Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0469, written 23 Nov 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Nov 2023 |
|---|---|
| Reference | 2023-0469 |
| Deceased | Philip Malone |
| Coroner | James Bennett |
| Coroner area | Birmingham and Solihull |
| Category | Suicide (from 2015) |
| Organisation named | Birmingham and Solihull Mental Health NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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. Chief Executive, Birmingham and Solihull Mental Health Foundation Trust. 2. NHS Birmingham and Solihull Integrated Care Board. 3. The Rt Hon Victoria Atkins MP, Secretary of State for Health and Social Care. CORONER I am James Bennett H.M. Area Coroner for Birmingham and Solihull. 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. INVESTIGATION and INQUEST On 13 July 2023 I commenced an investigation into the death of Philip Laurence Justin MALONE. The investigation concluded at the end of the inquest on 14 November 2023. CIRCUMSTANCES OF THE DEATH Mr Malone was diagnosed with treatment resistant schizophrenia in 1983 and had been sectioned multiple times. In May 2023 he was diagnosed with adult autism. At a review on 31 May he was considered to be stable. On 15th June a routine clozapine review identified sub-therapeutic levels but this was not notified to his clinicians. Sub-therapeutic levels of clozapine are likely to have contributed to a worsening in his symptoms. Around 24th June he was noted to have suffered a significant deterioration - with symptoms of thought disorder, anxiety, and responding to hallucinations - and following a mental health act assessment on 28th June clinicians wanted to detain him under section 2. No inpatient psychiatric bed was available. Whilst he awaited a bed, he remained in the community with daily visits from the mental health team. Last contact was on 1st July when he accepted his medication and appeared more settled. There was no answer when he was visited on 2nd July. His room at supported accommodation was entered on 3rd July and he was found deceased no suicidal ideation. Post-mortem examination confirmed the medical cause of death was: . Recently he had expressed 1a Cervical spinal cord injury. 1b Laceration 1c II The conclusion of the inquest was that death was the consequence of suicide. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. 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 to you. The MATTERS OF CONCERN are as follows. – 1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action. 1 2 3 4 5 2. The Patient Safety Manager gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved, and there is a genuine risk of the same problem with another patient in the future. 3. added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged. In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged, and amplifies the chronic shortage of beds. 4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board. The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding. My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate. Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken. 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. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 19 January 2024. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Mr Malone’s family. 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. 6 7 8 9 James Bennett H.M. Area Coroner for Birmingham and Solihull 23rd November 2023
3 responses 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.
1st Floor Wesleyan Colmore Circus Birmingham B4 6AR 4th March 2024 James Bennett Area Coroner for Birmingham and Solihull The Birmingham and Solihull Coroner’s Court Steelhouse Lane Birmingham B4 6BJ Dear Mr Bennett Re: Prevention of Future Deaths - Philip Laurence Justin Malone I am writing in response to your Prevention of Future Deaths report dated 23rd November 2023, in relation to the recent investigation into the circumstances surrounding the death of Philip Laurence Justin Malone. We note the response to you from Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) dated 10th January 2024. Firstly, may I apologise for the delay in our response; we have now been able to review a business case prepared by BSMHFT to increase their bed capacity with a proposed new build at the Highcroft site at the Birmingham and Solihull ICS System Investment Committee. Alongside the improvements BSMHFT set out in their response to you, in relation to managing demand and admission and improving overall patient flow, we are working collaboratively with BSMHFT to increase the mental health inpatient bed capacity. In March 2023, to increase capacity, an additional 20 mental health beds were commissioned in the independent sector within the Birmingham and Solihull geographic area. As per the response by BSMHFT, we continue to work with the Birmingham and Solihull Mental Health Provider Collaborative, with BSMHFT as the lead provider, to commission more local independent sector provision. The business case for additional mental health inpatient bed capacity has been supported in principle by the Investment Committee and we are working alongside BSMHFT to ensure that the case addresses actions raised by the Committee to allow it to progress to full support. We are, however, concerned as to whether the system will be able to raise the necessary capital to facilitate delivery because of the constraints placed upon NHS capital availability. Yours sincerely Chief Executive Cc ICB Chief Medical Officer
Legal Department Uffculme Centre 52 Queensbridge Road Moseley Birmingham B13 8QY Mr James Bennett, Area Coroner, Birmingham and Solihull Areas, BIRMINGHAM B4 6BJ Date: 10 January 2024 Dear Mr Bennett, Re: Prevention of Future deaths Philip Malone Thank you for your Prevention of Future Death’s report (PFD) dated 23 November 2023. I am sorry that you have felt it necessary to issue this against the Trust. I attach a copy of the previous two responses for similar PFD’s, highlighting the work that is being carried out by the Trust along with the ICB to try and ensure that patients are allocated a bed as soon as possible, when this is required. I would like to take this opportunity to explain that whilst many steps are being taken to address the matter of bed availability, the solution is very much reliant on our system partners as well. We are continuing to work closely with them . As you state within your PFD Report; this is a national problem. The Trust is therefore taking all available steps, within its power, in order to minimise and reduce the risks associated with this issue. I understand that in making the decision around the PFD at inquest you expressed that you took into account that multiple PFDs reports have already been issued, but in your view the volume of reports and repetition of issuing further reports is tangible and the fact that another report is being issued may contribute. I would like to express that the issuing of PFDs has not directly influenced the on going work the Trust has been undertaking for some time on this matter and we remain committed to do all we can to develop capacity and pathways that enable us to meet the needs of our population within the resources we have available to us. However, in order to offer further assurances I would like to update you on some of the work referred to in our previous attached letters. Since then we have made significant progress in providing timely access for patients who require an inpatinet admission and have outlined the processes taken since April. Birmingham and Solihull NHS Foundation Trust commissioned the services of Grant Thornton Consultancy to work with us on a specific 12-month project to address the issue of local bed shortages and the over-reliance on referring patients to private out of area hospital beds that are scattered across the country. The three main drivers to enable overall progress in accessing local timely beds has been: 1. 2. 3. The programme concluded in the summer of 2023 with the recommendation that two core workstreams are developed and delivered to improve bed capacity, namely: Managing demand and admissions Improving patient flow (by reducing length of stay and delayed transfers of care) Increasing bed base capacity locally. Locality model working 1. Throughout autumn 2023 we have had a dedicated project group leading the locality model work. This model described linking specific local hospital mental health beds to dedicated local home treatment teams, community mental health teams and local communities. It means that instead of patients being placed onto a generic bed waiting list, there is a local home treatment team and local hospital ward team working together to support prioritisation of admission to hospital based upon clinical risk and need. Gatekeeping 2. National mental health policy has for many years advocated home treatment teams leading on the gatekeeping function of acute mental health admissions. This process had been less rigidly adhered to in recent years for a variety of reasons. In response to the recommendations from the Grant Thornton project work, alongside the locality working we have developed processes to improve gatekeeping of acute admissions. Within core hours this is now a routine part of clinical decision making for admission. Overnight and at weekends it is not currently operationally possible, however processes have been developed and are currently being agreed to support how routine acute admissions will come through home treatment teams and urgent admissions out of hours will remain with on-call and urgent care services for the time being. Additional processes are also in place however, such as the 5-point plan framework which requires a level of clinical scrutiny when ensuring that admissions are appropriate and clinically necessary. Progress to date The Trust has been tracking clinical activity as part of the project and we have been able to demonstrate the following: i. We have been able to place less patients into “inappropriate out of area” beds situated across the country. This results in care closer to home with a better patient experience and greater continuity on the care pathway (See appendix 1) ii. The percentage of admissions gatekept through home treatment have increased through daily locality management of patient admissions. The detail of this is current subject to an audit process to be reported in February 2024. iii. The overall numbers of patients receiving increased unput and monitoring and as such may require inpatient admission have decreased from a peak of 67 in September to a low of 23 in December 2023 (See appendix 1) iv. The percentage of delayed transfers of care (DTOC) patients has continued to be challenging. As timely clinical discharges are optimised, the DTOCs will inevitably become more apparent. The Trust is working with our local authorities to improve the social care support to patients on our inpatient wards with an aim to provide speedier and safer discharges and thus create more capacity within our bed stock (See appendix 1) Governance and assurance There is a weekly out of area steering group: This system wide group meets weekly to monitor progress against agreed trajectories and ensure that action plans are delivered on. This group is supported by dedicated project management office support. Dedicated workstreams accountable to the out of area steering group: The workstreams have dedicated leads, meeting and support. They report weekly into the steering group. A clinical oversight group (COG) now meets regularly with all acute wards to support clinically appropriate discharges and enable escalation of discharge delays that occur as a result of non-clinical issues (appendix 2). 2 Assurance to the ICB in regard to clinical and operational safety oversight: The Trust have provided assurance to the medical director at the ICB that governance process are in place to support escalation and decision making around risk management of patients across the urgent and acute pathways (including acute care admissions). A copy of the process is available in appendix 3. Additional workstreams Highcroft redevelopment project: The Trust is currently leading on a business case to secure funding to build new acute hospital capacity on the Highcroft hospital site in North Birmingham. The long term plan is to replace all of the aging bed stock on the site. The medium term plan is to realise two new additional wards. Based on our acute bed case for need, these are currently proposed to be an 18-bedded acute ward and a 12-bedded acute intensive care ward (PICU). Business case submissions are scheduled to be submitted in early Spring 2024. However, even if the case is approved, this is only the first step and it would be at least a few years before it is likely to be completed. Strategic bed procurement steering group: This group is led by ICB with BSMHFT and FTB input. It is looking at how additional contracted beds can be contracted closer to Birmingham as an interim measure while the Highcroft programme is in development. We hope that we have been able to offer you further insights into the work that is being undertaken. You will note there is considerable work ongoing to try and reduce the number of people waiting for a mental health bed in the Birmingham and Solihull area. The Trust will continue to work above and beyond to achieve this within the scope and abilities we are able to fulfil. If you require any further information, please do contact us. Yours sincerely Chief Executive 3
From Maria Caulfield MP
Parliamentary Under Secretary of State
Department of Health & Social Care
39 Victoria Street
London
SW1H 0EU
Mr J Bennett
HM Area Coroner for Birmingham and Solihull
The Birmingham and Solihull Coroner’s Court
Steelhouse Lane
Birmingham
B4 6BJ
1 May 2024
Dear Mr Bennett,
Thank you for your Regulation 28 report to prevent future deaths dated 23/11/23 about the
death of Philip Malone. I am replying as Minister with responsibility for Mental Health.
Firstly, I would like to say how saddened I was to read of the circumstances of Mr Malone’s
death, and I offer my sincere condolences to their family and loved ones. The circumstances
your report describes are concerning and I am grateful to you for bringing these matters to my
attention.
Please accept my sincere apologies for the significant delay in responding to this matter.
The report raises concerns over the available psychiatric bed capacity in Birmingham and
Solihull.
In preparing this response, I have noted the responses received from the organisations to
which you issued your report, Birmingham and Solihull Mental Health NHS Foundation Trust
and Birmingham and Solihull Integrated Care Board.
My officials have informed me that the Trust remains committed to developing capacity and
pathways to ensure they are able to meet the needs of the population. The Trust initiated a 12-
month project with Grant Thornton Consultancy to address local bed shortages and reduce
reliance on out-of-area hospital beds. The trust has made progress in developing bed capacity
by implementing a locality model linking hospital beds to local mental health teams, enhancing
gatekeeping processes, and tracking clinical activity to reduce inappropriate admissions.
Birmingham and Solihull NHS Foundation Trust and Birmingham and Solihull Integrated Care
Board are working collaboratively to increase mental health inpatient bed capacity.
At a national level, through the NHS Long Term Plan we have provided record levels of
investment to expand and transform NHS mental health services and increase the workforce.
The long-term aim set out within the Plan is to improve community support for those with
serious mental illness to avoid the need for an inpatient admission where possible. We are set
to reach nearly £1 billion additional funding invested by 2023/24 (compared to 2018/19) to
transform community mental health services. However, we recognise that community-based
care will not always be appropriate for those with more complex needs. Major expansion in
funding for community mental health services commenced in all areas in 2021/22, which has
been key to managing pressures on inpatient beds.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Yours sincerely,
MARIA CAULFIELD
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