Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0119, written 4 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Mar 2025 |
|---|---|
| Reference | 2025-0119 |
| Deceased | Matthew Lynch |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Mental Health related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Service Evaluation Report: Use of Sections 2 and 3 of the Mental Health Act in BSMHFT 1. Introduction This report evaluates the application and use of Sections 2 and 3 of the Mental Health Act (MHA) by Section 12 approved Doctors (healthcare professionals) in BSMHFT . It particularly focuses on trends, decision-making challenges, and influencing factors. Data sources 1.A service evaluation online anonymous survey of all section 12 approved doctors in BSMHFT , 2.statistical insights, and data available from national datasets for BSMHFT . 2. Understanding Sections 2 and 3 2.1 Criteria for Applications under section 2 and 3 of the Mental health act • • Section 2: Applied when a patient requires short-term assessment and treatment (up to 28 days) due to a mental disorder requiring hospital admission for assessment and treatment. Section 3: Applied for longer-term treatment when the patient’s condition is well understood, requiring hospital detention including beyond 28 days. A person can be detained for assessment under section 2 only if both the following criteria apply: The person is suffering from a mental disorder of a nature or degree which warrants their detention in hospital for assessment (or for assessment followed by treatment) for at least a limited period, and The person ought to be so detained in the interests of their own health or safety or with a view to the protection of others. A person can be detained for treatment under section 3 only if all the following criteria apply: 1.The person is suffering from a mental disorder of a nature or degree which makes it appropriate for them to receive medical treatment in hospital 2.it is necessary for the health or safety of the person or for the protection of other persons that they should receive such treatment and it cannot be provided unless the patient is detained under this section, and 3.Appropriate medical treatment is available 2.2 Considerations for Application • Nature and Degree of Disorder: Severity, chronicity, and past treatment responses are evaluated. • Protection of Others: Risk factors, including previous history and likelihood of harm, are considered. • Alternatives to Detention: Informal admission is preferred if the patient has capacity and consents. • Legal Conflicts: Mental Health Act (MHA) versus Mental Capacity Act (MCA) considerations, particularly in fluctuating capacity cases. Section 2 should only be used if: • the full extent of the nature and degree of a patient’s condition is unclear there is a need to carry out an initial in-patient assessment in order to formulate a treatment plan, or to reach a judgement about whether the patient will accept treatment on a voluntary basis following admission, or there is a need to carry out a new in-patient assessment in order to re-formulate a treatment plan, or to reach a judgement about whether the patient will accept treatment on a voluntary basis. • Section 3 should be used if: the patient is already detained under section 2 (detention under section 2 cannot be renewed by a new section 2 application), or the nature and current degree of the patient’s mental disorder, the essential elements of the treatment plan to be followed and the likelihood of the patient accepting treatment as an informal patient are already sufficiently established to make it unnecessary to undertake a new assessment under section 2. • The rationale for decisions to use section 2 or section 3 should be clearly recorded 3. Statistical Overview and Service Evaluation Uses of Sections 2 & 3 88.1 61.8 BSMHFT England 48.0 38.6 Section 2 Section 3 Comparing the rate of use of Sections 2 and 3 per 100 000 population between BSMHFT and England. Note that a renewal of a Section 3 does not count as a 'use' of Section 3 in this comparison. 3.1 Key Factors Influencing Section 2 vs Section 3 Decisions A variety of factors influence the decision to use Section 2 instead of Section 3, including bed shortages, administrative barriers, and policy constraints. Figure 3 provides a breakdown of these key decision-making influences. 3.2 Reasons for AMHP Resistance to Section 3 AMHPs play a critical role in mental health assessments, and their resistance to Section 3 applications is influenced by several factors, including legal constraints, resource limitations, and lack of consensus among professionals. Figure 4 illustrates the key reasons for this resistance. 3.3 Use of Sections 2 and 3 A comparative analysis of the use of Sections 2 and 3 per 100,000 population between Birmingham and England highlights variations in application rates. Graphical data (Figure 1) illustrates how Birmingham exhibits a higher reliance on Section 2 compared to the national average, indicating potential systemic preferences or constraints. 3.4 Survey Findings (50 Respondents) A survey was conducted of All Section 12 approved doctors in BSMHFT asking them Are you Section 12(2) approved? o Yes: 100% o No: 0% 42% of section 12 approved doctors Said they had made section 2 recommendations when section 3 would have been more appropriate in their view • Have you recommended Section 2 when Section 3 seemed more appropriate? o Yes: 42% o No 58% • Key Reasons for Choosing Section 2 Over Section 3 when you did not want to : o o o 37% due to AMHP resistance 45% due to lack of beds 18% due to institutional policies i.e section 2 being seen as less restrictive in training and reference resources or similar 4. Challenges in Decision-Making 4.1 Influences on Decision-Making • AMHP Preferences: Many respondents noted resistance from Approved Mental Health Professionals (AMHPs) towards Section 3 applications. • Resource Constraints: The unavailability of beds was a major factor influencing decisions, with practitioners opting for Section 2 due to its lower administrative burden. • Policy Restrictions: Institutional policies, particularly in University Hospitals Birmingham (UHB), discourage direct application of Section 3. • Legal and Bureaucratic Hurdles: Concerns about completing Section 3 paperwork and finding appropriate hospital placements deter its use. 4.2 Notable Comments from Respondents • Themes • AMHPs often insist on Section 2 due to its less restrictive nature, even when the patient has a clear established mental illness and treatment plan and history are clear . This preference may stem from a belief that Section 2 allows for a more flexible and immediate approach to patient care, minimizing burdens such as need for consent from the nearest relative Additionally, AMHPs may be influenced by concerns over identified bed availability when the mental health act assessment occurs , which can make Section 3 recommendations more difficult to coordinate and Secure . i.e section 3 recommendation requires name of the hospital to be noted . • • However, this reliance on Section 2 can lead to repeated short-term rather than sustained treatment plans, potentially impacting long-term patient outcomes. In many cases, the refusal to approve Section 3 was considered by respondents to be linked to social service challenges in arranging aftercare.( section 117) Some professionals reported that AMHPs were reluctant to use Section 3 outside of standard hours. • • The absence of identifiable beds often led to Section 2 being preferred to avoid delays. I've had an AMHP forcefully argue with me that a 'section 2 is least restrictive' even when a patient has an established diagnosis, does not need any period of assessment and had a clear treatment plan Usually AMHP do not agree with the decision to go for sec 3. It is not that the AMHP suggest sec 2, it is that they are actively against it as much as they can. Unless I have very strong evidence and grounds for section 3 I cannot peruse it. For the AMHP sec 3 comes with 117 meeting aftercare and arranging for that it is a challenge for social services and amhp. Another reason is lack of bed. AMHPs prefer section 2 Mostly due to AMHP refusing to make application if the recommendations were Section 3 or when we are unable to state where the patient will be admitted. Amhp and second doctor reluctant to put patient on section 3 when admitted informally, if they have not been on section 2 in the last few weeks Patient not known to me or not been under 3. Issues with beds AMPH suggested No identifiable bed, social worker felt it was a more favourable option for patient Lack of beds availability Because UHB policy supports Section 2 to start with and discourages straight Section 3, UHB objects and wants to know the rationale of jumping a hoop. AMHP was insistent that s2 was used in all cases, despite patient(s) being known to services and not a significant change in their typical presentation when unwell Suggested as easier option as no specific hospital bed has been identified and to avoid delay in completing paperwork. I work in secure services and may not reflect the resource issues in the wider trust Pressure on beds, concerns around patient being stuck in hospital Patient has not been detained under MHA for the last few years, hence suggestion was to use a S2 instead of S3, although patient was known to MHS/CMHT. Patient's nearest relative objected to s3 and it was an urgent situation that required detention in hospital. I was persuaded to do section 3 due to lack of beds. There have been many times when the section 3 has been to section 2 by the AMHPs. I am aware that this has been an issue with my colleagues. I believe the AMHPs are often reluctant to go for Section 3, even when there is clear history and consistent patter in presentation. I haven’t done this for a long time, but definitely at some point in the last 5 years. There was a push from AMHP to go for Section 2 due to lack of beds and difficulty in finding the medics again to add the hospital name once a bed was found if we went for Section 3. Also difficulty for medics to know what to put on the Section 3 form for hospital name when no idea where bed may be found. Has felt more of a problem in Birmingham than Solihull. Lack of availability of beds AMHP did not accept S2 because, according to them, S2 would be the least restrictive option. AMHPs out of hours have not supported the use of Section 3 even for patients with well established patterns of illness and clear relapse of such, citing less restrictive practice. Section 3 was indicated but there was no known bed which could have been put on the application 5. Recommendations 1. Policy Review and Standardization: Develop clearer guidelines for when Section 3 should be applied to reduce inconsistencies. This responsibility should be undertaken by BSMHFT and BCC Jointly as lead agencies , ensuring alignment with best practices and resource availability. 2. Training and Collaboration: Enhance training sessions for AMHPs and medical professionals to align decision-making practices and ensuring that section 3 is used where appropriate and neither section 2or 3 are considered more or less restrictive 3. Improve early identification of hospitals where Bed availability will occur so that Doctors can make section 3 recommendations . 4. Resource Allocation: Address bed shortages and administrative bottlenecks that limit Section 3 applications. 5. Monitoring and Feedback: Establish an working group to review Section 2 versus Section 3 decisions and identify areas for improvement. 6. Data-Driven Decision Making: Utilize real-time statistics and trend analysis to inform policy adjustments and improve Section 3 application rates. 6. Conclusion This evaluation highlights significant barriers affecting the appropriate use of Sections 2 and 3 of the MHA, particularly due to AMHP resistance, administrative challenges, and resource i.e bed constraints. To address these issues, the report recommends policy standardization led by the BSMHFT and the BCC AMHP service , enhanced training for AMHPs and medical professionals, improved resource allocation to reduce bed shortages, and the establishment of an oversight committee/ working group to monitor decision-making practices. Additionally, leveraging data-driven approaches can help refine future policy adjustments and ensure better long-term patient care outcomes. The graphical insights presented further reinforce the systemic issues at play. Addressing these concerns through structured policy adjustments, increased training, and better resource allocation can lead to improved decision-making in mental health services. Future studies should continue analyzing trends in order to refine recommendations further. Dr.Dinesh Maganty
1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: • Birmingham and Solihull Mental Health NHS Foundation Trust • Provident Housing • Birmingham City Council CORONER I am Louise Hunt Senior 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 20 July 2023 I commenced an investigation into the death of Matthew John LYNCH. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Killed unlawfully CIRCUMSTANCES OF THE DEATH Birmingham. Between 05.30 and 05.51 Mr Lynch resided in room 1 in supported living accommodation which was shared with 3 others, including the offender, at on 11/07/23 Mr Lynch was attacked in the garden area outside the property and decapitated by the offender. The offender was known to suffer from treatment resistant paranoid schizophrenia which would be made worse if he stopped taking his medication and took illicit substances. He had been under the care of mental health services for some time. He had last been seen in clinic on 12/05/23 when he admitted he had stopped taking his medication but agreed to restart it and confirmed he had changed his address. Further efforts were made to contact him however he did not respond. There was concern at this time that his mental health condition was relapsing, and his case was discussed in an MDT on 17/05/23. An unannounced visit was made to an address on 24/05/23 when he was not present; however, it is not clear if the CPN attended his new address or the old address which remained on his clinical records. He was spoken to briefly by a CPN on 14/06/23 when he appeared intoxicated but agreed to attend a clinic appointment on 21/06/23 which he did not attend. Further attempts were made to contact him without success, but no attempts were made to contact his family or the landlord. In the days leading up to the attack the offender had been found to use weed at the address and was given a verbal warning on 26/06/23. He smashed up his room on 10/07/23 and was evicted from the property. In the past smashing up his room had been an indicator of declining mental health however this was not known to the landlord and the landlord was unaware he was under the care of the Community Mental Health Team (CMHT). He was taken to City Hospital by the landlord on 10/07/23 as he was concerned about his unusual behaviour but the offender left before being seen. CCTV confirmed he returned to the property at 02.48 on 11/07/23 and was seen in the garden area having an altercation with Mr Lynch around 05.30 before at 05.51 he is seen on CCTV striking Mr Lynch with force. After he was dead the offender decapitated Mr Lynch. At 14.23 the Landlord attended the property after another resident was unable to enter. The offender admitted to the landlord that he had killed Mr Lynch and the police were called. The offender was sentenced to a hospital order for the offence of manslaughter by diminished responsibility. Following a post mortem the medical cause of death was determined to be: 1a Multiple sharp force injuries 1b 1c 1d II 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. To Birmingham and Solihull Mental health Trust 1. Internal investigation: The internal investigation did not address how and whether the offender’s use of medication should have been monitored after the clinic visit on 12/05/23. This was important as non compliance with medication was a risk factor for relapse. In addition, during the inquest the trust confirmed they had not spoken to the CPN who attempted to visit the offender on 24/05/23 to verify whether they had attended the old or new address. This was a critical issue as the new address had not been updated on the clinical notes. This raises a concern about the quality of the investigation and whether the Trust is adequately learning from incidents. 5 To Birmingham and Solihull Mental Health Trust and Birmingham City Council 2. Mental Health assessments: The inquest heard evidence that there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing. This raises a concern that incorrect MHA assessments are taking place and patients may be detained on an inappropriate section impacting patient care. A copy of a report prepared by is attached. To Birmingham and Solihull Mental Health trust, Birmingham City Council and Provident housing 3. Information sharing between agencies and support worker training: The inquest heard evidence that Landlords have to rely on the information given to them by the residents and do not have access to other key information held by other agencies. This means the landlord is often not aware of key information about an individual. Given the potential for harm for residents and support workers consideration needs to be given to how best to share information to ensure residents are receiving the right care and landlords have sufficient information to be able to monitor residents and undertake risk assessments. The inquest heard evidence that support workers need more focussed training on mental health conditions and how to manage and help residents with enduring mental health conditions. 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 6 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 April 2025. 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: Mr Lynch's family West Midlands Police 8 I have also sent it to the Medical Examiner, ICS, NHS England, CQC, who may find it useful or of interest. 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. 4 March 2025 9 Signature: Louise Hunt Senior Coroner for Birmingham and Solihull
2 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.
REPORT FOR HER MAJESTY’S CORONER FOR THE BIRMINGHAM AND SOLIHULL AREAS Re: MATTHEW JOHN LYNCH (deceased) DATE OF BIRTH: 05/12/1979 DATE OF DEATH: 11/07/2023 ADDRESS - LATE OF: Midlands , Handsworth, Birmingham, West Report prepared by: Qualifications: Diploma in Social Work/BA Honours Applied Social Sciences Professional details: I am registered with Social Work England the professional body for the registration and standards of qualified social workers in England. Role: Head of Service Operations and Partnerships Adult Social Care and Health Birmingham City Council Length of Service with BCC: I have been employed within Birmingham City Council since 1999 continuously to date. Background This response is provided by Birmingham City Council (BCC) further to the Regulation 28 Report, issued by HM Coroner Louise Hunt on 4 March 2025. I would like to start by expressing our condolences to Matthew’s family for their sad loss. The Coroner explained in the Report that she is concerned that incorrect MHA assessments are taking place and patients may be detained on an inappropriate section impacting patient care. The Coroner is also concerned about information sharing between agencies and support worker training, specifically information that is provided to landlords about the residents. Adult Social Care involvement with Matthew Lynch (ML) and BCC did not have any contact or involvement with Matthew prior to his death. ML did not undergo a Care Act assessment and did not have a support plan. He was neither allocated, nor awaiting allocation to a social worker. There is no record of any current or previous request for a Mental Health Act assessment for ML, at any time and we have no record of him suffering from a mental disorder, requiring support or treatment from BCC at any time. KD did not undergo a Care Act assessment and did not have a support plan. He was neither allocated, nor awaiting allocation to a social worker. On 20 January 2023, a request for a Mental Health Act assessment was made. KD was in police custody for making threats to another tenant in his accommodation, which was at Hockley Birmingham, a supported living accommodation funded via housing benefit payments. It is reported KD had smashed his room. He was assessed and detained under Section 2 of the Mental Health Act 1983. He was admitted under Section 2 and BCC received a reminder that the Section 2 was expiring on 8 February 2023. Follow up calls were made to the admitting ward, who confirmed by telephone that an assessment for Section 3 detention would not be needed, as KD had agreed to continue to receive treatment as an informal patient. This concluded BCC’s involvement with KD until 11 July 2023, when following his arrest for murder, KD was in police custody and a request for a Mental Health Act assessment was made. From what I have been able to access from the case notes, the use of Section 2 was valid in KD’s case, as he had not previously been detained and his three previous Section 136 arrests had resulted in the conclusion that he was not suffering from a mental disorder. The Section 2 was based on presentation which was suggestive of a mental disorder and so, Section 2 allowed for assessment of this potential mental disorder. In this case, upon the expiry of the Section 2, we were informed that Section 3 was not required, as KD had agreed to remain an informal patient. We have no record of how long he remained in hospital or when, or to where, he was discharged. In relation to KD, I am not aware of any barriers to the use of Section 2 and Section 3 of the Mental health Act, due to AMPH resistance, administrative challenges, and resourcing. In terms of his diagnosis (as set out in the MHT Root Cause Analysis report at page 63 of the bundle, which we received after the issue of the Regulation 28 Report), it appears KD was diagnosed with schizophrenia in 2015. It is unlikely that the AMHP who assessed KD in 2023 knew of the previous detention, as this is not recorded in our records. Given the length of time and presentation, I do not believe this would have altered the AMHPs decision. The Mental Health Act 1983 Code of Practice states that the fact that someone has a mental disorder is never sufficient grounds for any compulsory measure to be taken under the Act. Compulsory measures are permitted only where specific criteria about the potential consequences of a person’s mental disorder are met. Mental Health Assessments BCC was not aware of the report prepared by until I became aware of the Regulation 28 Report and saw ’s report on the Court and Tribunals Judiciary’s website. I am unaware of when this report was prepared and for what purpose. The AMHPs follow the Mental Health Act 1983 and Code of Practice to the Act when making decisions. I cannot comment on the specific examples of cases provided in the report, as I do not have direct knowledge and details of the cases referred to. BCC AMPHs did not know they were being quoted, we were not made aware of this “study” and to date, despite requesting a copy, BCC has not received a copy of the report. Decisions pertaining to whether an application is made to detain a citizen under the Mental Health Act 1983 are made solely by the AMHP and with two medical recommendations from Doctors, one of whom must be approved under Section 12 of the MHA 1983 and preferably, where one Doctor has knowledge of the patient. The actual decision as to whether the criteria for detention is met and whether detention should be made and under which Section, is for the AMHP to make. Therefore, the report and suggestions that the wrong detentions are being made, are fundamentally inaccurate, as it is not for the Doctor to decide which section or whether the patient is detained. They make a recommendation which the AMHP then uses to make their decision and the AMHP makes the application which is the formal detention. The report prepared by refers to the findings of a survey of all Birmingham & Solihull Mental Health Foundation Trust Section 12 approved doctors. This is the perception of the doctors. In practice, this may differ from the reality of individual cases. I am not aware of any barriers to the use of Section 2 and Section 3 of the Mental Health Act 1983, due to AMPH resistance, administrative challenges, and resourcing. I cannot comment on AMHP resistance as the decision to admit and under which section, is for the assessing AMHP alone. AMHP resourcing is an issue nationally with there being a shortage of AMHPs across the country. Latest figures suggest there are approximately 93,000 registered social workers with around 3000 AMHPs. BCC are actively recruiting and training AMHPs with a plan to increase numbers by 35 new AMHPs over the next 5 years. The number of AMHPs employed within BCC is not a barrier to the use of Section 2 or Section 3, it has no bearing on the use of sections under the Mental Health Act. I can only make an assumption that administrative challenges can be interpreted as beds not being available. Bed unavailability is an issue but, this should never be a consideration as to the use of Section 2 or Section 3. The decision around the use of Section 2 or Section 3 should be jointly reached based on evidential need and presentation, not on resource availability. I am not aware of any further administrative challenges or inappropriate use of Sections 2 & 3. The use of Section 2 or Section 3 is a matter for the AMHP and assessing Doctor and ultimately the AMHP makes the decision based on two medical recommendations from the assessing Doctors. The independence on the AMHP in decision making around which section to use is explicit within Section 13 of the Mental Health Act 1983. BCC has agreed to prepare a guidance statement to be added to the Mental Health Policy owned by Birmingham and Solihull Mental Health Foundation Trust regarding the use of Section 2 versus Section 3. Information Sharing with landlords Where a citizen is in receipt of a package of care, relevant information will be shared with the care provider. In this case, a care provider was not involved as KD was not in receipt of a package of care under the Care Act 2015. The responsibility for providing information to Landlords about residents depends on how the resident accesses the accommodation. If the provision is direct access, then the resident will provide details directly with no other agency involved. If an agency or Local Authority makes the referral, a referral form will be completed. The information that goes to the landlord is based on the referring agencies discussion with the resident. Often there is a need to provide proof of income, which the resident can do by logging on to their Universal Credit portal. Given the emergency nature of lots of these placements, it is likely that the referring agency has limited information to begin with. Referrals from prison, hospital or care facilities are an exception as the resident is likely to have known the agency for a longer period of time, therefore more information can be provided. The agency is responsible for giving as much information as they can, although much of this is based on disclosure from the resident. Referral forms are designed by the landlord and generally set out the information they want to see. This might include proof of income, personal details (name, D.O.B, NI number etc.), physical and mental health conditions, general support needs and criminal convictions. Some landlords ask questions about previous housing history and why the resident is approaching. The landlord should provide the appropriate training and ongoing development of their support workers, so that residents can be appropriately supported.
Chief Executive Officer Uffculme Centre 52 Queensbridge Road Moseley Birmingham B13 8QY Tel: 0121 301 1086 Mrs Louise Hunt, HM Senior Coroner, Coroner’s Court, Steelhouse Lane BIRMINGHAM B4 6BJ Sent via e-mail only : Dear Mrs Hunt, Our Ref: Your Ref: Date: 25 April 2025 Dear Mrs Hunt Re: Prevention of Deaths report (Matthew Lynch Deceased) Thank you for your Prevention of Future Deaths report dated 4 March 2025. May I take this opportunity to offer my sincere condolences to the Family of Mr Lynch for their terrible loss. As you will be aware the Trust carried out an investigation into the circumstances of Mr Lynch’s death and a number of improvements in practice have been made in the Trust in order to ensure that we learn from the death and provide safer services. There were some areas you have identified requiring further action and assurance from the Trust and I will address each of these as you have set them out in your report. 1. Internal Investigation As part of the transition to Patient Safety Investigation Review Framework, the review took a system- based approach to the investigation, focusing on the processes within which the team was operating. This approach allowed the Trust to identify weaknesses in key systems, including the identification and management of changes of address and medication compliance oversight. The review acknowledged the risk of relapse identified in May 2023 on page 14, identifying that whilst plans were made within the Multi-disciplinary Team, there was no clear process to track these actions, leading to a lack of oversight. If there had been stronger oversight, the team would have been aware of the non-compliance with medication sooner, allowing for timely intervention. This would have included tracking the perpetrator’s prescription. To address this, the team has now implemented an actions tracker to ensure better oversight of agreed plans and follow up. In relation to the prescription, where the Community Mental Health Team is supplying a service user with their medication, this is recorded on the Electronic Prescribing and Medicines Administration System (EPMA). The Trust outlined at the inquest how this system now has better functionality and this Chair: │ Chief Executive: │ Website: www.bsmhft.nhs.uk Customer Relations: Mon–Fri, 8am–6pm │ Tel: 0800 953 0045 │ Email: bsmhft.customerrelations@nhs.net is monitored through the monthly medication audit, which is overseen by the Matron, followed up with individual service users by their Case Manager and reported through to the Integrated Community Teams Clinical Governance Committee and Trust Medicines Management Group for assurance. The review also found the process for updating and tracking address changes was not robust enough. To strengthen this process as referenced in the report, the team has implemented a “meet and greet” role to improve the accuracy of address updates and ensure better coordination. I will go into more detail around this point under point three. 2. Mental Health assessments At Inquest our witness gave evidence following the survey which had been carried out which identified that there were two areas where practice should be improved. These included: Improved training for AMHPS and doctors. The Trust is working with colleagues at Birmingham City Council on this and there is training in place with Doctors and AMPHS. Improve availability of identification of a named hospital which will admit / availability of beds. The Trust confirmed that actions on early identification of hospital with a bed which will admit the patient is challenging but work is ongoing though the Urgent and Emergency Care Pathway and Bed Strategy. Following the inquest our Associate Medical Director for Mental Health Legislation has been working with Birmingham City Council on a short joint guidance for the doctors and AMHPS which will be included in the Trust’s Mental Health Act Assessment policy. This is now a priority for the organisations and the aim is for this to be completed by the end of June. This guidance will progress through the relevant governance processes to ensure it is properly embedded in both organisations. The aim is that this will assist in ensuring that patients who are currently being admitted and need detention under the Mental Health Act are under a section that is most appropriate for them, in line with the code of practice. Assurance on appropriate use of the Mental Health Act is gained through the Trust Mental Health Act Committee and reported to Trust Board. The Trust offers specific training to all trust section 12 approved doctors as part of their approved clinical reapproval training/ section 12 reapproval. This training is mandatory as part of the reapproval process and has been in place for the last 5 years. The Royal College of Psychiatrists offers this training to our Doctors. All doctors from the Trust on the section 12 rota and who participate in mental health act assessments for the Integrated Care Board are assured as section 12 approved. Once the joint guidance has been agreed, this will be used to train both doctors and AMHPs and be incorporated into our procedures. 3. Information sharing between agencies and support worker training In terms of ensuring our service user demographic information is up to date we now have Meet & Greet workers based across our CMHT receptions to check with service users that the information we have on record for them is correct and up to date where necessary, this includes address, contacts and telephone number. In addition to this, when checking the address is correct, the Meet & Greet workers now also ask what type of accommodation their address is, if it is identified that this is a supported accommodation or a hostel and this is recorded with the details. The service user will be informed that we will potentially share any information about their care or treatment if the need arises, or in case of an emergency. Any information being shared will be carefully considered as part of an MDT discussion/review and the decision to disclose information is proportionate to the circumstances. As a Trust we will always ensure that a patient’s confidentiality and consent is adhered to. We have also written to all clinical staff to remind them that if they are notified of a change of address (or contact number) that this is recorded on the service user demographic information in Rio, the electronic patient record, which updates the “front page” and not just in the “progress notes”. 2 In relation to service users not being available when staff are visiting them at home. This is recorded in Rio following that visit, including; what attempts have been made to contact the service user and what the initial plan is in response to a lack of contact. Where there are repeated unsuccessful attempts, this is escalated to the MDT for discussion, review and a plan regarding the next steps. This is documented on the MDT action tracker, which is then monitored. The Trust will review the standard operating procedure for non-contact with appointments to ensure consistency in escalation to the MDT. Following the review into the deaths in Nottingham, the Trust has reviewed the Did Not Attend policy and does not discharge patients following a lack of contact and is in the positive position of having an Assertive Outreach Team where specifically experienced case managers actively engage in the care provided to high risk individuals in the community. We recognise the benefits of working in partnership with Birmingham City Council and Supported Housing Providers and will continue to commit to strengthening our joint procedures, relevant information sharing and enabling our professionals to work collectively at every opportunity. I hope that the actions taken offer reassurance that the Trust has taken your concerns seriously. If you require any further information, please do let me know. Yours sincerely Chief Executive BSMHFT 3
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