Kiefer Fraser-Phillips

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 

When a coroner sends a prevention of future deaths (PFD) report to a person or organisation, 
they must respond within 56 days. Recipients of a PFD report can apply to the coroner for an 
extension.  A response to a PFD report must detail the action taken or to be taken, whether in 
response to the report or otherwise, or it must explain why no action is proposed. 

The purpose of the response template below is to promote clarity, ensure that responses 
address the coroner’s concerns directly and transparently, and support consistency and good 
practice across organisations and sectors. It does not restrict how a person or organisation 
formulates their response; recipients remain responsible for determining what action is 
appropriate and for ensuring that their response accurately reflects the steps taken or planned. 

In accordance with the Chief Coroner’s PFD Publication Policy (2026) representations regarding 
publication of a response should be sent to the coroner. These representations should be made 
at the same time as the response is provided. The coroner will pass any representations 
received to the Chief Coroner for a decision 

RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 

(Please do not include any living persons’ names in this document, in accordance with the 
Chief Coroner’s PFD Publication Policy (2026)) 

 THIS RESPONSE IS BEING SENT TO: 

 HM SENIOR Coroner Louise Hunt for Birmingham and Solihull in response to a ‘REPORT TO 
PREVENT FUTURE DEATH REGULATION 28’ following an inquest into the death of Keifer 
Fraser-Philips that concluded on 15 Apil 2026.  

 RESPONDENT 

 In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, 
Birmingham and Solihull Mental Health NHS Trust provides this response within 56 days 
(plus any extension granted) of the date of the Report to Prevent Future Deaths 

 DATE OF RESPONSE  

9 June 2026 

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  CONFIRMATION OF CORONER'S MATTERS OF CONCERN 

 The MATTERS OF CONCERN were identified in the report as follows: 

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1. Staff had not been completing the comments section during therapeutic observations as 
the electronic device they used would drop Wi-Fi signal making it impossible to record the 
observations until they were back in the ward office. This creates a risk that observations 
are not being recorded accurately and effectively and creates a risk of future deaths. 

2. Many patients with enduring mental health conditions on long term medication will have 
significant physical health conditions due to the side effects of the medication. These often 
include  considerable  weight  gain,  and  in  Mr Fraser-Phillips'  case  sleep  apnoea  and  the 
associated  risk of  position  asphyxia.  There  was  no  care  plan  in  place  to  address  these 
risks.  Consideration  needs  to  be  given  to  ensuring  patients  with  significant  physical 
healthcare needs have adequate care plans in place to address any risks identified.  

 DETAILS OF ACTION TAKEN, how has the concern been addressed. 
(If no action is proposed please explain why here) 

 Please note that any links to webpages included in the response will not be checked for 
sensitive information prior to publication, as the information is already online. 

Wifi signal on the wards  

1.  A Survey has now been carried out on a number of the acute wards to understand the 
extent of the Wifi problems on the wards and ICT are exploring the best solution to resolve 
the issue where hot spots have been noted. Whilst this might seem like a straightforward 
problem to solve the ideal solution would be to move the receivers from above the ceilings 
but  due  to  the  nature  of  the  clinical  area  that  creates  a  ligature  risk.  Alternatives  are 
currently being explored and the trust and will be tested to ensure efficacy for Wifi, as well 
as it being clinically safe to use with mitigations in place whilst this is completed.  

2.  Whilst a more permanent solution is finalised staff have access to desktops and laptops 
on the ward to input their observations. Staff have also been reminded of the importance 
of documenting their observations. Staff are being involved to ensure that the solution is 
sourced as a matter of urgency. I can assure you that the Trust will continue to review 
this matter until a satisfactory outcome is resolved.  

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Recording of physical heath conditions in care plans. 

1.  Thank you for raising concerns through the Prevention of Future Death report regarding 
the  management  of  physical  health  risks  in  patients  with  enduring  mental  health 
conditions who are prescribed long‑term psychotropic medication. 

2.  We  recognise  and  fully  accept  the  Coroner’s  concern  that  patients  with  significant 
physical health conditions arising from, or exacerbated by, their mental health treatment 
require clear, documented care plans to identify and mitigate risks, including those related 
to  weight  gain,  sleep  apnoea  and  the  associated  risk  of  positional  asphyxia.  We 
acknowledge that, in this case, an explicit care plan addressing these risks was not clearly 
articulated. 

 
 
  
 
 
 
 
 
 Existing Physical Health Assessment and Documentation Systems 

3.  The  Trust  utilises  the  RIO  electronic  clinical  records  system,  which  includes  a 
comprehensive  Physical  Health  Assessment,  Systemic  Enquiry  and  Physical 
Examination form. This structured record, in addition to other comprehensive questions 
and areas of enquiry, also captures: 

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Current physical health problems 
Past medical history and long‑term conditions 
Relevant risk factors associated with mental health medication 
Action Plan sections 
Follow‑up and ongoing management plan sections 

4.    These  sections  are  designed  to  prompt  clinicians  to  identify,  document  and  actively 
manage  physical  health  needs  alongside  mental  health  care,  and  to  ensure  risks  are 
translated into clear actions and review plans. However, we recognise that the presence 
of an electronic template alone does not guarantee consistent or effective care planning, 
and  that  further  assurance  is  required  to  ensure  physical  health  risks  are  clearly 
addressed and followed through in practice.  

Care Planning Improvements: Implementation of Dialog+ Care Planning 

5.  To  strengthen  and  standardise  care  planning  across  inpatient  settings,  the  Trust  has 

recently implemented Dialog+ Care Planning in all inpatient services. 

Dialog+ Care Planning provides a structured, patient‑centred framework that ensures key 
domains  are  proactively  explored,  agreed  and  documented  during  care  planning 
discussions.  Importantly,  Physical  Health  is  a  core  Dialog+  domain,  alongside  mental 
health, medication, daily activities and safety. 

6.   This approach supports: 

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Explicit  identification  of  physical  health  risks  linked  to  medication  and 
comorbidity 
Collaborative formulation of clear actions to mitigate identified risks 
Improved visibility of physical health needs within the overall care plan 
Regular review and updating of agreed actions 

We believe this represents a more robust and systematic approach to integrating physical 
healthcare needs into mental health care planning. 

Audit and Assurance Framework 
7.      In  response  to  the  Coroner’s  concerns,  the  Trust  has  strengthened  its  Audit  and 
Assurance  Framework  for  Dialog+  Care  Planning  at  ward  level.  This  framework 
includes: 

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Routine ward‑level audits of Dialog+ care plans 
Specific checks that relevant domains are being appropriately used, including 
the Physical Health domain 
Assurance that identified physical health risks are clearly reflected in the action 
plan, with proportionate and documented follow‑up arrangements 
Feedback  to  clinical  teams  and  incorporation  of  findings  into  local  quality 
improvement activity 

8.    This provides additional governance and oversight to ensure that physical health risks 
are  not  only  identified  but  are  actively  addressed  through  documented  actions  and 
review. This will be further supported by implementation and auditing of the Inpatient 
MDT standards where senior clinical inpatient staff (including medical and nursing, and 

 
 
 
 
 other  professionals  as  appropriate)  will  be  supporting  with  follow  up  of  any  required 
actions identified in the Physical health action plan.  

Learning and Prevention of Future Risk 
9.   The Trust has shared learning from this case across inpatient teams, emphasising: 

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The  increased  physical  health  risks  associated  with  long‑term  psychotropic  
medication 
The importance of translating physical health assessments into clear, actionable 
care plans 
The  need  to  explicitly  address  risks  such  as  sleep  apnoea,  obesity  and 
positional asphyxia where relevant 

10.  Combined  with  enhanced  care  planning  through  Dialog+  and  strengthened  audit 
arrangements, these actions are intended to reduce the risk of similar omissions occurring in 
the future and to ensure that patients with significant physical healthcare needs have clear, 
documented plans to manage identified risks. 

11.  The Trust is grateful for the opportunity to reflect on this case and remains committed to 
continuous improvement in the integration of physical and mental healthcare for our patients. 

 DETAILS OF FURTHER ACTION PROPOSED 

 Please note that any links to webpages included in the response will not be checked for 
sensitive information prior to publication, as the information is already online. 

During our investigations the Trust has also put into place actions to review the observations 
on the ward more closely, to ensure a high quality of observations. Monthly audits will now 
be taking place to review the quality of the observations. Actions will be taken where staff 
do not comply with policy and results of the audits will be taken to Quality Assurance Group 
for assurance, to ensure the Trust is providing the best care possible to our in-patients. This 
will  also  enable  the Trust  to monitor  not  just the  quality  of  the  observations  but ensure  if 
there are any systemic issues, these are raised and addressed immediately.  

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  SIGNATURE 

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Chief Executive