Matthew Lynch

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: , Handsworth, Birmingham, West Midlands

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.