Javed Iqbal

Date of report	3 Mar 2025
Reference	2025-0117
Deceased	Javed Iqbal
Coroner	James Bennett
Coroner area	Birmingham and Solihull
Category	Mental Health related deaths
Source	judiciary.uk record · original PDF
Responses published	1

The report

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

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Also filed under 2025-0117: Javed-Iqbal-Prevention-of-Future-Deaths-Report-2025-0117.pdf

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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:  All Care In One Ltd via Managing Director, 

CORONER

I am James Benne(cid:425), H.M. Area Coroner for Birmingham and Solihull areas.

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Jus(cid:415)ce Act 2009 and regula(cid:415)ons 
28 and 29 of the Coroners (Inves(cid:415)ga(cid:415)ons) Regula(cid:415)ons 2013.

INVESTIGATION and INQUEST

On 4 June 2024 I commenced an inves(cid:415)ga(cid:415)on into the death JAVED IQBAL. The inves(cid:415)ga(cid:415)on concluded 
at the end of the inquest on 19/02/25.

CIRCUMSTANCES OF THE DEATH 

Javed was aged 57 and had a long-term diagnosis of soma(cid:415)sa(cid:415)on disorder and paranoid schizophrenia.
He was under the care of mental health services. He was known to drink alcohol to excess and use
cannabis regularly, and it was recognised his mood and behaviour could be changeable and erra(cid:415)c. He 
was last reviewed by mental health clinicians on 29/02/24 when his mental health appeared se(cid:425)led, and 
he agreed to con(cid:415)nue his medica(cid:415)on with the next rou(cid:415)ne review in August 2024. His residen(cid:415)al 

support worker and social worker recognised his behaviour could be challenging but did not consider
mental health interven(cid:415)on was required. On 22/05, he had a 9-minute telephone consulta(cid:415)on with a GP 
about a recent chest infec(cid:415)on and known COPD with no apparent acute mental health issues. The
following day, 23/05, his care co-ordinator telephoned the GP recep(cid:415)onist repor(cid:415)ng his carer had 
reported a 3-4 day history of worsening mood and irra(cid:415)onal behaviour, she was advised to set it out in 
an email for the GP. No email was sent. Carers con(cid:415)nued to visit Javed on 23 and 24/05. On 25/05 Javed 
deliberately ignited his room with ﬂammable liquid and remained in and around the ﬁre for a prolonged
period before exi(cid:415)ng through a window when the condi(cid:415)ons became unbearable. He was comba(cid:415)ve 

and aggressive with emergency services consistent with him experiencing a mental health episode. He
was sedated and admi(cid:425)ed to Queen Elizabeth Hospital Birmingham cri(cid:415)cally unwell. Despite treatment 
for major burn injuries and smoke inhala(cid:415)on he went into mul(cid:415)-organ failure and died on 01/06/24.
Toxicology indicated he had not been taking his an(cid:415)-psycho(cid:415)c medica(cid:415)on.

The conclusion of the inquest was: Death was the consequence of trauma caused in a deliberately set
ﬁre however the available evidence does not reveal his inten(cid:415)on in se(cid:427)ng the ﬁre.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed ma(cid:425)ers giving rise to concern. In my opinion 
there is a risk that future deaths will occur unless ac(cid:415)on is taken. In the circumstances it is my statutory 

duty to report to you.

5

The evidence demonstrated there is a con(cid:415)nuing risk that All Care In One Ltd staﬀ will not recognise and 
take appropriate ac(cid:415)on when a service user presents with serious acute mental health issues.  For 

example:

(1) At a fundamental level staﬀ did not understand what is in the best interests of a service user:
(a) Carers did not want to embarrass Javed, therefore they felt jus(cid:415)ﬁed in making repe(cid:415)(cid:415)ve 

inaccurate contemporaneous records recording behaviour and mood was well despite having
serious concerns about his worsening mental health and triggering an urgent call to his GP; (b)

 
 Then, having contacted the GP two days before his death, the care co-ordinator did not ac(cid:415)on 
the request from the GP to send an email se(cid:427)ng out these serious concerns in wri(cid:415)ng.  

(2) There was no formal internal post-death inves(cid:415)ga(cid:415)on report. 
(3) Whilst some post-death internal training has been iden(cid:415)ﬁed it remains outstanding despite 8 
months passing since the death. However, I was not sa(cid:415)sﬁed this training has recognised the 

above concerns. 

ACTION SHOULD BE TAKEN

In my opinion ac(cid:415)on should be taken to prevent future deaths and I believe you have the power to take 
such ac(cid:415)on.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 28 
April 2025.  I, the coroner, may extend the period.

Your response must contain details of ac(cid:415)on taken or proposed to be taken, se(cid:427)ng out the (cid:415)metable for 
ac(cid:415)on. Otherwise you must explain why no ac(cid:415)on is proposed. 

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner of England and Wales and to the following 
Interested Persons: (1) Family of Javed, (2) Birmingham and Solihull Mental Health NHS Trust, (3) West 
Midlands Fire Service, (4) 

, GP, and (5) Modality GP Partnership. 

I have also sent it to the Care Quality Commission who may ﬁnd it useful or of interest.

I am also under a duty to send the Chief Coroner of England 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 
representa(cid:415)ons to me, the coroner, at the (cid:415)me of your response, about the release or the publica(cid:415)on of 

your response by the Chief Coroner.

 3 March 2025 

James Benne(cid:425), H.M. Area Coroner for Birmingham and Solihull

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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 from All Care in One Ltd (PDF)

27/05/2024

Both carers and
care-coordinator
statements.

Appendix 1 7

Prompt action was
taken to call in and
interview both
carers AK SH also
GR care-
coordinators
statement accounts,
as soon as the
incident occurred

b) All in One acted
to ensure all accounts of
incidents were looked at.

Javed Iqbal — Regulation 28
To Prevent further Deaths

a)Completed
27/05/2024

b) Completed

The statements were the first port
of call for all the staff involved in
the care. So we as a company could
understand what occurred and what
we need to go ahead and check.

It was an open atmosphere due to the
shock of the incident and we had to
support our staff too. To see them face
to face.

Appendix 2
02/06/2024

Consultants
Contract
Attached

a) Consultants hired by
the company to go
through a
comprehensive training
programme and support
all staff in the
company.

b) We have appointed x2
consultants to oversee the
implementation of these
changes and to monitor
compliance with care
standards on an ongoing
basis. This will include

regular audits and

reporting to ensure

improvements are
sustained.

The consultancy is

called the Al

3) Guidance of retraining
staff, group work large and
small groups. completed
see Appendix 3

To look at the Birdie
system and encourage the
management team to
monitor logs and alerts
highlighted on the system.

Completed
ongoing

Started
02/06/2024

So the company is able to have a fresh
pair of eyes to look at the processes.
To support and guide on incidents
such as this and how to improve
performances from staff, what steps to
take and to confidence build for
individual care staff and the team as a
whole.

Domiciliary Care
Consultancy.

Appendix 3 CPD Safeguarding training for | Revisiting training staff to | 03/06/2024 Staff can now identify early signs

03/06/2024 E-cert online all staff involved in the be alert of home of mental distress and intervene
care for Mr JI environments and visually appropriately.

Certificates enclosed GR, SI, AK,SH. look for hazards inside the Consistent care methods have been

Safeguarding property. implemented to ensure high-quality

training Safety of people and mental health support by our staff.
premises training Employees have gained skills in

Safety of People | Certificates completed. transparency and sensitive

and Premises

Service
Improvement
Plan Policy

This is enclosed in the
action plan

Again, we would look
into home environment
assessments for citizens
who present with
instability.

This policy was looked at
by the Director with the
care team as it talks
about the Mental Health
Act 1983

This was important for us,
as this was a internal
requirement, for us to
adopt robust monitoring
systems and to read and
refresh ourselves.

3/1/2025- the reason
why the date is in
2025 as we followed
the new policies. We
Focused on HOT as
from this scenario
and lessons learned
Honest, open and
transparent and our
carers should not
have pleased Mr JI
and logged all events
in the daily log.

communication, fostering a more
supportive environment for our
citizens

All staff involved in Mr JI’s care—
GR, SI, AK, and SH—have given
support and improve their
understanding of acute mental
health issues. They are now better
trained with best practices for care
and improved communication
protocols, ensuring a more
structured and effective approach to
Safeguarding.

Copies of Improvement plan given
to all staff.

Appendix 4
20/02/2025

Safeguarding
training for all
staff

Safeguarding training,
real life example.

External training
brought in to support
all the team.

Group training, small
groups and large groups,
Birdie re-briefing for all
staff with an external
trainer.

External Trainer has
shared specific examples
and case studies to give
carers a practical
understanding of the
challenges they may face
and the appropriate
response care staff
should take.

Questions and answers
workshect completed by
staff.

Trainer had assessed the
carers understanding of the
training through scenarios
quizzes and feedback
session which were held to
address any uncertainties.
evidence Appendix 5

(2 x sessions were held @
the given dates please sce
attacked documents)

20/02/2025

This training has strengthened the
carers’ ability to provide safe,
informed, and responsive care,
ensuring they meet safeguarding
standards cffectively.

Through real-life examples and
case studies, staff gained a practical
understanding of the challenges
they may face and the appropriate
responses to ensure effective care.
We want an external trainer so our
staff could have a variety of
training from paper to live face to
face.

They were able to ask questions,
talk about examples and give
answers to the questions asked.

Appendix 5
Supervision

Out staff are able
to express their
thoughts, feelings
and lessons
learned

Guidance and
Development: We are
Ensuring that carers
and coordinators fully
understand their duties,
including acting in the
best interests of service
users and recognizing
signs of deteriorating
mental health.

Reflection and Learning:
we are providing an
opportunity for staff to
reflect on past actions,
assess their practices, and
identify arcas for
improvement.

It is better to talk to get
this information into the
open, reflect and improve
for any future scenarios.

We are offering a platform
to review staff
performance, ensure
compliance with policies
of our Supervision, i.e.
identifying solutions to
problems, improving
practise and increase
understanding of work —
related issues.

Through our supervision
our staff were offered

27/05/2025

Staff showed their emotions at
supervisions and were able to
express themselves. This will
continue as development strategies
and has been on going since the
company was founded.

Our main aim is to promote positive
work environments and to support our
staff. In scenario for Mr JI we needed
to support and build on this case. We
must look towards what can be
improved by the company and even
though relationships were great in the

counselling through
Avensure, an agency

package of care we need to enhance
on the reporting and recording. This
was looked at in depth with the
supervisions.

Appendix 6
Process change
within the
company
20/02/2025

New ways of
working — pin
chart

Ongoing

One to one briefing
with staff, GR/other
staff member in the
office.

This has been given to
staff in the office.

Clear guidelines have been
established for recognising
and responding to acute
mental health issues and
any types of issues.

Staff are now required to
immediately escalate
concerns to healthcare
providers and document
these concerns in writing.
Follow through with a
paper trail as evidence

Follow the pin chart, take
all action, check and
double check appropriate
action has been taken. Get
more support from the
MDT.

Completed
20/02/2025

Staff arc aware and look towards
the Chart which is readly available
in the office, GR also sign posts
other staff to this process put in
place and support office staff and
care staff.

Director SI is always readily
available in person or over the
phone to support and look towards
the policies and procedures to get
guidance.

Appendix 7
confidence build
through IT
support

Ongoing- long term
contract

We are revising our
protocols to ensure that
all communication with
healthcare providers is
clear, timcly, and well-
documented. Staff will
receive specific training
to reinforce the
importance of accurate

IT Company

Bespoke Computing
company has been (
engaged to provide
comprehensive support to
all my office staff, this will
enhance their ability to
record and report
information via e-mail this

02/05/2025
Ongoing long-term
contract

Staff now follow structured
protocols for timely and clear
interactions with IT matters,
reducing misunderstandings and
ensuring accountability.

Training will enable staff to record
essential details meticulously,
preventing omissions and
inconsistencies in patient records.

records and reporting.
We will follow our
policies and procedures
and processes and look at
new ways of working.

initiative aims to update
communication process
and ensure accuracy in
documentation. Bespoke
Computing can log on
(remote access) and
support staff if they get
stuck at any point in their
daily work.

appendix 8
Reviewed new
policics and
procedures of the
safeguarding.

We have revised our
internal policies to
ensure they align with
best practices,
regulatory
requirements, and the
specific needs of our
service users. Clearer
protocols have been
introduced to guide
staff in recognising and
responding to acute
mental health issues,
including escalation
procedures and record-
keeping standards.

We have touched on the
Care Act 2014 with all
staff after following
this policy.

Access to this policy is
granted to all staff and
encouraged lo read part
by part and sent via email
to all staff.

This policy has
highlighted we can get
support from GP, district
nurses, Ambulance
services, social works
and work jointly to
achieve outcomes. We
must adapt open attitudes
from the MDT so joint
working can be achieved.
We aim to follow this
guidance and improve
further to achieve
outcomes for our
citizens.

The updated policies are
being disseminated across
the organization, and staff
will receive detailed
briefings to ensure full
understanding and
compliance.

- Enhanced procurement
protocols are being
embedded into our
operations to maintain
consistent quality and
accountability moving
forward.

Staff now have well-defined
protocols for identifying and
escalating acute mental health
issues, ensuring timely intervention
and structured record-keeping.

‘These improvements have created a
more structured and informed
approach to safeguarding and
service delivery, empowering staff
with the necessary tools and
protocols to provide high-quality
care.

British Red Cross have been
contacted by our team for
additional Mental health training in
the coming months. We have
researched out to this company.
They start of discussing and
training with what is anxiety’? How
can stress be defined ? and what are
the tell tell signs and give a blown-

out picture of the full extent of
Mental health and its impact on
individuals. We are due to get some
dates for training at our offices for
all the team in group numbers from
five to six. I will enclose the email
as appendix 9.

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