Anthony McCormack

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 Joseph McCormack.  

1.2  The Regulation 28 report raises a number of concerns about the care provided 

to Mr McCormack between 6th March 2019 and his untimely death on 7th May 
2019.   

1.3  The CCG has previously provided a number of reports to the Senior Coroner 

for Birmingham and Solihull on mental health services in the area, in response 
to a previous Regulation 28 reports to prevent future deaths. Much of the 
information contained in those reports 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 27th September 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 Joseph McCormack, who sadly passed 
away on 7th May 2019. 

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  The CCG, through these contractual arrangements and through its quality 
function, has quality monitoring processes in place, which include serious 
incident reporting systems and improvement monitoring. All investigations into 
serious incidents are quality assured by the CCG to ensure that necessary 
actions are identified and implemented.  

2.4 

It is understood by the CCG that Mr McCormack had a long history of contact 
with the Birmingham and Solihull mental health services.  

1 

 
 
 
 
 
 
 
 
 
 
 
 2.5  On 6th March 2019, a deterioration in Mr McCormack’s mental health resulted in 
him being referred to the Birmingham and Solihull Mental Health Foundation 
Trust (BSMHFT) Home Treatment Team. By 14th March Mr McCormack was 
identified as needing admission to hospital under section 2 of the Mental Health 
Act, and he was placed on the bed waiting list.  

2.6  Contact was maintained with Mr McCormack by the Home Treatment Team 
whilst he remained on the bed waiting list, but priority for a bed was given to 
other patients on the waiting lead whose need was assessed as greater. Mr 
McCormack was removed from the bed waiting list on 25th April 2019 following 
his discharge from the Home Treatment Team. Mr McCormack was referred 
back to the Community Mental Health Team, although there does not appear to 
have been any further contact with Mr McCormack between the discharge from 
the Home Treatment Team and his death.  

2.7  The CCG has no direct knowledge of these events and has ascertained this 

information through documents provided by BSMHFT.   

2.8  HM Coroner has identified a number of concerns around the care and 

treatment of Mr McCormack relating to difficulties locating beds for patients in 
need of admission and high case loads amongst the Home Treatment Team.  

2.9  BSMHFT have carried out a root cause analysis investigation into this serious 
incident which has identified a number of gaps in care, and for which an action 
plan for improvement has been completed.  

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 steps taken by the CCG to date are set out in the CCG’s previous 
responses to Regulation 28 reports to Prevent Future Deaths, and this 
response provides an update on those actions.  

3.3  The CCG recognises that there has been increased demand for crisis 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 

2 

 
 
 
 
 
 
 
 
 
 
 
 Partnership (the STP) to look at different ways of working throughout the 
system.  

3.4 

In addition, the CCG has been, and continues to work with, system partners to 
understand the reason for the increased need, and to look at how the system 
can be improved to make best use of the existing resources.  

3.5  The CCG is committed, with its system partners, 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.  

3.6 

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

3.7  The CCG has been 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. Stakeholders are working on 
designing community based services, which will increase accessibility for those 
in crisis and their families, to deliver the most appropriate support at the earliest 
opportunity. 

3.8  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 
£2.6m (increasing to £2.9m), to support making these fundamental changes to 
how crisis is managed within the region.  

3.9  From this funding, psychiatric liaison services within acute hospitals will receive 
£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. 

3.10  A further £1.4m (increasing to £1.7m) is being spent on the development of a 
crisis pathway to increase the capacity in secondary mental health crisis 
services.  

3 

 
 
 
 
 
 
 
 
 
 
 3.11  Part of this increased funding will be used to set up a network of four Crisis 

Cafés across the Birmingham and Solihull area. Each will be open seven nights 
a week and will be operated by MIND, the mental health charity. With a direct 
pathway into secondary crisis services and specialist understanding of 
available third sector interventions, this service will offer a community based 
setting for people to be able to seek the appropriate support when in a crisis. 

3.12  In the future, 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. 

3.13  It is understood that in response to this increased funding, BSMHFT are 
actively recruiting staff into the Home Treatment Team, as well as other 
BSMHFT services, supported by initiatives to improve early intervention, crisis 
support and bed flow. The intention is to use a number of mechanisms to 
improve access to beds for those who need them.  

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 health providers and other agencies 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  The CCG recognises the need to take a multiagency approach to the delivery 

of services and the prevention of deaths, including creating robust partnerships 
with mental health support services. 

4.3  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, and can confirm that system wide working is being reviewed at all 
levels with the intention of ensuring that appropriate and timely care is available 
for those who need it.  

4.3  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