Anthony Watson

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 Birmingham and Solihull Coroner, in 
respect of the Regulation 28 report to prevent future deaths issued to NHS 
Birmingham and Solihull Clinical Commissioning Group (the CCG), relating to 
the death of Anthony John William Watson.  

1.2  The Regulation 28 report raises concerns about the fact that no elderly care 

bed was available for Mr Watson between 18th October 2018 and his death on 
22nd October 2018.   

1.3  The CCG has recently provided a comprehensive report to the Senior Coroner 
for Birmingham and Solihull on mental health services in the area, in response 
to a previous 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 12th 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 Anthony John William Watson who sadly passed 
away on 22nd October 2018. 

2.2  The CCG commissions mental health services for over 25s from Birmingham 
and Solihull Mental Health Foundation Trust (BSMHFT) through an NHS 
standard contract. The standard contract sets out the required operational 
standards, as well as national and local quality requirements.  

2.3  Statements submitted to the inquest confirm that Mr Watson had been 

receiving care from BSMHFT since 2017. By 18th October 2018 Mr Watson’s 
condition had deteriorated such that he required admission to hospital. The 
CCG has no direct knowledge of these events and has ascertained this 
information through documents provided by HM Coroner.   

2.4  On 18th October 2018, Mr Watson was referred to the Community Enablement 

and Recovery Team (CERT), which forms part of Mental Health Services for 
Older People (MHSOP). The referral was made by the Community Mental 

1 

 
 
 
 
 
 
 
 
 
 Health Team for Older People, under which Mr Watson had been receiving 
treatment.  

2.5  Mr Watson was visited at home by the CERTS Team on 18th, 19th and 20th 

October. He was visited on the 21st October, however, Mr Watson was in 
hospital at that point. A referral to the Home Treatment Team had been made 
on 19th October by the CERTS Team, but that referral was not actioned with the 
result that the Home Treatment Team did not make any visits to Mr Watson 
over that weekend. Both Mr Watson and his wife had been provided with crisis 
access numbers for further support.    

2.6  The CCG has been provided with a draft root cause analysis report by 

BSMHFT. It is understood from the report that, although enquiries were made 
as to availability of an inpatient bed and no local beds were available, there was 
no attempt to locate an out of area bed. Other beds may have been available 
out of area but still within a reasonable travelling distance of Mr Watson’s home 
and these would not necessarily be 70 miles away as mentioned in the inquest 
statements.    

2.7  The CCG has reciprocal arrangements in place for patients to access out of 
area beds when there are no local beds available. This arrangement is 
delivered through the MERIT Vanguard, which arose out of the Department of 
Health New Models of Care Programme and 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 more flexible use of bed stock across the region and by 
seeking to embed ‘recovery principles’ in practice. In addition, the CCG can 
authorise the use of ‘overspill’ arrangements if asked, and would have done so 
on this occasion based on the clinical decision that an inpatient bed was 
needed. BSMHFT’s root cause analysis investigation identified a lack of 
understanding within the BSMHFT service as to the process for requesting an 
out of area bed and who could authorise one, along with the overall belief that 
they could not be requested. The CCG’s reciprocal arrangement on beds was 
not utilised appropriately and therefore resulted in Mr Watson potentially being 
prevented from accessing a bed in the West Midlands. 

2.8  On this occasion, although there was no local bed available for Mr Watson, no 
attempt was made by BSMHFT to locate an out of area bed within the MERIT 
Vanguard, or elsewhere. Whilst it is recognised that it is not ideal for a patient 
to be admitted to a unit outside of their local area, pressure for inpatient beds 
sometimes dictates that beds may not be available close to the patient’s home 
and that the nearest available bed may be outside of the immediate area.   

2 

 
 
 
 
 
 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 01 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 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 Forward Thinking Birmingham 
(providers of mental health services across Birmingham and Solihull for those 
aged up to 25), BSMHFT and the local Sustainability and Transformation 
Partnership (the STP) to look at different ways of working throughout the 
system. The CCG will continue to monitor the situation to ensure that all 
partnership working across Birmingham and Solihull is focussed on improving 
access and the quality of care. 

3.3  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 STP and the Mental Health Programme 
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. 

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 

3 

 
 
 
 
 
 
 services, as well as looking at new and innovative ways to improve all mental 
health services.  

4.2  The CCG has previously provided HM Coroner with an overview of the steps 

being taken in response to the increased demand for mental health services in 
the region.  

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 further recognises that these measures will not provide an immediate 
solution which ensures there is always sufficient bed capacity, as there are 
other considerations that impact on the system. Achieving improved capacity 
and flow cannot be realised solely through investment and must be supported 
by optimised models of care and practice such as those described above.  

4.5  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. 

4.6  Notwithstanding the above, there appears, in this instance, to have been 

failings in care delivery which impacted on the ability for a bed to be located for 
Mr Watson. BSMHFT have identified these failings and have taken actions to 
rectify them.  

4.7  The CCG will continue to monitor and review mental health services in 

Birmingham and Solihull, and is happy to have an ongoing dialogue with HM 
Coroner in relation to any concerns.  

4

Mr James Bennett

NHS)

Professor Stephen Powis
National. Medical Director.
Skipton House

80 London Road

SE1 6LH

HM. Assistant:Coroner Birmingham
and Solihull

Coroner's Court

50 Newton: Street

Birmingham

B4 6NE . 29" April 2019

Dear Mr. Bennett

Re: Regulation 28 Report to Prevent Future Deaths — Anthony John William
Watson, deceased 22.10.2018

Thank-you. for your Regulation 28 Report (hereinafter the. ‘report’) dated 42%
February 2019 concerning the death of Mr Anthony John William Watson on 2am
- October 2018; Firstly, | would like to express my deep condolences to Mr Watson's
family. ; mae

Your report concludes that Mr: Watson’s death was.as a result of significant head
trauma following a: fall from height. The incident occurred whilst Mr Watson: was
waiting to be admitted to a local inpatient mental-health bed based on the advice
from the mental health services that immediate admission was necessary.

Following the inquest and-noting the report's similar themes to the 7 reports issued
by the Birmingham. and Solihull Coroners on 4" October 2018, you highlighted: the
ongoing .issue that not all patients who require immediate admission for inpatient
“mental: health treatment.in Birmingham and Solihull are found an appropriate bed.in
the area. “As such, you expressed your concerns that there are an. insufficient
number of beds in Birmingham and Solihull, and that. out-of-area beds are too far
away. Further, in this. particular case, you also noted the impact of Mr Watson's age

on: the ‘inability of. Birmingham and. Solihull Mental‘Health NHS. Foundation Trust.’

(‘Trust’) to:find him an appropriate bed for.a timely hospital admission.

|-note.that a copy of your-report has.been sent to the Trust, however, you. may wish
to seek a formal response. from the Birmingham and Solihull Mental Health NHS

Foundation Trust regarding the concerns raised in your report-for a response on the

specific circumstances relating to Mr Watson's death. At the same time, |- wanted to
’ “highlight some key national.policies and priorities which-| believe are relevant to the
issues you have identified in your report as both having a bearing on:Mr Watson's
death and continuing to pose ongoing concerns for patient safety.

Concern 1 — the lack of beds and that Mr Watson was not offered a bed out-of-area

NHS England and NHS Improvement

In.recognition. of the importance of. continuity of care. and the proximity. to existing
support networks, NHS England has committed to eliminating the practice. of
sending people out of. area for non-specialist acute inpatient care due to local bed
pressures by 2021. This applies to older. adult beds, as well as general adult and
psychiatric intensive care units (PICUs) and is underpinned by the expectation that
there is always local capacity to meet the needs of individuals requiring this type. of
~ ‘Support: .

Concern 2 —:similar themes to the 7 linked PFDs issued on 04/10/2018

| shave enclosed a. copy of the letter. sent to Mrs Louise Hunt, senior. coroner. of
Birmingham and. Solihull, in December 2018, in response to the concerns she
raised about the 7 linked deaths identified by Birmingham and Solihull coroners. It
includes a summary of relevant outcomes from a ‘deep dive’ meeting in November

2018, which brought together all stakeholders involved: in the commissioning, |

provision and regulatory oversight of mental health: services in. Birmingham and
Solihull in response to the concerns raised.

More. recently, members. of the. national) NHS. England Mental Health Team

attended.a_ further. follow-up. deep. dive meeting. in March 2019 focused on:

Birmingham's Suicide Strategy and Mental Health Improvement Plan, which
included .very. senior. representation’ from the CCG, Trust, local authority public
health team and regional NHS England and NHS Improvement teams.

Concern 3 — Mr Watson’s age

Under the Equality Act 2010, it is unlawful to deny an older person treatment on the -

. basis of their age. NHS England's. national policy position is that the decision
whether to admit a person to.a general adult or older adult mental health service
should not be based on.a person’s.age but.on theirneeds. This decision should not
be made at the expense of the person's immediate safety. As this decision is the
provider's responsibility, you may wish to. seek a formal response on this specific
issue from Birmingham.and Solihull Mental Health NHS Foundation Trust.

Concern 4a — Availability of beds on young adult units on 18-22 October.2018:

Concern 4b — Offer of ‘an out.of area bed due to contractual issues; Concern 4c —

at least:one patient_every day in Birmingham and Solihull is advised no bed is

available; and. Concern 5.—‘lack of inpatient beds — insufficient numbers of beds in

Birmingham and Solihull'and out of area beds

The reduction of out of area placements (OAPs) is a ‘high priority both nationally
and locally and | can confirm as part of the 2019/20 NHS Operational Planning and
Contracting Guidance. all Sustainability and Transformation: Partnerships. (STPs)
are reviewing their.plans and trajectories. for reducing these placements. Over. the
last: year we have been. working jointly with NHS Improvement: to provide a
clinically-led support offer to assist areas in their. work to reduce OAPs. This has
involved local workshops run by clinical experts with the necessary experience of
leading complex. system change, which is required to enable the safe ‘and
sustainable reduction of OAPs. Birmingham and Solihull STP.are engaged with this
support offer.and participated in a bespoke clinically-led workshop in.March 2019.

This . provided .an - opportunity. for system © stakeholders -to discuss current.
approaches and _ to have their local plans reviewed. and informed by the national

_ team’s clinical experts.

NHS England and NHS Improvement

However, further-to this issue it is important to note that ending. OAPs by. 2021 is a.

“stretching ambition as OAPs are.an indicator of broader system pressures and
‘underlying. capacity © challenges, and. therefore, long-term system-wide
transformation is required if OAPs are to be sustainably eliminated. Bearing this in
mind, NHS England and NHS Improvement have clearly communicated that patient
safety should be prioritised above all. else; no-one in need of an acute inpatient
admission: should. be. turned. away to avoid using an OAP. Trying to end. OAPs too

quickly; without making the appropriate system changes, will. be unsustainable in...

the long-term and has the potential to risk patient safety if the quality and timeliness
of care are compromised to reduce OAP. usage. While your report states that Mr
Watson would very likely have declined an out-of-area bed had one been offered,
due to the significant distance involved, it is still concerning that this offer was not
made, and that there was nothing else available in closer neighbouring areas

“ because of ‘contractual issues’. Your report mentions that you are already aware of
local remedial action underway to address issues raised in the 7 linked reports of 4
October 2018. From a national perspective, NHS England and NHS Improvement
will continue to follow up through our regional colleagues in the West Midlands and
existing. governance structures to ensure that all of the actions described and
committed to.in response to these reports have been taken, and that lessons have
been learned, with this learning applied to improve safety and quality. This. will
follow on from discussions that took place in March 2019 referred to above.

NHS England’s ambition : : :
NHS England is committed to ensuring that by. 2020/21. all areas have properly
resourced Crisis Resolution and Home Treatment Teams (CRHTTs); providing a
high-quality, 24/7, community-based crisis response and intensive home treatment,
as a. genuine alternative to hospital admission for adults. of all’ ages. This
commitment is supported by central investment and is intended to:

¢ -ensure people can. be. effectively supported in. the least restrictive setting
where itis safe and appropriate for the individual; and in doing so

« -help.address avoidable pressures and high bed occupancy in the acute
mental health pathway, to ensure beds are always available for those that
need them. :

I:can confirm that evidence from those areas which maintain local bed availability
suggests that this is not simply down to the number of locally commissioned beds,
but largely related to.the effective management of the whole system pathway and
investment in local services, in particular community alternatives. As such, || also
wanted ‘to reassure you about the specific steps we are taking to improve. access:
to, and quality of, crisis and-community mental health care as part of the NHS Long
Term Plan, which includes a specific focus on provision for older adults:

« By 2023/24, anyone experiencing mental health crisis will’be able to

call- NHS. 111. and. access 24/7 age-appropriate: mental health.

community support.

e .. By 2020/21 no acute hospital will. be without a mental health liaison
service for all ages in A&E departments and inpatient wards, and at

least 50% of these services will meet the ‘core 24’ service standard as

~ NHS England and NHS Improvement

a minimum. ‘Increasing ‘to.70% by. 2023/24, working towards 100%
coverage thereafter. ;

. Finally, the NHS Long Term Plan also details how new and integrated .
models of primary and community health services will support adults
and older adults with severe mental illnesses. A new community-:

- based offer 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. By 2023/24; new. models of. care,
underpinned by improved information sharing, will give 370,000 adults °°
and older adults greater. choice. and control over. their. care, and
support them to live well in their communities.

| hope the information above addresses the concerns you have raised within your.
report and provides you with the assurances that you tequested. If you require any
further information, please do not hesitate to contact me. ~ ;

Yours sincerely,

Hi

Professor Stephen Powis
National Medical Director
NHS England and NHS Improvement

NHS England and NHS Improvement