Peter Fleming

Dear Mr Bennett,

RE: Prevention of Future Deaths Report for Mr Peter Fleming (deceased)

Further to the Prevention of Future Deaths Report dated 14th July 2023, the Trust has now had an opportunity to review the Matters of Concern you have raised within the same. I would first like to begin by offering my sincere condolences to the Family of Mr Fleming for his very sad loss. As a Trust we have taken your concerns very seriously and have aim to act on these issues as quickly as possible to ensure lessons are learned to benefit other patients in the future. I will respond to each issue in turn;

1. A continuing lack of resources to treat seriously mentally ill patients in Birmingham and Solihull

As you will be aware, the Trust received a previous Prevention of Future Deaths report into this matter by Mrs Louise Hunt, which was responded to in April 2023. I attach a copy of this to set out the joint work that is currently being carried out alongside the Integrated Care System.

In addition to this we can highlight other areas where we are trying to assist with this as follows:

I. Places of Safety Whilst it is best practice that a service user presenting with a mental health concerns is taken to a mental health Place of Safety, this could not be achieved on the particular day in question as all the mental health Places of Safety within the Trust were taken. However, Mr Fleming was conveyed to the Accident & Emergency Department at Heartlands Hospital which is an appropriate Place of Safety and indeed there are a number of A&E departments across the Birmimgham and Solihull area where service users can be taken too as Places of Safety. In terms of its own provision the Trust has three Places of Safety available across the organisation. The pressure on these facilities is multi-factorial. Work is ongoing in this area with the Police to streamline the s.136 process.

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II. Care Coordinators The Care Programme Approach (CPA) has had a central role in the planning and delivery of secondary care mental health services for the past 30 years. There is a recognition that principles were sound when initially introduced and implemented. It was associated with resource allocation, clinical care delivery and planning whilst being closely associated with risk management. The two main aspects of a CPA package of care involved allocation of a care coordinator and development of a care plan. It was also used as an overarching framework to join up health and social care assessments. The CPA has been superseded by The Community Mental Health Framework (2019) which proposed replacing the CPA for community mental health services while retaining the sound theoretical principles of good care coordination and high-quality care planning. The focus is on shifting away from generic care coordination to a more meaningful intervention-based care. For there to be a named key worker with a clearer Multi Disciplinary Team approach, with a high quality co-produced, holistic personalised care and support planning. The Framework also focuses on better support for and involvement of carers and a more accessible, responsive and flexible system. The use of a Dialog Plus Care Planning tool will be the foundational component of the framework to ensure the holistic identification of needs with allocation of the appropriate clinician within teams to support those needs to be met, to liaise with other professionals who need to input into care and to ensure the Action Plan is reviewed in a timely manner.

From March 2023 to April 2024 the Trust is in a transition phase of implementing the new Dialog Plus Care planning tool. Once this is completed, the required/recommended changes to the CPA Framework, will be reviewed (with learning from other organisations as part of the process) in line with NHS England Guidance and implementation.

The Local Authority will be addressing separately the point around Approved Mental Health Professionals.

2. Communication between specialist mental health teams is not effective and this caused delays

In preparation for our transition to the Patient Safety Incident Response Framework we have undertaken an analysis of data from various sources, with aim of looking for opportunities for improvement, areas where gaps in care and treatment/or incident types remain a concerns. As part of our Incident Response Plan we are proposing that fragmented working and poor communication is a safety priority for the organisation. It is anticipated that the Response Plan will be approved in October 2023. By way of a general update on the Trust’s management of PFDs going forward, the Associate Director of Nursing and Governance is currently undertaking a deep dive review of the last 2 years of Regulation 28 Reports. This will facilitate a detailed thematic review and learning exercise. This work will subsequently feed into an overarching piece of work the Trust has already commenced pulling a variety of patient safety data sources together including SIs, Safeguarding Reviews, Complaints, Legal Claims, CQC, and Local Investigation information. This rich dataset will be formed into themes, and a QI approach taken to addressing the bigger and most impactful areas of required improvement. Anticipated timelines for this work are below:

• The thematic review of PFDs will be completed in 8 weeks.
• The overarching review of multiple patient safety datasets and subsequent forming into themes and trends will be completed in 16 weeks.
• Formulation of the major QI workstreams will commence in 18 weeks’ time.

3. Carbamazepine management indicating a problem with process and systems

A review of the RiO notes and discussions with the SI review lead and others highlighted that the patient has not been under a shared care arrangement and was discharged by BSMHFT back to their GP following non-attendance in 2012. The specialist advised the GP to prescribe carbamazepine in line with locally agreed practice, a letter was sent to the GP and acknowledged as received, but the GP stopped prescribing carbamazepine for reasons unknown. BSMHFT Home Treatment team re-started prescribing carbamazepine when the patient was admitted into their service. Carbamazepine is on the Birmingham and Solihull IMOC formulary as an AMBER medicine, meaning that once a specialist has advised initiation of this medicine, any prescriber can prescribe it. There is no requirement for a shared care agreement for carbamazepine and there has never been a template for one. Communication is evidenced via clinical correspondence.
4. Communication between different health organisations is not as effective as it could be causing important information to be missed and delay in treatment occurring

Following the introduction of the shared electronic system across Birmingham, Sandwell and Solihull areas through Your Care Connected some years ago, the Trust could access some clinical information from primary care services. However, in the last 12 months this has been enhanced, and is now known as the Shared Care Platform. This allows a number of different organisations to access different clinical information across the system, including investigation results, thus improving the exchange of clinical information and thus improving patient care.

5. GP’s are not able to proactively check patients are collecting prescribed medication due to excessive patient lists as a consequence of a lack of resources at a national level

The Trust cannot respond to this point and will leave this to others to respond to. If a patient is open to BSMHFT, our staff will regularly speak to the patient about all aspects of their care, including medication.

Dear Mr Bennett,

Background This response is provided by Birmingham City Council (BCC) in response to the regulation 28 report to Prevent Future Deaths, dated the 14th July 2023, made by James Bennett Area Coroner for Birmingham and Solihull areas, under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. This report was made following an Inquest touching upon the death of Mr Peter Martin Aaron Fleming. BCC was not an Interested Person and took no part in the Inquest.

Mr Fleming died on the 10th November 2022. The conclusion of the Inquest on 4th July 2023 was Suicide. At the outset of this response, the local authority offers its deepest condolences to the family of Mr Fleming. The matter of concern is that Birmingham City Council could not provide an Approved Mental Health Practitioner (‘AMHP’) to attend in a 24-hour period.

OFFICIAL AMHP resources and decisions made on the 14'" and 15th October 2022

BCC had been informed by Heartlands Hospital at 18:58 hours on 14 October 2022 that Mr Fleming had been placed on a s.136 at 17:07 hours on 14th October 2022. At 22:53 hours on 14th October 2022 a call was made to Heartlands hospital to confirm the whereabouts of Mr Fleming as it had been stated in the referral that he was being moved to the Place of Safety at the Oleaster Hospital. During the call at 22:53 hours it was confirmed that the hospital were waiting to hear back from the Place of Safety regarding the transfer. There was no further update provided overnight on 14th October. On 15th October 2022 at 11:27 hours a follow up call was made to Heartlands hospital and it was confirmed that Mr Fleming was remining at the Emergency Department and Police were with him and that he remained settled. At 11:36 hours on 15th October a further call was received from Police requesting an update of 4 s136 cases the team were managing through and he reiterated this was urgent. There was a second call received from Police at 12:50 hours requesting an update on allocation of an AMHP and at 15:59 BCC were informed Peter’s s136 had now lapsed and that he had discharged himself. There are no recordings of actions taken between these escalation calls. Birmingham does have a dedicated Place of Safety namely the Oleaster Hospital, which has up to 3 spaces available at any one time. A hospital or a care home may also be used as a place of safety under the provisions of the Mental Health Act so in this instance the use of accident and emergency was an acceptable alternative to a placement being available at Oleaster.

There was a delay in allocating the assessment to an AMHP as there were multiple calls between Heartlands Hospital and the dedicated Place of Safety Oleaster to determine whether Mr Fleming would be transferred.

During the day shift of 15th October 2022 Birmingham City Council Out of Hours Team were dealing with 4 s.136 requests.

BCC were also given conflicting information regarding the actual end time of the s136 and Birmingham City Council believes Mr Fleming was released from the s136 before the 24 hour timeframe was ended.

OFFICIAL A call was made to Heartlands Hospital at 15:59 hours on 15th October 2022 to a member of the Psychiatric Liaison Team to discuss allocating an AMHP to complete the Mental Health Act Assessment. It is recorded within BCC electronic records that BCC were informed the s136 had lapsed and that Mr Fleming had discharged himself and had gone home. This was an hour and 8 minutes before the s136 would have expired assuming that the time we were given for the s136 to have commenced was at 17:07 hours.

From the staffing levels on 15th October 2022 BCC did have sufficient AMHPs on shift in which to complete the assessment before the end of the 24 hour timeframe. BCC holds an electronic diary showing that on 15th October 2022 there were three AMHPs on duty from 8 am to 7 pm which covers the time period prior to the expiry of the s136 at 17:07 hours. The BCC Out of Hours Service operates with an average of 5/6 AMHPs on Duty covering the 22 hours period from 8 am to 6 am the following day. On 15th October 2022 there were 5 AMHPs on duty over 24 hours.

AMHP Availability Birmingham City Council is actively seeking to recruit, retain and train Approved Mental Health Professionals and is maximising AMHP resources through use of Agency Workers and requiring all AMHPs to contribute to our AMHP service on a daily basis. We recognise the impartiality of the AMHP role and we reserve the right under s13 Mental Health Act 1983 to consider all requests for Mental Health Act Assessments and we encourage staff to look at alternatives to assessment where possible. BCC has seen an increase in requests for assessments which has risen by at least 20% this year suggesting that the acuity of people requiring formal admission under the Act has increased. The lack of bed availability increases the number of times we assess individuals as medical recommendations which are valid for 14 days often expire whilst the person is waiting for a bed, which also impacts on our referrals. BCC has also seen a significant increase in the use of s136 in Birmingham and in our Out of Hours Service s136 assessments account for 47% of all Mental Health Act assessments completed Out of Hours. Figures are retained by BCC detailing all requests for Mental Health Act Assessments and this includes the outcome of all assessments completed. A monthly report is usually produced giving these details. The Mental Health System in Birmingham meets as a partnership monthly at a Joint Strategic Meeting chaired by Birmingham and Solihull Mental Health Trust where s136

OFFICIAL assessments are regularly discussed and reported and figures are retained by the Trust around conversion rates.

Birmingham City Council has the responsibility under the AMHP regulations to Approve and Authorise AMHPs who work for or on behalf of the Local Authority. Birmingham City Council, Birmingham and Solihull Mental Health Foundation Trust and Birmingham Women’s and Children’s Trust are currently consulting on a new Memorandum of Understanding which will mean that AMHPs employed directly by the NHS in Birmingham will all contribute to the AMHP rota increasing the capacity by a further 14 AMHPs available to cover AMHP duties on a monthly basis. This includes a commitment from Birmingham City Council to fund AMHP training for NHS staff who meet the criteria for the course.

Within the regulation 28 report the Coroner recognises the chronic lack of resources including Care Coordinators, Mental health Inpatient beds and Approved Mental Health Professionals (AMHPs) at a local and national level. This is also recognised by the Chief Social Worker and their staff including who represents Mental Health Services at a National Level. As a Local Authority BCC is represented at the National AMHP Leads Network and we have a dedicated AMHP Lead who is promoting and actively supporting the training of AMHPs in Birmingham both within the Local Authority and with local NHS partners.

In 2022 we received funding from Skills For Care for an additional 10 AMHPs and we were successful in training 8 AMHPs in the first year – AMHP Training takes 2 years to complete with a period of supported practice following successful completion of the qualification. Birmingham City Council aims to train 5 AMHPs per year . Birmingham City Council has the responsibility under the AMHP regulations to Approve and Authorise AMHPs who work for or on behalf of the Local Authority. Birmingham City Council, Birmingham and Solihull Mental Health Foundation Trust and Birmingham Women’s and Children’s Trust are currently consulting on a new Memorandum of Understanding which will mean that AMHPs employed directly by the NHS in Birmingham will all contribute to the AMHP rota increasing the capacity by a further 14 AMHPs available to cover AMHP duties on a monthly basis. This includes a commitment from Birmingham City Council to fund AMHP training for NHS staff who meet the criteria for the course.

OFFICIAL Birmingham City Council regrets that Mr Fleming felt compelled to take his own life, however we cannot predict what the outcome of a Mental Health Act Assessment may have been if completed within the 24 hour timeframe allowed for this assessment. We attend almost 100% of s136 assessment requests within the timeframe and we would remind partners that Police can apply for an extension if they feel the risk necessitates this.