Ricky Monahan

NHS Birmingham and Solihull 
8th Floor Alpha Tower 
Suffolk Street Queensway 
 Birmingham B1 1TT 

NHS Black Country ICB 
Civic Centre 
 St Peter’s Square 
Wolverhampton 
WV1 1SH 

3 December 2025 

Ms Hunt 
Senior Coroner for Birmingham and Solihull 

Dear Ms Hunt 

Inquest concerning the death of Ricky James Monahan 
Response to Regulation 28 of the Coroners (Investigations) Regulations 2013. 

I am writing in response to the Regulation 28 notice issued following the conclusion of the  
investigation into the death of Ricky James Monahan on the 22nd October 2025, who sadly died  
on the 18th March 2025.  I extend our sincere condolences to Ricky’s family and friends.  

We have carefully considered the concerns raised within your report to prevent future deaths 
and would respond as follows. 

1.  Environmental Risk Assessment and Fire Escape Safety 

The report raises concerns over an unprotected fire escape at the rear of the building which could 
be easily accessed from the garden which in turn gave easy access to the roof. The inquest heard 
evidence that no environmental risk assessment had been completed regarding how accessible the 
fire escape was and how it easily provided access to the roof due to inadequate railings at the top 
of  the  staircase.  The  trust,  Birmingham  and  Solihull  Mental  Health  Foundation  Trust  (BSMHFT), 
relied on individual risk assessments when considering what controls were required for individual 
patients when accessing the garden. 

In  preparing  this  response,  we  have  confirmed  with  BSMHFT  that  the  Environmental  Risk 
Assessment  has  been  updated  to  include  the  Fire  Escape  and  that  they  have  completed  the 
following actions: 

•  The installation of three metal fence panels and an eight-foot-high gate on the ground floor. 
The gate has a concealed push to exit button on the inside of the gate and a key operated 
lock on the outside of the fire escape that is accessed with the internal master key to 
prevent access. 

•  At the top of the fire escape platform (second floor) three metal panels at eight feet high have 
been installed and this included a section on the staircase where leverage could be used 
along the gutter section 

 
                                                  
 
 
 
 
 
 
 
 
 
 
 
 I  would  welcome  your  advice  as  to  whether  any  additional  action  is required  by  Birmingham  and 
Solihull  Integrated  Care  Board  (BSol  ICB)  or  whether  this  needs  to  be  referred  to  BSMHFT  to 
respond and take further action. 

2.  Lack of National Guidelines for Fire Escape Protections 

The inquest also heard how there are no current guidelines setting out what protections are required 
for fire escapes in rehabilitation settings. The lack of any guidelines presents a risk of future deaths 
and therefore action should be taken. 

We have carefully considered this issue and feel that NHS England are most appropriately placed 
to provide a response. While the development of such guidance sits with NHS England, the ICB will 
take proactive steps to escalate and monitor this issue. 

3.  Learning and System Improvement 

The ICB is committed to ensuring lessons from this case are embedded across the system.  We will 
share  learning  from  this  incident  with  all  local  mental  health  and  rehabilitation  providers  by17th 
December 2025. 

We  take  the  recommendations  within  the  Regulation  28  report  extremely  seriously  and  are 
committed to working with BSMHFT and NHS England to prevent future deaths. Please let us know 
if you require any further detail or clarification.   

Yours Sincerely 

Chief Executive Officer  
Birmingham & Solihull & Black Country Integrated Care Board 

2

Louise Hunt 
HM Senior Coroner 
Coroner's Court 
Steelhouse Lane 
Birmingham 
B4 6BJ 

16th December 2025 

Dear HM Senior Coroner Louise Hunt, 

Prevention of future death report following inquest into the death of Ricky 
James Monahan 

Thank you for sending the Care Quality Commission (CQC) a copy of the Regulation 
28: Report to Prevent Future Deaths, which was issued following the death of Ricky 
James Monahan, in which CQC was named as a respondent.  

Firstly, we would like to offer our sympathy and condolences to Ricky’s family and 
loved ones. 

We note the legal requirement upon CQC to respond to your report within 56 days, 
by 17 December 2025. 

We will respond to each of your concerns in turn. 

1.  Mr Monahan was in a 10 bedded rehabilitation unit and was detained under 
S37 of the Mental Health Act. There was an unprotected fire escape at the 
rear of the building which could be easily accessed from the garden which 
in turn gave easy access to the roof. No environmental risk assessment 
had been completed regarding how accessible the fire escape was and how 
it easily provided access to the roof due to inadequate railings at the top of 
the staircase. The trust relied on individual risk assessments when 
considering what controls were required for individual patients when 
accessing the garden. 

 
 
 
 
 
 
 
 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 apply 
to all registered persons (providers and managers) registered with the Care Quality 
Commission (CQC) that carry out regulated activities. 

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 
Regulations 2014 refers to Safe care and treatment. The intention of this regulation 
is to prevent people from receiving unsafe care and treatment and prevent avoidable 
harm or risk of harm. Providers must assess the risks to people's health and safety 
during any care or treatment and make sure that staff have the qualifications, 
competence, skills and experience to keep people safe. 

We do not specify that all providers must carry out specific environmental risk 
assessments, however providers must make sure that the premises and any 
equipment used is safe and where applicable, available in sufficient quantities. CQC 
understands that there may be inherent risks in carrying out care and treatment, and 
we will not consider it to be unsafe if providers can demonstrate that they have taken 
all reasonable steps to ensure the health and safety of people using their services 
and to manage risks that may arise during care and treatment. 

As part of our inspection process, CQC will routinely ask for the most recent 
environmental risk assessment to provide assurance that providers have made the 
premises safe for people who use the service. CQC inspectors will also observe the 
ward environment as part of an inspection. In our inspection in October 2023, CQC 
found that there were risk assessments in place in all ward areas which removed or 
reduced any risks they identified. The report in October 2023 does not make specific 
reference to the external fire escape.  

2.  The inquest heard how there are no current guidelines setting out what 

protections are required for fire escapes in rehabilitation settings. The lack 
of any guidelines presents a risk of future deaths and in my view, action 
should be taken. 

Your concerns relate specifically to the availability of national or local guidance. We 
are unable to comment directly on this point due to it being outside of the remit of our 
regulatory scope. We are currently not aware of guidelines regarding fire escapes 
specifically in rehabilitation settings. However, the CQC signposts registered 
providers to information regarding fire safety and the environmental safety of their 
premises on our website. 

•  https://www.cqc.org.uk/guidance-regulation/providers/regulations-service-

providers-and-managers/relevant-guidance  

 
 
 
 
 This webpage includes other guidance from other bodies which is available. I have 
included a sample of links below: 

•  https://www.gov.uk/government/publications/fire-safety-risk-assessment-

residential-care-premises  

•  NHS England » Health technical memoranda 
•  https://www.hse.gov.uk/healthservices/  
•  https://www.hse.gov.uk/guidance/index.htm 
•  Health and safety in care homes - HSE 
•  Leading health and safety at work Actions for directors, board members, 

business owners and organisations of all sizes 
•  Managing for health and safety (HSG65) - HSE 

Further Queries 

Should you have any further queries please contact our National Customer Service  
Centre using the details below: 

If your query is regarding this letter, please quote the CQC reference. 

Yours sincerely  

Deputy Director of Operations Mental Health

Louise Hunt 
Senior Coroner for Birmingham and Solihull 
Birmingham and Solihull Coroner’s Court  
Steelhouse Lane  
Birmingham 
B4 6BJ 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

15th December 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Ricky James Monahan 
who died on 18th March 2025.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated  22nd 
October 2025 concerning the death of Ricky James Monahan on 18th March 2025. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Ricky’s family and loved ones. NHS England is keen 
to  assure  the  family  and  yourself  that  the  concerns  raised  about  Ricky’s  care  have 
been listened to and reflected upon.   

Your Report raised the concern that there was an unprotected fire escape which gave 
access to the roof in the rehabilitation unit where Ricky was detained under Section 
37  of  the  Mental  Health  Act.  An  environmental  risk  assessment  had  not  been 
completed for this fire escape regarding its accessibility and particularly the access to 
the roof. You were also concerned that there are no current guidelines advising what 
protections  are  required  for  fire  escapes  in  rehabilitation  settings.  This  concern  is 
within NHS England’s remit to address. 

National Risk Assessment Guidance 

The  evidence  regarding  assessment  of  the  risk  of  harm  to  self  has  been  recently 
updated, to indicate that the use of risk stratification tools should be avoided as it can 
lead to false assurances about a person’s risk. There is evidence that many people 
acting on suicidal or self-harm impulses may have no plans or intentions to do so even 
minutes beforehand. This means it is really important to develop an understanding of 
factors that may  reduce  or increase  safety  for the  individual in  future.  The  National 
Confidential  Inquiry  into  Suicide  and  Safety  in  Mental  Health  (NCISH)  has  been 
commissioned  through  the  NHS  England  national  Culture  of  Care  programme  to 
support  every  provider  of  NHS  commissioned  inpatient  services  to  move  to 
personalised safety planning in line with evidence.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 NHS England also published the Staying Safe from Suicide: Best Practice Guidance 
for Safety Assessment, Formulation and Management on 4 April 2025. It promotes a 
shift  towards  a  more  holistic,  person-centred  approach  rather  than  relying  on  risk 
prediction,  which  can  be  unreliable  because  suicidal  thoughts  can  change  quickly. 
Instead,  it  recommends  using  a  method  based  on  understanding  each  person’s 
situation and managing their safety. The purpose of this guidance is to enable mental 
health practitioners to adopt best practice principles in working with people of all ages 
to stay safe from suicide. The guidance highlights environmental safety as one of six 
steps of safety planning, which should include reducing access to or avoiding high risk 
locations. 

Work is also underway to make training available to all mental health practitioners to 
incorporate the principles of this guidance into their practice. This training was recently 
launched and is available via an e-learning module. This complements existing local 
training on suicide prevention, and a number of other national e-learning products that 
are already available.  

Local Risk Assessments 

NHS  England’s  regional  mental  health  team  has  liaised  with  the  Birmingham  and 
Solihull Mental Health Foundation Trust (BSMHFT) regarding your concerns, including 
the lack of environmental risk assessment of the fire escape, and particularly its ability 
to allow unauthorised access to the roof. 

The  Regulatory  Reform  (Fire  Safety)  Order  2005  (RRO)  does  permit  controls  to 
prevent unauthorised access to fire escapes, subject to conditions ensuring that exit 
from these areas is not impeded. No such controls were in place on the fire escape in 
this facility to prevent or alert staff to unauthorised access from the garden. 

The  lack  of  environmental  assessment  of  the  fire  escape  meant  there  was  no 
evaluation of the opportunities this route provided to gain a position of height, and the 
fact  that  the  control measures  at  the  top  of  the  escape  were  insufficient  to  prevent 
unauthorised  access  to  the  roof.  The  inherent  nature  of  a  fire  escape,  to  allow 
unimpeded  exit  from  a  building,  means  it  should  be  considered  as  part  of  an 
environmental risk assessment to establish whether unintended risks are created.  

Regular  assessment  of  environmental  risks,  and  their  audit  and  logging  within  risk 
registers, allow visibility within the clinical team and enables appropriate controls to be 
adopted.  These  controls  could  include  additional  physical  measures  or,  if  relevant, 
restrictions on granting or supervising leave. The assessment, logging and reporting 
within organisational risk registers would be an effective way to manage this risk. The 
infrastructure for assessment of the environment and its oversight already exists and 
is  subject  to  scrutiny  both  by  providers’  own  processes  and  by  the  Care  Quality 
Commission (CQC) during routine inspection. 

I note that your Report is also addressed to the Birmingham and Solihull Integrated 
Care Service, who will be able to address the position locally in more detail. 

 
 
 
 Fire Safety Guidance and NHS Estates 

Health  Technical  Memorandum  (HTM)  05-03  Part  K  (HTM  05-03  Part  K)  gives 
comprehensive  advice  and  guidance  on  the  design,  installation  and  operation  of 
specialised  building  and  engineering  technology  used  in  the  delivery  of  complex 
healthcare premises. Appendix C - Assessment of escape routes including electronic 
locks on doors - details how to assess escape routes and security in mental health 
units: 

Escape routes and security 

C6 All doors on escape routes and final exit doors should normally open in the direction 
of travel and be quickly and easily openable without the need for a key. This is the 
starting point for all securing devices. 

C7  Exceptionally,  there  are  specific  life-safety  protection  reasons  for  additional 
security. If this is the case, each circumstance should be assessed individually.  
Such circumstances may include: 

•  mental health units where the safety of patients, staff and members of the public 

could be at risk. 

C8 Additional security measures put in place simply to secure areas from theft or to 
manage the movement of people are not appropriate. The need for extensive escape 
the  design  stage. 
routes 

through  sensitive  areas  should  be  addressed  at 

NHS  England’s  Estates  Team  are  currently  scoping  HTM  05-02,  fire  safety  in  the 
design of healthcare premises, which will to be revised imminently. 

The  NHS  Premises  Assurance  Model  (NHS  PAM)  is  a  self-assessment  by  NHS 
organisations of their implementation of estate and facilities guidance. This includes 
fire safety and asks whether all areas of the premises have had a fire risk assessment 
undertaken,  with  any  necessary  risk  mitigation  strategies  applied  and  regularly 
reviewed. BSMHFT was noted as “compliant, no action required” for this area of self-
assessment within the NHS PAM for 2024-25.  

The  NHS  PAM  is  being  revised  for  2025-26  to  move  from  an  assurance-based 
approach to a compliance-based approach. 

There is also guidance on security measures for garden areas in secure rehabilitation 
settings  within the  Environmental Design  Guide for Adult  Medium  Secure  Services, 
published  in  2011.  This  document  outlines  physical  and  procedural  security 
requirements for secure services, including outdoor spaces, considering areas such 
as: 

 
 
 
  
  
  
 
  
 
 
  
 •  Perimeter security: Garden areas should be enclosed with secure fencing that 

prevents absconding. 

•  Controlled access: Entry and exit points should be monitored and lockable. 
•  Visibility and surveillance: Design should ensure staff can observe patients at 

all times. 

• 

Additionally, the Health Building Note (HBN) 03-01 Supplement 1: Medium and Low 
Secure Mental Health Facilities for Adults recommends: 

•  Secure  outdoor  areas  must  be  designed  to  support  therapeutic  use  while 

maintaining safety. 

•  Physical  barriers  (e.g.  anti-climb  fencing)  and  procedural  controls  (e.g. 

supervised access) should be tailored to the patient population. 

• 

Finally, the CQC monitoring highlights that outdoor access is therapeutically beneficial, 
but security and design quality vary across services.   Facilities should ensure safe, 
well-maintained and supervised outdoor spaces.  

Whilst  none  of  the  documents  mentioned  above  specifically  refer  to  fire  escapes, 
secure  access  to  fire  escapes  should  be  embedded  within  the  providers’  risk 
assessments. The clinical risk assessment should cover the patient’s current level of 
risk (absconding, self-harm etc) and the patient should be supervised according to the 
level of risk posed.  

Ultimately, there appears to be appropriate guidance in place to ensure that incidents 
such as this should not happen, however it appears that the local risk assessment did 
not take the specific risks of the fire escape and access to the roof into account. NHS 
England  is  not  able  to  comment  further  on  this  and  directs  the  Coroner  to  the 
Birmingham and Solihull Integrated Care Service in this regard.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Ricky, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

 
  
 
  
 
 
 
  
 
 National Medical Director 
NHS England