list for psychological 
services. Throughout 2018 he never received any psychological services. I am concerned 
that the main treatment option for the deceased was not available to him due to internal 
structures and long waiting lists. 

2. In August 2018 the deceased required inpatient treatment. There were no beds 
available and as a result he had further episodes of self-harm and suicide attempts. The 
availability of acute beds is a serious concern. 

With regard to the matter of Psychological Therapy, I am able to confirm that we now have 
a plan for investing in clinical psychology capacity within our Home Treatment Team 
services. From September 2019, subject to recruitment, we anticipate to be in a position 
whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist 
within their team. Approval has been given to advertise these posts and this will help us to 
ensure compliance with NICE guidance and to deliver clinically effective care as per 
recommended guidelines. The Clinical Psychologist will also contribute to multi disciplinary 
team assessments, discussions and decisions relating to care planning and treatment 
options for patients, aswell as providing supervision to other members of the team. We are 
also increasing nursing capacity to ensure that community caseloads are more 
manageable.  

In addition, we have developed a tiered training programme in the best practice 
management of patients with Personality Disorder. This will be a mandated training 
requirement for all staff working within our Home Treatment Teams during 2019/20.  

Our Chief Psychologist is leading a Personality Disorders Strategy which includes clinical 
standards to be met for patients with a diagnosis of Personality Disorder. We are currently 
in discussion with our Clinical Director of Community Mental Health Teams about the 
opportunities to roll out these standards in a clinically effective way. There are some 
challenges relating to resources which we have raised with our Commissioners and at the 
time of writing this response these have not yet been resolved. We will continue to pursue 
this matter and also seek to understand any further opportunities for improvement if 
investment is not forthcoming.  

On the matter of bed availability, it is recognised that at times patients are unable to 
access a bed at the point of clinical decision making and that this can lead to increased 
risk, despite best efforts to manage patients safely in an alternative environment. We are 
undertaking a number of initiatives to try to mitigate this risk including:- 

  A review of patient flow 
  Efforts to reduce delayed discharges 
  Appointment of patient flow coordinators 

In the longer term, our Estates Strategy aims to increase the inpatient bed stock of the 
Trust to try to meet the increased demands and acuity of patients across the City and in 
Solihull.  

2 

 I would like to take this opportunity to express my sincere apologies for the failings in the 
care delivered to Stephen by our Trust and to extend these apologies to his family 
members. This is clearly a tragic event for all and one that the Trust is taking seriously in 
its efforts to prevent future incidents of this nature.  

I do hope that this response gives you some assurance of the efforts being taken by the 
Trust in response to your matters of concern. 

Yours sincerely 

Roisin Fallon-Williams 
Chief Executive 

3

we From Jackie Doyle-Price MP

Parliamentary Under Secretary of State for Mental Health,
Department inequalities and Suicide Prevention

of Health &
Social Care 39 Vitra Steet
SW1H 0EU
020 7210 4850

Your Ref: 126699- Stephen Anthony Kennedy
Our Ref: PFD-1166496

Ms Louise Hunt

HM Senior Coroner, Birmingham & Solihull
Coroner's Court

50 Newton Street

Birmingham B4 6NE

Deo Ne tock

Thank you for your correspondence of 8 February 2019 to the Secretary of State
about the death of Mr Stephen Anthony Kennedy. I am replying as Minister with
portfolio responsibility for mental health services.

Kh April 2019

Firstly, I would like to say how sorry I was to read of the circumstances of Mr
Kennedy’s death. I appreciate his loss must be extremely distressing for his family
and loved ones and I offer my sincerest condolences. It is essential that we look to
make improvements where we can to ensure the safety of healthcare and prevent
future deaths and I am grateful to you for bringing these matters to my attention.

Your report raises matters of concern around access to psychological therapies and
the availability of inpatient beds for those requiring mental health treatment.

You will know that the provision of mental health services is a matter for the NHS
locally, except where specialised services are required and NHS England is the
responsible commissioner. You have issued your report to the Birmingham and
Solihull Mental Health NHS Foundation Trust and the Birmingham and Solihull
Clinical Commissioning Group (CCG), and I expect the local NHS to take firm
action to respond to the concerns and learn from Stephen’s death to ensure the safety
of healthcare services.

I would like to explain the action we are taking at a national level to improve access
to treatment for those with severe mental illness.

On the availability of beds in the acute mental health sector, we are aware that the
number of mental health beds overall have reduced and this is in large part due to the
growth of care in the community. It may also be of interest to note that mental health
bed occupancy rates have remained stable at between 87.1 per cent and 90.8 per cent
(from Quarter 1, 2010-11 to Quarter 3, 2018-19), and that latest data for Quarter 3,
2018-19 shows a bed occupancy of 88.5 per cent. However, it remains the
responsibility of local commissioners to determine the levels of service provision
based on the needs of their local populations, and I note that the NHS in Birmingham
and Solihull has taken action to commission a further 32 inpatient beds.

To support the NHS, we have committed to a comprehensive expansion of mental
health services and are backing this up with an additional £2.3billion investment in
real terms by 2023-24. This commitment is made clear in the NHS Long Term Plan',
published in January 2019 by NHS England.

With regard to access to psychological therapies, on a national level, I would like to
assure you that we recognise the importance of both psychological interventions and,
where clinically appropriate, access to National Institute for Health and Clinical
Excellence (NICE) concordant psychological therapy for people receiving secondary
mental health care in both inpatient and community settings.

A matter of concern in your Report is that patients cannot access psychological
therapy while under the care of the Home Treatment Team (HTT). By 2020/21,
Crisis Resolution and Home Treatment Teams (CRHTTs) should provide a 24 hour,
seven day community-based mental health crisis response and offer intensive home
treatment as an alternative to acute inpatient admission. CRHTTs should aim to
deliver care in line with quality benchmarks described in the University College
London CORE fidelity criteria, a quality improvement tool.

Significantly, this criteria includes the provision of brief psychological intervention
during an initial urgent and emergency mental health response and, where required,
ongoing therapeutic psychologically-informed care delivered by a multi-disciplinary
home treatment team, benefitted by input from clinical psychologists.

Over £400million of supporting investment is being made available over four years
from April 2017 for the expansion of CRHTTs, in line with CORE criteria.

' https://www.longtermplan.nhs.uk/

? https://www.ucl.ac.uk/core-resource-pack/fidelity-scale

Overall, the NHS long-term plan sets out a programme of expansion and
improvement for mental health services to deliver parity of esteem between mental
and physical illness. It also sets out proposals on building increased integration
between primary and secondary care so that that those experiencing mental ill-health,
including those with complex mental health needs or a diagnosis of personality
disorder, can access the right support.

A new community-based offer for people with Severe Mental Illness will include
access to psychological therapies; improved physical health care; employment
support; personalised and trauma-informed care; medicines management; and support
for self-harm and coexisting substance use. This will give 370,000 adults and older
adults greater choice and control over their care, and support them to live well in their
communities. ; ;

Crisis care is also a key element of the Long Term Plan and this includes establishing
a national, single point of contact, for anyone experiencing mental health crisis
through the NHS111 service. This means that people in crisis will be able to access a
trained mental health professional when they need to.

Finally, the long-term plan reaffirms the NHS’s commitment to make suicide
prevention a priority over the next decade, and sets out further measures for suicide
prevention, including full coverage across the country of the existing suicide
reduction programme.

I hope this information is helpful in setting out our commitment to improve access to
mental health services and the measures being taken to support the NHS to deliver
high quality, effective services for those experiencing mental ill-health.

ACKIE DOYLE-PRICE