Nigel Abbott

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
(1) NHS Birmingham and Solihull Clinical Commissioning Group (‘CCG’).
(2) NHS England.
(3) Rt Hon Matt Hancock MP, Secretary of State for Health and Social Care.
(4) Clive Heaphy, Acting Chief Executive, Birmingham City Council (‘BCC’).
(5) Roisin Fallon‐Williams, Chief Executive, Birmingham and Solihull Mental Health
Foundation NHS Trust (‘BSMHFT’).
(6) Dave Thompson, Chief Constable, West Midlands Police (‘WMP’).
1 CORONER
I am James Bennett Area Coroner for Birmingham and Solihull.
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3 INVESTIGATION and INQUEST
On 06/08/2018 I commenced an investigation into the death of Nigel Byron Abbott. The
investigation concluded at the end of an inquest on 30th September 2019.
My conclusion was a narrative conclusion, as follows:
‘Nigel Abbott was killed by another person unknown to him. That person had been
suffering from a serious mental illness and had not been detained in hospital when he
should have been. The mental health services had the means to detain him. Had he
been detained within a reasonable amount of time the death would not have occurred.
Systemic failings contributed to Nigel’s death, namely:
1) There was a lack of psychiatric inpatient beds in Birmingham.
2) There were no section 140 beds in Birmingham.
3) The Joint Memorandum of Understanding for Mental Health Professional
Requesting Police Assistance with Mental Health Act Assessments and s.135
Warrants was ambiguous and misunderstood.
4) The Home Treatment Standard Operational Procedure was inadequate and failed
to provide the necessary safeguards.
5) There was a lack of leadership within the HTT.
6) There was a lack of resources within the HTT.
7) There was no adequate system for mental health professionals to communicate
with each other and therefore they did not communicate effectively.
8) As a consequence of (4) – (7), no Doctor was tasked to review the person on 27
July in accordance with the Home Treatment Standard Operational Procedure.
9) There was no adequate system to record and react to the family’s telephone calls
in which they raised concerns.
Further, specific failings by an AMHP contributed to Nigel’s death, namely:
1) She decided not to contact the person’s family.
2) She did not escalate her concerns.
3) She closed the person’s case.
4) She did not alert the out‐of‐hours AMHP that she had requested a new referral.
These specific failings were contributed to by the above systemic failings.’
4 CIRCUMSTANCES OF THE DEATH
On 27 July 2018 Nigel Abbott left his home to walk the short distance to meet his friend
at a local public house. Shortly before 23.00hrs, the familiar route took him along
Turchill Drive, Walmley. A stranger ran out of his house and commenced a frenzied and
prolonged assault on Nigel. He was punched to the head, had his head stamped on, was
struck about his head with his own walking stick and a spirit level, and was stabbed in
the neck 52 times with two small kitchen knives. Having been alerted by 999 calls the
police arrived and interrupted the assault. Nigel was already deceased outside no.81
Turchill Drive. A paramedic formally confirmed death at 23.01hrs.
The background to the assault is as follows.
The person was aged 29, a tradesman and lived with his partner and two children. He
was a healthy and fit person competing professionally as a Thai boxer. Between 2003‐
2006 he was formally reprimanded, warned and cautioned by the police for Actual
Bodily Harm x 2 and Battery. He was otherwise a law‐abiding person.
Both he and his family could not have known he was genetically pre‐disposed to
develop schizophrenia.
Without any warning, in July 2018 he suffered a sudden and dramatic decline in his
mental health. It began on 11 July when he reported that a man in a van had stopped
him in his car and threatened him with a knife in connection with an on‐going work‐
related dispute. This event remains unverified. It is likely there was a stressful event
around this time ‐ a known trigger for schizophrenia ‐ but the precise details remain
unclear.
Over the next two weeks he displayed increasingly erratic and bizarre behaviour. He
put two kitchen knives next to his bed. He developed unshakeable and entrenched
beliefs focussed around him being blessed by God and that he was the ‘chosen one’. He
would refer to the devil. He would repeatedly say ‘you are either with me or against
me’. He believed televisions and his tattoos were talking to him. He became
increasingly fixated with (verified) wild fires in Greece and a (verified) forthcoming
astronomical event known as a ‘blood moon’. He believed he did not need to eat or
drink. He stopped working and sleeping. He was driving fast and through red traffic
lights, believing that they were changing to green specifically for him as he approached
them. His family were extremely concerned and tried to persuade him to get medical
help but he refused.
On 26 July 2018 his mother asked a family friend, who was a nurse, to informally visit
him. His brother persuaded him to see his General Practitioner, who recognised he was
having a psychotic episode, and at approximately 17.00hrs made an urgent referral to
the Crisis team. It was agreed he needed an initial assessment within 24 hours and
arrangements would be made via the brother. A Home Treatment Team (‘HTT’) nurse
inadvertently telephoned the man. He repeated his psychotic beliefs and was angry at
being telephoned, was irritated, and hung up. She contacted the out‐of‐hours Doctor
for an assessment that evening.
With considerable effort his family persuaded him to wait at his mother’s house.
Arranged via the brother, at approximately 23.00hrs the Doctor, a Specialist Registrar
Psychiatrist, and a mental health nurse assessed him. They quickly concluded he was
suffering from first episode psychosis. He was unknown to the mental health services
so there was no history to inform them how he might behave. He lacked capacity and
needed a full Mental Health Act 1983 (‘MHA’) assessment with a view to being
detained under section 2. The Doctor briefly considered and dismissed the use of
section 4 – a rarely used section. The bed manager confirmed there were no psychiatric
unit beds available.
In relation to the specific issue of risk to others:
• The brother warned the Doctor and nurse they needed to be careful because
his brother was ‘handy’.
• They were told he was a trained Thai boxer.
• That he had old charges or convictions for Actual Bodily Harm and Grievous
Bodily Harm.
• They found him to be a physically imposing man, who was at times extremely
irritated and hostile.
• His psychotic beliefs about being the ‘chosen one’ were entrenched and they
avoided challenging him. He reported a Clairvoyant (verified) had told him 4‐5
years earlier ‘the devil is going to put a spanner in the works’.
• They were told he had been driving fast and through red lights believing they
were specifically changing to green for him.
• He reported no thoughts to harm anyone, but stated that if anyone gets in his
way ‘I know what I am capable of’.
• He described himself as a ‘ticking time bomb’.
• The severity of his mental illness led them to anticipate a general acute
psychiatric ward would offer inadequate safeguards and that he would need to
be admitted to a psychiatric intensive care unit (‘PICU’).
• They anticipated the police would be required to help facilitate the full MHA
assessment and extract him to a PICU.
They concluded his reported history of erratic driving presented a risk to other people.
They did not believe he presented a general risk of violence.
They asked him to take anti‐psychotic medication but he refused. They asked him to
remain at his mother’s house but he refused. They asked his brother to block his car in.
At approximately 00.00hrs he drove off, alone, but in a controlled manner. They
considered but rejected informing the police. They did not check to see whether he
actually drove home. The Doctor did not contact the out‐of‐hours Consultant for
advice. The bed manager should have been asked to prioritise him but wasn’t. In the
early hours of 27 July the Doctor and nurse completed their RIO notes and section 2
recommendation.
The Approved Mental Health Practitioner (‘AMHP’) service had responsibility for co‐
ordinating the full MHA assessment. The nurse made an informal call to the out‐of‐
hours AMHP. The nurse should have referred him to the AMHP service immediately but
did not do so. This caused a delay of approximately 10 hours. A day‐shift HTT nurse sent
the referral at 10.08hrs. It did not mention the urgency when it should have done so.
The referral stated he had not shown any signs of violence, but cited his statement that
if anyone gets in his way ‘he knows what he’s capable of’ and there were potential risks
to others because he was hostile and irritable.
A Senior Practitioner allocated his case to an AMHP. Mid‐morning the AMHP read the
RIO notes made by the HTT Doctor and nurse. She was clear that the man needed to be
detained and he presented a real risk of harm to other people. She was not prepared to
conduct the assessment and detain the man, without police assistance and the ability
to immediately take him to a psychiatric unit. She discussed what to do with a different
Senior Practitioner. He had no prior knowledge of the case. They incorrectly
understood that outside of a 999 call situation the police required 24 hours’ notice. A
multi‐agency Memorandum of Understanding to request police assistance contained
ambiguous wording. They anticipated the police would be too busy to execute a
warrant because it was the weekend. They did not contact the police to ask them. They
agreed the court would be unlikely to grant the warrant until a bed was available.
At a midday bed management meeting the HTT Acting‐Team Manager asked for him to
be prioritised. The general AMHP service was not represented. It was agreed the Place
of Safety, if free, would be made available for the MHA assessment pending a bed
being found. The HTT should have informed the AMHP about the availability of the
Place of Safety but didn’t. The HTT should have informed the AMHP he was a priority
but didn’t. It was agreed a section 135 warrant would be required. The HTT requested
the AMHP apply for a section 135 warrant at 14.27hrs. The Senior Practitioner who
allocated the AMHP at 10.08hrs knew about this request. He did not inform the AMHP.
The AMHP remained unaware of the request.
The AMHP telephoned the bed manager direct and was told it was unlikely a bed would
be available that day. There was no discussion about using the Place of Safety as agreed
at the bed management meeting.
The AMHP telephoned the HTT at 12.35hrs but no clinicians were available. At 15.35hrs
a HTT nurse returned her call. The AMHP said it was an ‘urgent’ assessment but
because the man presented a risk to other people she was not prepared to undertake a
MHA assessment until there was a bed available. It was the responsibility of the HTT to
locate a bed. This update from the AMHP should have resulted in the HTT making a
determined effort to locate a bed, but it didn’t. There was no discussion about using
the Place of Safety as agreed at the bed management meeting.
The AMHP was told the man’s family had been calling repeatedly. The AMHP should
have telephoned the family but decided not to because she had no update for them.
This was a missed opportunity to check on the man’s risk. The AMHP did not escalate
her concerns within the HTT when she should have. The AMHP did not escalate her
concerns with the bed manager when she should have. The AMHP did not escalate her
concerns within the AMHP service when she should have. The AMHP was about to
finish her shift and incorrectly caused his case to be closed. The AMHP instructed the
HTT nurse to send a new referral to the out‐of‐hours AMHP. Having caused the case to
the closed the AMHP should have alerted the out‐of‐hours AMHP but didn’t. The
AMHP’s rationale for her actions was long standing frustration with the challenging
environment in which the mental health professionals were working. The AMHP’s
actions were not in accordance with recognised practice and were contrary to her code
of conduct.
At approximately 17.00hrs the out‐of‐hours AMHP checked the list of requests for a
MHA assessment. The man should have been on the list but wasn’t and she left the
office to assess a different person. She remained unaware the man needed a MHA
assessment until a bed manager asked her to progress it, but the man had already killed
Nigel.
The HTT nurse had made the second referral at 18.01hrs. The nurse should have
requested a section 135 warrant but did not do so. The nurse should have requested
urgency but did not do so. It contained contradictory statements about risk: ‘risk self
very vulnerable, no known risk to others’ and ‘at risk to others due to his agitation’. The
HTT nurse and an AMHP service care facilitator spoke at approximately 18.17hrs and
20.09hrs. The HTT nurse stated the family had reported the situation was continuing to
deteriorate. The out‐of‐hours AMHP was not informed.
The family had understood a bed would be found early on 27 July. The man had not
slept all night. With considerable effort, his family persuaded him to consent to
treatment. He packed a bag at home and at approximately 8.00hrs went to his father’s
house. Between 8.24hrs and 20.06hrs his family telephoned the HTT over 60 times. The
overwhelming majority of their calls were not answered. When answered they
explained he was willing to voluntarily present at hospital and that his mental health
was worsening. They were told no bed was available. After 16.30hrs the family had one
further call connect at 20.06hrs. They were told the HTT were waiting for an update on
a bed.
The HTT Standard Operational Procedure required a Doctor to review the man on 27
July. There is no evidence a Doctor was made aware of the man on 27 July. He should
have been reviewed by a Doctor in accordance with this procedure but wasn’t.
Due to a failure of mental health professionals to correctly record and communicate
effectively with each other and the family, no mental health assessment took place. In
addition the processes in place at the time were inadequate and failed to provide the
necessary safeguards. Mental health professionals became procedurally driven by the
lack of an available bed. No one mental health professional or organisation had the
complete picture.
This is against a background of (1) the demand for mental health beds in Birmingham
increasing significantly (2) there being no section 140 beds in Birmingham (3) the HTT
and AMHPs having to operate significantly beyond their recognised capacity (4) the HTT
was being led by an Acting‐Team Manager and Locum‐Consultant Physiatrist, there was
a lack of proactive leadership on 27 July.
Mid‐evening the man was taken home. As the evening progressed his partner was so
concerned about his presentation she discretely removed and hid the two knives he
had placed next to his bed and all kitchen knives except two small kitchen knives. These
were later used during the assault. Having gone to bed alone, shortly before 23.00hrs,
he woke her up and made her go into the back garden and run around together. He
was fixated with the ‘blood moon’ and repeating ‘you are either with me or against
me’. By coincidence, Nigel Abbott walked past the front window. He shouted ‘that’s the
devil’ and ran after Nigel and killed him. After a post‐mortem the cause of death was
blunt force trauma to the head.
He was arrested on suspicion of murder. He was assessed and sectioned under the
MHA. He reported being God and at war with the devil. He was diagnosed with a severe
form of untreatable schizophrenia. The severity of his mental illness could only be
explained by genetic predisposition. He was charged with murder. Based on the agreed
evidence of two expert consultant forensic psychiatrists, on 14 February 2019 a Crown
Court jury found him not guilty ‘by reason of insanity’, meaning he was found not
responsible for his actions.
5 CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern.
1. Previous Prevention of Future Death Reports
The Birmingham and Solihull Coroners issued nine relevant Prevention of Future Death
reports (‘PFDs’) in the 12 months preceding this inquest. Four of the deaths pre‐dated
the death of Nigel Abbott (27 July 2018) and five post‐dated his death. All nine PFDs
were issued after his death. Namely:
No. Name of Deceased Date of Death Date of Report
1 Simon Graham 4 May 2018 4 October 2018
2 Bradley Morgan 13 May 2018 4 October 2018
3 Michael Cooper 22 June 2018 4 October 2018
4 Michael Wheeler 26 July 2018 4 October 2018
5 Stephen Jackson 11 August 2018 4 October 2018
6 Claire Ryder 12 August 2018 4 October 2018
7 William Edge 18 August 2018 4 October 2018
8 Stephen Kennedy 8 October 2018 7 February 2019
9 Anthony Watson 22 October 2018 12 February 2019
NB. The PFDs and responses are available publicly on the Chief Coroner’s website.
All nine PFDs shared commonality of circumstances – the deceased was known to the
mental health services, had taken their own life, and the lack of an inpatient psychiatric
bed had featured in the chronology. PFDs no.1‐7 were issued as one batch on 4 October
2018 (some of the seven pre‐dated the corresponding inquest) because the strain on
the system of mental health services had become apparent to the Birmingham and
Solihull Coroners, and in their judgment, there was an on‐going risk of future deaths
from chronic underfunding of mental health services in Birmingham. NHS England and
Birmingham and Solihull CCG responded pointing to additional investment and funding.
Two further PFDs were issued on 7 and 12 February 2019. In the judgment of the
Birmingham and Solihull Coroners there remained an on‐going risk of future deaths
from chronic underfunding of mental health services in Birmingham. PFD no.8 was sent
to Rt Hon Matt Hancock MP, Secretary of State for Health and Social Care. A response
was delegated to Jackie Doyle‐Price MP, Minister with portfolio responsibility for
mental health services. She acknowledged that nationally the number of mental health
beds had reduced and pointed to additional national investment and funding.
2. concerns
On 22 March 2019 , wife of Nigel Abbott, emailed Rt Hon Teresa May, Prime
Minister setting out her concerns about her husband’s death. An undated response was
again delegated to Jackie Doyle‐Price MP, Minister with portfolio responsibility for
mental health services. She acknowledged the above PFDs and specific concerns raised
by the Care Quality Commission about BSMHFT in its latest report, adding ‘It is clear
that this situation is not acceptable and that there is an urgent need for improvement
to prevent further incidents. I have asked my officials to keep me updated on the
situation’.
3.
is a Consultant Forensic Psychiatrist and the Chief Mental Health
Legislation Officer for BSMHFT. His evidence included, in summary:
 Section 4 of the Mental Health Act 1983 (‘admission for assessment in cases of
emergency’) is a rarely used provision. He was unaware of it being used
nationally with a combination of a section 12 approved Dr and the nearest
relative. This is a training and education issue. Following Nigel Abbott’s death he
emailed all relevant Drs in the Trust reminding them that section 4 is available
to be used in urgent cases where there are problems with resources.
 Section 140 of the Mental Health Act 1983 requires every Clinical
Commissioning Group to specify hospital(s) in their area which can, from time to
time, receive patients in cases of special urgency. This has been on the statute
book since 1983 however there remain no section 140 beds in Birmingham and
Solihull. For 4 years he has been pursuing Birmingham and Solihull CCG to
provide section 140 beds.
 He did not agree with the Birmingham and Solihull CCG response to the batch of
seven PFDs issued on 4 October 2018 (see above). He said ‘deaths are occurring
in Birmingham because of a lack of resources’ and the mental health services in
Birmingham are in a ‘massive crisis’. This had not been laid out in the
Birmingham and Solihull CCG’s response to the PFDs.
 There are on‐going ‘systemic issues’ and he is ‘seriously concerned’. This is not a
secret but an open fact. There is no lack of effort but there remains a ‘perfect
storm’ due to the ‘paucity’ of resources. This creates a prohibitive environment
for clinicians and AMHPs. Further context is that the number of psychiatric
patients in Birmingham and Solihull has gone up whilst simultaneously cuts have
been made to mental health funding in Birmingham and Solihull
4.
is a Consultant Psychiatrist and a Clinical Director within BSMHFT. He has
three HTTs within his portfolio. He was BSMHFT’s lead psychiatrist on its Root Cause
Analysis investigation. His evidence included, in summary:
 There are on‐going ‘system failures’ within the mental health services in
Birmingham. The service is ‘broken.’ In the Birmingham local health economy –
mental health, police, social care – the leaders are ‘weak and incompetent’.
 Birmingham and Solihull CCG does not adequately fund mental health services
in Birmingham, and does not distribute what funding it does provide
appropriately.
 Modelling has demonstrated Birmingham needs 40+ more psychiatric beds.
 The system failures impact on the decision making of clinicians who have
consequently developed ‘learned helplessness’ – they have learnt that there is
‘no point’ in asking for a bed.
5. Generally
I heard evidence from a number of front line mental health Drs, nurses and AMHPs and
senior witnesses from BSMHFT, BCC and WMP. The evidence included, in summary:
 Drs, nurses, AMHPs and police officers do not understand the Joint
Memorandum of Understanding for Mental Health Professional Requesting
Police Assistance with Mental Health Act Assessments. WMP’s mental health
lead officer Inspector stated its wording was ambiguous and he
would ‘bin it and start again’. The MoU is still being used.
 The HTT, bed managers and AMHP services are operating caseloads significantly
beyond their recognised capacity:
o Referral rates to the 5 HTTs in Birmingham and Solihull have increased
from 7238 in 2014/2015 to 9282 in 2018/2019.
o The 5 HTTs have resources to manage a caseload of 250‐300 however
are actually managing around 500.
o The AMHP service carried out 2680 MHA assessments between April
2017 and March 2018. This increased by 49% ‐ 4002 ‐ between April
2018 and March 2019.
o The 5 HTTs have vacancies for front line nurses and at a leadership level
that cannot be filled, in part due to the unattractive working conditions.
o The number of AMHPs has decreased by 17% whilst the number of
detentions under the MHA has increased by 47%.
o At the time of the incident there were 24 patients waiting in the
community for a bed. 16 had been fully assessed under the MHA and
detained. 9 had received initial assessments under the MHA and deemed
detainable.
A similar picture is continuing.
 Generally, front line mental health professionals – Drs, nurses, bed managers,
AMHPs – are working in an extremely challenging environment which impacts
negatively on their attitudes and working practices.
6. Home Treatment Team Policies
The lack of psychiatric beds means it is not uncommon for patients who have had a full
MHA assessment and patients who have had an initial assessment to both have to
remain in the community whilst a bed is found, sometimes for many weeks. Their risks
and safety in the community are managed in accordance with HTT policy, however, the
respective policies are not consistent.
For patients who have had a full MHA assessment and been detained, The Bed
Management and Maximising Bed Use Policy and Bed Management Acute Admissions
and Capacity Utilisation Policy contain a detailed process requiring the HTT to assess
the patient and their family’s needs, and put in place a written care plan to provide a
safe and appropriate management plan, pending a bed being found. In contrast, for
patients who have had an initial assessment and deemed detainable the Home
Treatment Standard Operational Procedure simply requires them to be ‘medically
reviewed by [HTT] doctor the next working day’ pending a bed being found.
It follows the applicable policy is determined by the technical status of the patient
rather than their personal circumstances. The man who killed Nigel Abbott was initially
assessed by a section 12 Dr as lacking capacity, in severe first episode psychosis and
was detainable. He was predictably a risk to himself and others and refused to stay at
his mother’s house and take medication. His risk in the community was no different to
someone who had actually been detained. However, the difference in status meant the
more robust and detailed HTT process, only applicable to patients who have had a full
assessment, did not apply.
I heard no explanation as to why The Bed Management and Maximising Bed Use Policy
and Bed Management Acute Admissions and Capacity Utilisation Policy process for
managing risks and safety for fully assessed and detained patients in the community,
are not replicated in the Home Treatment Standard Operational Procedure for patients
who have had an initial assessment and deemed detainable.
Summary of Concerns
In summary, the evidence raised five generic on‐going matters of concern. The
consequence is that acutely unwell people who need to be detained, because of the
risk they pose to themselves and others, will remain unnecessarily free in public when
in fact the agencies have the mechanism to detain them.
The five generic on‐going matters of concern:
(1) The agencies involved in this area are not working together effectively and there
is a misunderstanding around the Joint Memorandum of Understanding for
Mental Health Professional Requesting Police Assistance with Mental Health Act
Assessments.
NB. I issued pre‐inquest a PFD dated 31/07/2019 in relation to this concern.
Having heard the evidence at the inquest the concern remains ‐ WMP’s mental
health lead officer Inspector stated its wording was ambiguous
and he would ‘bin it and start again’. The content of this PFD therefore remains
valid.
(2) There continues to be a chronic shortage of resources within the mental health
services in Birmingham and Solihull. In particular, mental health professionals
are operating caseloads well in excess of recommended levels and there is a
chronic shortage of psychiatric beds.
(3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT.
(4) Whilst section 4 is available to be used, it is not used.
(5) The Home Treatment Standard Operational Procedure is inadequate to
safeguard patients in the community who have been initially assessed and
deemed detainable but are waiting in the community for a bed. This procedure
is inconsistent with the corresponding safeguards for fully assessed and
detained patients waiting in the community for a bed.
In my opinion there is a risk that future deaths will occur unless action is taken. In the
circumstances it is my statutory duty to report these concerns to you.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have
the power to take such action.
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 17 December 2019. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
8 COPIES and PUBLICATION
I have sent a copy of my report to:
(1) The Chief Coroner for England and Wales.
(2) The following Interested Persons:
a) , Consultant Psychiatrist.
b) , AMHP.
c) Family of Nigel Abbott.
d) Family of .
(3) The following who may find it useful or of interest:
a) , Chief Mental Health Legislation Officer for BSMHFT.
b) , Consultant Psychiatrist.
c) Mind, 15‐19 Broadway, Stratford, London E15 4BQ.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it
useful or of interest. You may make representations to me, the Coroner, at the time of
your response, about the release or the publication of your response by the Chief
Coroner.
9 22/10/2019
Signature
James Bennett Area Coroner Birmingham and Solihull

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response to the Birmingham and Solihull Coroner’s Regulation 28 Report to Prevent Future 
Deaths- Nigel Byron Abbott 

1. 

Introduction 

1.1  This report provides a response to the Area Coroner for Birmingham and Solihull Coroner in 

respect of the Regulation 28 report issued to: 

  NHS Birmingham and Solihull Clinical Commissioning Group  
  NHSI/E 
  Clive Heaphy, Acting Chief Executive, Birmingham City Council  
  Roisin Fallon-Williams, Chief Executive, Birmingham and Solihull Mental Health 

Foundation NHS Trust  

  Dave Thompson, Chief Constable, West Midlands Police. 

1.2  This response is submitted jointly on behalf of: 

  NHS Birmingham and Solihull Clinical Commissioning Group (the CCG) 
  Birmingham City Council (BCC) 
  Birmingham and Solihull Mental Health Foundation NHS Trust (BSMHFT) 
  West Midlands Police (WMP). 

2. 

Background and context  

This response to the Coroner relates to the death of Nigel Byron Abbott who died on 27th July 

2.1 
2018. All of the agencies that have contributed to this response offer a sincere and unqualified 
apology to the family and friends of Mr Abbott, as well as the friends and family of the service user.  

On 22nd October 2019, the above agencies received a Regulation 28 Report to Prevent Future 
2.2 
Deaths from the Area Coroner for Birmingham and Solihull. This report followed an earlier Regulation 
28 report issued on 31st July 2019 to BCC, BSMHFT and WMP. This response covers issues raised in 
both of the Regulation 28 reports.  

2.3 
The Regulation 28 report related to the death and subsequent inquest into the death of Nigel 
Byron Abbott who died on 27th July 2018. Mr Abbott was killed by an individual, unknown to him, who 
was in acute mental health crisis and whose family had sought care from Birmingham and Solihull 
health and care services.  

The agencies do not seek to recite the tragic events of that night in this response, save to say 

2.4 
that it is recognised that failings occurred at both an individual agency and system wide level.  

This response will respond to specific concerns raised by the Coroner but also provides an 

2.5 
update on the learning that has taken place outside of the specific concerns.  

 
 
 
 
 
 
 
 
 
                  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3. 

Improvements in System Wide Working 

3.1  
In response to this serious incident the agencies listed, along with Birmingham Women’s and 
Children’s NHS Foundation Trust (BWCT), who provide mental health services to under 25s through 
Forward Thinking Birmingham (FTB), have formed a multi-agency working group to firstly respond to 
the issues that have been identified by this event, but also to ensure work in the future to ensure that 
multi-agency working is integrated into current learning and future improvement.  

The working group, chaired by the CCG, has been set up to monitor actions arising from this 

3.2 
event but to also explore options for multi-agency learning in relation to serious incidents that may 
occur in the future.  

3.3  
This includes carrying out joint investigations and preparing joint action plans where 
appropriate, in addition to multi-agency responses to Regulation 28 reports issued by the Coroner.  

3.4   A Memorandum of Understanding for Joint Investigations around avoidable deaths is currently 
being developed and will be completed in January 2020, following review by the Multi-Agency 
Working Group.  

The group is currently overseeing five main work streams in response to the Coroner’s 

3.5 
recommendations, which are: 

a.  A collective process to investigating serious incidents 

b.  Joint standards and policies  

c.  The development of electronic ‘action cards’ to ensure that staff have clear processes to 

follow, including the points of interaction between the agencies 

d.  Development of culture and workforce across all agencies, and 

e.  A workshop to ensure awareness and embedding of the new processes.  

3.6 
Clarity has been introduced in relation to the use of sections 135 and 136 of the Mental Health 
Act. Section 135 requests are now subject to multi agency ‘call in’ and prioritisation at 10am and 7pm. 
This process has only recently been introduced, and it is recognised that a more robust escalation 
process is needed to determine priority cases.  

3.7 
In relation to Section 136 matters, the agencies are working to determine the management of 
these cases. This is likely to comprise a criterion for cases to be identified for urgent admission, with 
non-urgent cases being managed with positive risk processes and diversion to least restrictive options 
wherever possible.  

4.  Responses to the Coroner’s Concerns 

5. 

The agencies involved in this area are not working together effectively and there is a 
misunderstanding around the Joint Memorandum of Understanding for Mental Health 
Professional Requesting Police Assistance with Mental Health Act Assessments  

A new Memorandum of Understanding has been developed and agreed by all of the relevant 

5.1 
agencies, WMP, BCC, BSMHFT and BWCH. This memorandum has been developed and will receive 
formal approval at the multi-agency working group on 22nd January 2020.  

5.2 
The revised memorandum has been developed following a partnership event in September 
2019, which provided an opportunity to seek feedback from a range of agencies and to discuss the 
challenges that continue to exist.  

Response to the Birmingham and Solihull Coroner reg 28, version 1.2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5.3  
The new memorandum provides clarity for front line staff working in pressured situations, is 
clear on the roles and responsibilities of the agencies involved and seeks to remove the ambiguity 
relating to the incorrect perception that WMP require 24 hours’ notice when providing police support. 
This approach has been communicated to staff in advance of the final sign off of the full document.  

The memorandum will be presented to frontline staff and the agencies will continue with a 

5.4 
programme of engagement and support, as well as undertaking scenario testing in the first quarter of 
2010.  

6 

There continues to be a chronic shortage of resources within the mental health services 
in Birmingham and Solihull. In particular, mental health professionals are operating 
caseloads well in excess of recommended levels and there is a chronic shortage of 
psychiatric beds.  

The CCG and the health care agencies have previously provided the Coroner with information 

6.1  
on the background to the increase in demand and for mental health services in the Birmingham and 
Solihull area, and steps that had either been taken or were planned to increase funding, as well as 
improve the system to ensure early intervention for those in crisis and to manage flow to ensure that 
beds are available for those for whom there is no alternative.  

6.2 
The agencies recognise that there has been increased demand for crisis mental health 
services since 2016, and the CCG has responded to this additional pressure with increased funding 
and through working with FTB (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.  

In addition, the agencies and system partners have been working to understand the reason for 

6.3 
the increased need, and to look at how the system can be improved to make best use of the existing 
resources.  

6.4  
The system 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. This is 
being addressed through the STP and the CCG Mental Health Programme Delivery Board. The 
ambition of the STP is to achieve sustainability, through a strong focus on prevention and recovery 
(ref 11.2).  

Included in this programme is consideration of the need to reinforce services that already exist 

6.5  
within secondary mental health services, by increasing the staffing levels in crisis resolution home 
treatment teams, whilst also understanding what an alternative crisis support service might look like.  

6.6   System partners are working closely with both local mental health service providers and the 
third sector, with the aim of improving the service offer for people experiencing a mental health crisis.  

6.7   As a result of partnership working and guidance from people with lived experience, the CCG 
has been successful in securing recurrent funding from two separate NHS England Transformational 
funds, totalling in the region of £2.9m, to make fundamental changes to how crisis is managed within 
the region.  

6.8   Psychiatric liaison services within acute hospitals have received £1.15m to increase staffing 
levels within all hospitals which have an emergency department, with the aim of providing a more 
robust, specialist and diverse workforce, to help reduce waiting times, increase flow and improve 
patient experience. 

Response to the Birmingham and Solihull Coroner reg 28, version 1.2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 6.9   A further £1.7m is being spent on the development of a crisis pathway to increase the capacity 
in secondary mental health crisis services.  

6.10  We have developed plans for now and when, significant funding will be allocated towards the 
establishment of crisis houses, an evidence based initiative which will complement inpatient mental 
health facilities for those who may need support managing higher levels of risk (ref 7). 

6.11  BSMHFT have determined the matter of patient flow and access to inpatient beds a key 
priority to the organisation, and this is also recognised as a risk within the wider health and social care 
economy across Birmingham and Solihull. As such, BSMHFT are working closely with system 
partners including the CCG to redesign and invest in both primary and secondary care interventions 
to try to meet the demands that are being faced today but also as part of planning for a sustainable 
future. The following new developments are key to improving urgent care for patients. 

7 

New Urgent Care Centre- expected completion autumn 2020 

This centre will provide an appropriate clinical environment for the All Age Urgent Care Model 

7.1 
(for those aged 12 years upwards), incorporating age appropriate place of safety suites and 
psychiatric decision units, together with an ‘all age’ integrated bed management function alongside 
flexible assessment suites.  

This centre (based at the Oleaster Centre in Selly Oak) will provide a working base to enable 

7.2 
improved integrated working and communication across agencies with facilities to locate the multi-
agency street triage team, BSMHFT and FTB Crisis Services and Local Authority AMHP services.  

8 

Crisis House- expected completion spring 2020 

Both BSMHFT and BWCT have agreed in principle to pool resources to provide a Crisis 

8.1 
House. Such a facility will provide a viable alternative to a psychiatric inpatient admission for those 
who would benefit from psychological interventions during short term crisis.  

8.2 
There is substantial evidence that demonstrates Crisis Houses increase inpatient bed 
capacity, are more accessible, reduce bed days and improve flow. The Crisis House will be able to 
feed into this pathway for both service providers, for short term Crisis Admissions. 

9 

Crisis Café Expansion 

9.1  MIND, the mental health charity, are currently running a Crisis Café in the North of 
Birmingham three nights a week, following a successful pilot in 2018.  

There are plans to expand this model to a city wide service as a viable alternative for 
9.2 
accessing support for those in crisis. There will be four cafes covering Birmingham and Solihull by 
Spring 2020, two of these opening in January 2020.  

The service also provides advice and guidance to the network of third sector and charity 

9.3 
organisations already in existence. 

10 

Improving Flow Internally at BSMHFT 

10.1  BSMHFT have appointed independent experts to help them review their current internal 
pathways of care, with the aim of ensuring that they have the maximum capacity possible in the right 
teams to meet patient demand. This work is ongoing. They are also piloting an evidence based 
national initiative called ‘Red to Green’ aimed at improving flow and reducing length of stay within 
adult acute inpatient units, by ensuring pre-discharge planning and touch point reviews for all patients. 
This approach has already demonstrated success in partnerships with other providers.  

Response to the Birmingham and Solihull Coroner reg 28, version 1.2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 11 

Increasing Home Treatment Team Resource 

11.1  BSMHFT have recognised the need for additional investment in the Home Treatment Team 
service and have committed in excess of £1m to create additional teams with smaller caseloads.  

11.2  BSMHFT are currently recruiting additional staff within the Home Treatment Teams as follows: 

  Five full time additional Staff Grade Associate Specialist doctors- this will effectively provide an 
additional 0.5 whole time equivalent (WTE) senior medical input to each team (locum doctors 
are currently in place until the substantive postholders start)  

  One Senior Psychologist  

  Five further psychology posts to allow a 0.5 WTE equivalent per team. Two individuals are 

already in post and recruitment is continuing.  

  Four Senior Team Managers have now been recruited and have started in their roles  

  Three senior out of hours’ clinical coordinator posts- these posts will provide clinical leadership 
and expertise out of hours to Home Treatment Team staff. They will support senior clinician 
led assessments in line with protocol which will inform a quicker response out of hours for 
patients and relatives.  The coordinators will also provide senior advice and support for 
complex crisis calls and will support supervision and monitoring of clinical practice out of 
hours. All positions have been filled and staff are now in their roles 

  Four Team Administrators- these roles will support the current administrators in place with the 

increasing demand on home treatment and supporting the increase in phone calls  

  One post to support families of patients accessing the Home Treatment Team with psycho-

social education, emotional support, practical advice and signposting. Recruitment to this post 
will commence shortly. 

  Two band 6 and two band 5 Home Treatment Team CPN posts- these posts are currently 

being recruited to 

11.3    Since 1st August 2019 BSMHFT have been monitoring daily caseloads for each of the Home 
Treatment Teams and the actions set out above have led to demonstrable reduction in the 
average caseload of the teams.  

12  Commissioning Funding  

12.1  Using nationally benchmarked data the CCG can demonstrate that on overall weighted 
population the CCG is within the highest quintile of all CCGs for mental health and learning disability 
spend, and fifth highest from ten comparator CCGs using spend per 100,000 population.  

12.2  Using mental health weight population, the CCG is the in third quintile for spend in mental 
health (compared to all CCGs). 

12.3  The CCG has exceeded the mental health investment standard (MHIS) since its inception.  
The table below sets out the CCG’s overall growth allocation for the next five years in line with the 
NHS long term plan and the level of growth planned for Mental Health. This meets the annual 
requirement within the Mental Health Investment Standard. 

Response to the Birmingham and Solihull Coroner reg 28, version 1.2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 2019/20 

2020/21 

2021/22 

2022/23 

2023/24 

5.6% 

4.4% 

4.2% 

4.0% 

3.8% 

6.3% 

6.1% 

4.2% 

4.0% 

3.8% 

CCG Growth 
(Overall 
Allocation) 

Growth in 
Planned Mental 
Health 
Investment as per 
MHIS 

13  Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT. 

13.1    The CCG recognises the responsibility to provide emergency beds pursuant to Section 140 of 

the Mental Health Act.   

13.2  The CCG has entered into local arrangements with both BSMHFT and BWCT to delegate the 
management of access to emergency beds, in accordance with the 2015 Mental Health Act Code of 
Practice.  

In practice this means that both Trusts are able to access emergency beds through local 

13.3 
arrangements. Both Trusts have autonomy and authority to admit patients to emergency beds 
available within the CCG, neighbouring CCGs or an independent sector placement, funded by the 
CCG.  

13.4  The difficulties in implementing the Code of Practice was reviewed by Care Quality 
Commission in their report issued in June 2019, which recommended that “local leadership teams 
work together to discuss the way this [Section 140 provision] is working for patients and how to 
improve any problems with local implementation”.   

13.5  The agencies believe that arrangements set out within this delegation arrangement reflects 
this recommendation whilst providing the flexibility to manage this emergency provision in the best 
possible way.  

14  Whilst section 4 is available to be used, it is not used.  

14.1  Section 4 of the Mental Health Act is a rarely used provision for admission to hospital, both 
nationally and locally. Good practice is that the provision should be used in exceptional circumstances 
only.  The MHA permits an application for detention for assessment to be made under  
Section 4 on the basis of a single medical recommendation but only in very limited circumstances. 
The use of Section 4 would be considered as an emergency application for detention under the MHA 
and would need to meet the criteria of “urgent necessity”. Hospital Managers and Local Authorities 
are required to monitor the use of section to ensure it is not misused and to allow action to be taken to 
address issues of lack of resources.   

14.2  BSMHFT and BWCT have joint policies and protocols setting out the application of the Mental 
Health Act, including the use of Section 4. Section 4 admission is an option for all clinicians in the 

Response to the Birmingham and Solihull Coroner reg 28, version 1.2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 correct circumstances using clinical judgement and this is clearly set out in the Joint Assessment for 
Admission Under the Mental Health Act Policy.  

14.3  The use of Section 4, as well as other Mental Health Act provisions is monitored through the 
West Midlands Mental Health Act Scrutiny Group.  

15  The Home Treatment Standard Operational Procedure is inadequate to safeguard 

patients in the community who have been initially assessed and deemed detainable but 
are waiting in the community for a bed. This procedure is inconsistent with the 
corresponding safeguards for fully assessed and detained patients waiting in the 
community for a bed. 

15.1  The Home Treatment Team Operational Procedure has now been revised, and approved 
though governance procedures to ensure that it fully corresponds with the safeguards for fully 
assessed and initially assessed patients waiting for a bed, as detailed in the Bed Management Policy. 
The revisions have been cascaded throughout the operational teams and the bed management team 
and highlighted through lessons learnt process.  

16  Conclusion 

16.1  The Birmingham and Solihull health and care system and partners are committed to providing 
the best possible care to people, at the earliest opportunity, it will do this by working in partnership 
through its governance framework via the oversight group chaired by the CCG. 

16.2  System wide learning has taken place since this tragic incident and the agencies are now 
working closely to prevent a reoccurrence, underpinned with a commitment to prevent avoidable 
deaths in the region.  

16.3  We hope this response goes someway to assuring the Coroner, but also the families and 
friends of those affected, that lessons have been learned and system wide improvements have taken 
place, and will continue through the ongoing work of the multi-agency working group.  

Response to the Birmingham and Solihull Coroner reg 28, version 1.2

Related reports

Other reports by James Bennett

• REDACTED — 29 Apr 2026
• Javed Iqbal — 3 Mar 2025
• Kieran Lavin — 1 Aug 2024
• Robert Fray — 6 Jun 2024
• Tcherno Bari — 3 Jun 2024
• Charles Harper — 16 Jan 2024
• Philip Malone — 23 Nov 2023
• Peter Fleming — 14 Jul 2023

See all →

More reports categorised “Community health care”

• Lilian Behrendt — 9 Jun 2022
• Matthew Evans — 18 May 2022
• Sarah Dunn — 12 May 2022
• Susan Carling — 28 Apr 2022
• Volodymyr Korol — 19 Apr 2022
• Ryan Merna — 5 Apr 2022
• Natalie Turner — 25 Mar 2022
• Donald Compton — 20 Mar 2022

See all →

Track Birmingham and Solihull Mental Health NHS Foundation Trust

See every Prevention of Future Deaths report matching Birmingham and Solihull Mental Health NHS Foundation Trust, and how often a new one appears.

What would an alert for this have sent me? Search the full text

Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.

These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.