Source · Prevention of Future Deaths

Leroy Hamilton

Ref: 2023-0013Deceased Date: 11 Jan 2023 Coroner: Louise Hunt Area: Birmingham and Solihull Responses identified: 3 / 5 View PDF

Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police also failed to correctly classify and risk-assess mentally unwell individuals as high-risk missing persons.

Date 11 Jan 2023

56-day deadline 9 Mar 2023

Responses identified 3 of 5

Other related deaths

Coroner's concerns

AI summary

View full coroner's concerns

1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU. Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
2. Safe space: The inquest heard how it is often the case that due to the lack of inpatient beds and PDU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed. This means that acutely ill mental health patients are often left for long periods without any specialist care, support or observation. Consideration should be given to setting up a safe space where patients can wait for a bed or PDU space which is able to cater for their special needs and keep them safe.
3. Multi agency protocol for informal missing patients: The inquest heard how there is no agreed protocol to deal with informal patients who abscond from emergency departments. Consideration should be given to setting up an agreed protocol so that all agencies involved understand their respective roles and responsibilities.
4. WMP Missing person investigations: The inquest heard how on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr Hamilton as a missing person when he was reported as missing. On both occasions he should have been treated as a high risk missing person. This raises a serious concern that staff do not understand when people should be classified as missing. Consideration should be given to ensuring staff properly understand how to assess if someone should be treated as a missing person and WMP should consider whether further training is required.
5. WMP risk assessments for missing persons: When Mr Hamilton was first reported as missing no risk assessment was undertaken about his level of risk to himself. The call had confirmed he was at risk of harming himself. The leads to a concern that staff do not understand when and how to risk assess incidents and when to identify high risk incidents.

Responses

3 respondents

West Midlands Police Police / Law Enforcement

9 Mar 2023 PDF

Action Taken

West Midlands Police have taken multiple steps including updating missing person investigation training, providing a toolkit for staff interactions with missing persons, upgrading the missing persons recording system, and developing training in partnership with Birmingham and Solihull Mental Health Foundation Trust. (AI summary)

View full response

Dear Mrs Louise Hunt - HM Senior Coroner for Birmingham and Solihull, This is the response of the Chief Constable of West Midlands Police to the Regulation 28 report issued by His Majesty's Area Coroner for Birmingham and Solihull on 11 January 2023 following the conclusion of the inquest into the death of Leroy Patrick Hamilton. HM Area Coroner identified five concerns, set out in Part 5 of the report, which are as follows:
1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (POU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in POU. Consideration is needed urgently to fund further mental health beds and POU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
2. Safe space: The inquest heard how it is often the case that due to the lack of inpatient beds and POU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed. This means that acutely ill mental health patients are often left for long periods without any specialist care, support or observation. Consideration should be given to setting up a safe space where patients can wait for a bed or POU space which is able to cater for their special needs and keep them safe.
3. Multi agency protocol for informal missing patients: The inquest heard how there is no agreed protocol to deal with informal patients who abscond from emergency departments. Consideration should be given to setting up an agreed protocol so that all agencies involved understand their respective roles and responsibilities.
4. WMP Missing person investigations: The inquest heard how on 2 occasions (03/12121 and 07/12121) there was a failure to treat Mr Hamilton as a missing person when he was reported as missing. On both occasions he should have been treated as a high risk missing person. This raises a serious concern that staff do not understand when people should be classified as missing. Consideration should be given to ensuring staff properly understand how to assess if someone should be treated as a missing person and WMP should consider whether further training is required.
5. WMP risk assessments for missing persons: When Mr Hamilton was first reported as missing no risk assessment was undertaken about his level of risk to himself. The call had confirmed he was at risk of harming himself The leads to a concern that staff do not understand when and how to risk assess incidents and when to identify high .risk incidents. Preventing crime, protecting the public and helping those in need west-m1dlands.pol1ce.uk

Whereas the third, fourth and fifth of the Coroner's concerns are pertinent to West Midlands Police (WMP), the first and second concerns relating to the Psychiatric Decisions Unit (POU) are, in my view, pertinent to other addressees of the report, namely: (i) the Birmingham and Solihull Mental health NHS Foundation Trust; (ii) the Birmingham and Solihull Integrated Care Board; (iii) University Hospital Birmingham NHS Foundation Trust; and (iv) the Secretary of State for Health. WMP has no involvement in the commissioning and operation of the POU. For these reasons, this response focusses on the third, fourth and fifth concerns identified by the Coroner. In relation to the Coroner's third concern, relating to a multi-agency protocol to deal with informal patients who abscond from emergency departments, WMP is currently setting up a working group with key partner agencies, including mental health agencies and professionals, to discuss and design a joint missing person protocol. I anticipate that these discussions will take into account the circumstances of Mr Hamilton's case, as well as the Authorised Professional Practice (APP) of the College of Policing, current national best practice, information sharing, the operation of lead agencies, communications (including with and to relevant partner agencies) and on-going governance. The department within West Midlands Police responsible for the investigation of missing person reports is called 'Locate'. A key tenet of the team's remit is to work with partner agencies to ensure that accurate information is shared, and that partner agencies understand WMP's role and responsibilities. WMP has also established a Multi Agency Missing Meeting (MAMM). This is a monthly meeting chaired by the Detective Superintendent lead for the Locate department and will encompass representatives from relevant partner agencies and key external stakeholders. MAMM provides an opportunity for multi-agency discussion relating to risk and joint learning to improve multi-agency collaboration. It is anticipated that MAMM will improve WMP's response to missing persons, including where 'informal patients' abscond from emergency departments. WMP welcomes the opportunity to collaborate more closely with mental health stakeholders, with a view to ensuring that Locate is best placed to carry out its functions. MAMM will also provide an opportunity for further training for WMP staff and other agencies and key stakeholders. While not strictly related to the Coroner's concerns, work is now also underway to implement the 'Philomena Protocol' within WMP. This is a joint working agreement between the police and local authorities to ensure that appropriate information is shared for missing children and that the right response is in place from the outset to minimise risk and safeguard missing children. I am mindful that this work, which WMP is supporting nationally to ensure best practice across all forces and local authorities, is a strong foundation for the implementation of policies and working practices within the mental health arena. As to the Coroner's fourth and fifth concerns relating to missing person investigations and risk assessments, I wish to inform HM Area Coroner that following steps have been taken, and are being currently being carried out. First, to specifically consider whether ongoing support is required for Force Contact and Force Response staff, a 'Task and Finish' group has been established to address learning points. The first meeting took place on 20 February 2023 and work in this regard is on-going. Preventing crime, protecting the public and helping those in need , west-m1dlands.pol1ce.uk

Second, the Missing Operational Group (MOG) has been in place for a significant period of time. This meeting provides governance at a senior leadership level for all aspects of the missing person process. There is representation from all stakeholders including Force Contact and Force Response. The MOG agenda entails feedback concerning individual cases where certain risk factors have not been identified, or where the response has not been appropriate. I anticipate that the concerns raised by HM Area Coroner concerning Mr Hamilton's case will be addressed by MOG, resulting in corrective action, including targeted training. Further, priority response call escalations are now a standing agenda item each month at MOG. Third, a full review has been conducted concerning the recording of priority response logs and internally generated logs. This involved work with Force Contact, Force Response and Locate. While this was part of a wider review process, it incorporated missing persons at the front-end reporting stage and quality assurance activity. This was carried out through weekly audits and weekly senior leadership meetings to discuss individual cases or themes where the correct risks had not been identified during call handling. To support this development, feedback was provided, improvements were noted, and training was delivered to Force Contact staff by experienced Locate supervisors. Fourth, following the full review, a 'Support Desk' was created. This entailed continuity of staff dealing with calls for service - including missing persons - with an increased number of supervisors in post to review and scrutinise the work of support staff. This provides a focused training opportunity for Locate staff, as well as on-going support. Fifth, WMP is considering whether to establish a specialist desk within Force Contact that will entail the same staff dealing with more complex calls, such as missing persons. This will ensure that Force Contact staff receive the right support and training as a continuation of the 'Support Desk'. Sixth, detailed audits have been carried out which reveal a marked improvement from 2020 to 2022. While there is still work to do, the audit revealed 90% compliance with the '12 key questions' and 100% of all calls audited accurately recorded, and correctly applied, the appropriate risk grading. Just 2% of all incidents audited in 2022 had no clear full risk assessment, compared to 66% in 2020. Seventh, a pilot scheme was recently implemented, led by the Chief Inspector Missing Lead for Force Response, which amends the response to missing person reports. This pilot scheme entails an early Inspector review to ensure that the right response is in place from the outset, that risk is correctly identified, and that there is ongoing management throughout the initial stages of investigation including any required escalation. The pilot scheme creates a central point of control and progression for all missing person investigations. This is an on- going project and a further update concerning the conclusion of the pilot scheme is awaited. Eighth, the Locate learning portal is in the final stages of design. This resource will adopt a new approach to learning which will provide staff with a toolkit for their interactions with missing persons. The content is being produced in consultation with key stakeholders and will be extended to add partner information where appropriate. Relatedly, an online missing person package is currently available on WMP systems, which is regularly refreshed. Officers are requested to complete the package, which supports them in identifying missing persons and understanding primary actions to be taken. As of October 2022, more than Preventing crime, protecting the public and helping those in need west-m1dlands.pol1ce.uk

2,100 WMP operational frontline officers have completed the package. This training package is also embedded into student officer training. Ninth, WMP has completed an upgrade of its missing persons recording system (COMPACT). The main benefit of this upgrade is to ensure that the police prevention interview is more detailed, and that relevant information is passed to other agencies in order to support vulnerable persons in a holistic way. The upgrade to COMPACT prompts officers to consider things such as presentation and wider risk. This will improve the overall approach missing persons and ensure that information about history and risk are properly documented and accessible. Another beneficial feature of the upgrade is that it allows improved data insight into high demand missing locations and persons. This data will be used to understand where action and support is needed to support missing persons and reduce future threat, risk and harm. I hope that the above response provides you with assurance of the steps taken by the Force in responding to reports of missing persons and its continued efforts seeking to improve the service that we offer to our communities. Signed in the absence of CC Guildford by T/DCC

Chief Constable Preventing crime, protecting the public and helping those in need west-m1dlands.pol1ce.uk

NHS Birmingham and Solihull ICB Integrated Care Board

28 Apr 2023 PDF

Action Planned

Birmingham and Solihull ICB, with BSMHFT and UHBFT, are jointly reviewing pathways of care for acutely unwell people requiring mental health support, including the need for increased mental health beds and Psychiatric Decision Unit spaces. A consistent system-wide protocol across urgent care services for mental health patients who go missing will be led by the Mental Health Provider Collaborative. (AI summary)

View full response

Dear Ms Hunt

Leroy Patrick Hamilton - Response to Regulation 28 report to prevent future deaths

I write in response to the Regulation 28 Report dated 11th January 2023 which was issued following the inquest on the death of Mr Leroy Patrick Hamilton in December 2021. I note the narrative conclusion of the inquest was ‘drowned whilst suffering an acute psychotic relapse’ and that a Regulation 28 Report to Prevent Future Deaths has been issued in respect of this incident. I extend my sincere condolences to Mr Hamilton’s family and loved ones.

You raised five matters for concern, three specifically relating to the provision of services by Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT), NHS Birmingham and Solihull ICB and University Hospitals Birmingham NHS foundation Trust (UHBFT) and two related to West Midlands Police.

Please accept this letter, authored by Birmingham and Solihull ICB in conjunction with both BSMHFT and UHBFT, in response to the concerns identified. The issues identified during the above inquest into Mr Hamilton’s death, regarding the provision/resourcing of health care to acutely unwell people requiring mental health support are complex and the subject of significant review at both a national and regional level consequent to the current unprecedented demand for mental health services.

Lack of inpatient mental health beds and lack of Psychiatric Decisions Unit ( PDU) spaces. Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.

This cohort of vulnerable people often, through necessity, initially attend at acute hospital Emergency Departments (ED) when in crisis. Initial assessment and subsequent placement into an appropriate therapeutic environment can take several hours resulting in the person waiting within the ED, which is busy and unsettling. This is a pathway of access into care that we as an ICS recognise does not provide a suitable experience for a person with an acute mental health (MH) crisis. It reflects the widely recognised need for further acute bedded capacity for the Birmingham and Solihull system; it is unfortunately usual

Page2 for the ICS to have many patients placed in beds out of area and managed within the community whilst awaiting access to a bed.

A Mental Health Provider Collaborative was formed April 2023 within Birmingham and Solihull ICS with responsibility for designing and delivering appropriate mental health services across the ICS. This collaborative is leading on the strategic cases to establish further bedded capacity, but we recognise that this will take time. The developing health infrastructure strategy for the local NHS will highlight additional inpatient mental health facilities as a priority for any bids for national capital.

As an ICS we, therefore, recognise the need to place significant focus on pathways for people with acute MH crisis to, whenever possible, ensure direction to the most appropriate pathway of care at first contact, thus avoiding the ED, and once within an ED to progress to definitive care as soon as possible.

Over this winter period the ICB have commissioned additional beds to aid flow through bedded capacity to enable step down ahead of discharge and to facilitate return into the system from out of area placement. There is also a considerable focus on flow through all MH bedded capacity, with a focus on overcoming delays in discharge of stable patients to maximise productivity of available capacity.

For patients known to MH services, support is already provided through their community teams, the crisis and home treatment teams with work in progress to further strengthen these support mechanisms. In addition there are plans to extend the Street Triage team and a focused project with West Midlands Ambulance Trust has introduced ‘call before you convey’ giving direct access to MH advice diverting people away from the ED to more appropriate pathways wherever possible. BSMHFT have recently appointed a Director of Urgent Care Transformation to lead all pathway changes.

The Psychiatric Decision Unit (PDU) based at Oleaster Unit in BSMHFT, has been commissioned for patients who have capacity, are able to consent to attend the PDU and who are assessed as “low risk”. It is an ambulant assessment area which provides a calming environment for the assessment and development of treatment and pathway plans. As such it is not an admission area; it does not have beds within it. Like ED, there are no powers of detention for individuals accessing the PDU. There are six spaces (three male, three female) in the PDU. Processes implemented by the ICS help to divert suitable people to the PDU capacity rather than attendance at ED and the capacity is used regularly to take people from ED who meet the relevant criteria. However, it is recognised that review of the current PDU service is required; we need capacity that provides care for people with higher acuity of MH need, with clear pathways for access and onward care. As part of the review we will also be looking at the clinical support for PDU. As a system we recognise accessing help prior to coming to ED or PDU will be best for many patients.

Despite efforts to offer alternatives to people with known mental health issues, and to proactively support those in crisis, it is not possible to completely prevent attendance of people with acute MH crisis to the ED; personal behaviour will direct health seeking behaviour, and some people require assessment and treatment of physical health and MH needs (the latter through the embedded psychiatric liaison teams) before transfer to MH care. Where the person presents to the ED a system focus is applied to ensure that they are moved to the most appropriate environment as capacity allows in the shortest possible time.

Within the EDs, nursing staff complete a triage on all patients. When a patient presents with a MH issue, staff will complete an additional assessment, the ‘Threshold Assessment Grid’. During this assessment, additional questions are asked to understand the risk of the patient to both themselves and others. Where a significant MH need is identified, this will be escalated to the nurse in charge for consideration of a high visibility cubicle and need for enhanced observation including the need for the request for a mental health nurse to ‘special’ the patient. Ongoing observations are then performed and level of risk is also escalated as needed to the liaison psychiatry team for an urgent assessment.

Page3 Initial assessment is performed by the liaison psychiatry team. The liaison psychiatry team aim to review all patients in ED within one hour of referral. If a suitable placement is available the person is moved to this as soon as possible.

Where admission or further assessment is required and there is no immediate admission destination available the person will sometimes remain in the ED whilst this is progressed. The care of such a person is escalated to the ICS Urgent and Emergency Care meetings which are held three to four times per day and discussed within BSMHFT bed meetings held twice daily. People may be transferred to the PDU during this period of waiting for a suitable placement if considered appropriate.

We recognise as an ICS that even with the introduction of the significant focus on pathways for individuals described above, the care for this group of people must remain a priority for us all. We have therefore established a system wide clinical oversight group to lead together this piece of work. This emphasizes joint ownership of care and pathways and will be a single liaison point with external agencies. Through the Mental Health Collaborative we are also ensuring that all work in this area is being streamlined and joined up under one programme linking clinical and operational elements along the whole pathway across all provider organisations. The clinical work programme includes an immediate adoption of jointly owned care standards across the pathway, with audit and learning against provided care, and exploration of different PDU models to meet ICS need. This group will report to ICS quality governance into the ICB Quality Committee as well as into individual provider quality oversight.

Consideration should be given to setting up a safe space where patients can wait for a bed or PDU space which is able to cater for their special needs and keep them safe.

We feel that the creation of a physical safe space, that is not a psychiatric hospital, where a person is admitted either informally or under Part 2 or Part 3 of the MHA 1983, within the ICS would not prevent a person in Mr Hamilton’s circumstances from leaving the premises of an acute hospital.

In this context, however, we recognise the need to keep people safe within the environment we have. The actions outlined above focus on ensuring where possible, ED is avoided. When a person does present to ED, a structured process of care assesses an individual’s need and provides care to this need when the person remains in the department. This time within the department is minimised by system ownership of the need to progress the person to a more suitable place of care as a matter of urgency within jointly owned care standards and regular escalations to progress onward care placement. This will remain a crucial focus whilst bedded capacity is expanded to meet the local need. We also ensure all system partners will communicate with each other as needed when our patients leave PDU or ED to provide maximum safeguards for our patients.

Multiagency protocol for informal missing patients.

BSMHFT and UHB both have Missing Patients Policies in place. These are single agency policies and it is recognised that there will be significant potential benefit in establishing a consistent system wide protocol across urgent care services for mental health patients who go missing, consistent with the National Framework Document (‘The multi-agency response for adults missing from health and care settings’ (Up- dated August 2021). A multi-agency agreement of this type defines roles and responsibilities, allows for consistency across services, and includes clear escalation pathways. This work will be led by the Mental Health Provider Collaborative with input from all system stakeholders.

I trust that the actions outlined above will provide the assurances you seek in respect of the matters of concern. We recognise that there is considerable work to be done and some of the aspects of this work will require input at a national level. We are conscious, therefore, that we have not been able to provide an action plan with detailed timelines. As an ICS we are, however, utterly committed to working together

Page4 to own jointly the pathways of care for patients with acute mental illness and ensure we use our currently available capacity as effectively as we can for individuals and the population.

Department of Health and Social Care Central Government

10 May 2024 PDF

Action Planned

The Department of Health is supporting the NHS to reduce waiting times in A&E by adding beds, speeding up discharge, and increasing transparency. West Midlands Police are setting up a working group with key partner agencies to discuss and design a joint missing person protocol. (AI summary)

View full response

Dear Miss Hunt,

Thank you for your Regulation 28 report to prevent future deaths dated 11 January 2023 about the death of Leroy Hamilton. I am replying as the Minister with responsibility for mental health and patient safety. Please accept my sincere apologies for the delay in responding.

Firstly, I would like to say how saddened I was to read of the circumstances of Leroy and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter.

The report raises concerns over numbers of inpatient mental health and psychiatric decisions unit beds and arrangements for informal missing patients. It also raises concerns about local policing arrangements and you will understand that these are outside of my remit as a Health Minister.

I note that West Midlands Police and Birmingham and Solihull Integrated Care have each already carefully considered the matters of concern in your report and have provided you with comprehensive responses setting out the actions being taken to improve care quality and patient safety.

Regarding the lack of inpatient mental health beds and psychiatric decisions unit (PDU) spaces and the availability of ‘safe space’, we are supporting the NHS to take action to reduce waiting times in A&E, including through adding 5,000 more permanent general and acute beds, speeding up hospital discharge and increasing transparency and the available information on waiting times and the NHS’s progress in reducing them.

To support adult social care and discharges across the NHS, including from mental health inpatient settings, up to £2.8 billion was made available in 2023/24 and £4.7 billion in 2024/25, with the aim of reducing bed occupancy.

The Department has also worked with NHS England and other system partners to develop statutory guidance for discharge from all mental health inpatient settings, which was

published in January 2024. This sets out how NHS bodies and local authorities can work together to support the discharge process, improving flow and ensuring the right support in the community. The guidance is available at: Hospital discharge and community support guidance - GOV.UK (www.gov.uk)

In addition, we are providing £150 million of capital investment for mental health urgent and emergency care infrastructure over 2023/24 and 2024/25. This includes investment into a range of wider local mental health infrastructure schemes, including new and improved crisis cafes, crisis houses, health-based places of safety and improvements to emergency departments and crisis lines. Over 160 schemes have been allocated funding by NHS England so far and 99 have been completed. The funding will also provide for specialised mental health ambulances which will be rolled out across the country – and be supported by practitioners trained to provide advice and treatments in cases of co-occurring physical and mental health issues.

More widely, through the NHS Long Term Plan, we have invested almost £1 billion extra in community mental health care for adults by March 2024, expanding community mental health services, so that patients are supported to stay well in their communities. This major expansion in funding for community mental health services commenced in all areas in 2021/22 and one of its aims is to reduce reliance on inpatient treatment.

Turning to the matter of a multi-agency protocol to deal with informal patients who abscond from emergency departments. The WMP have addressed this in their response as they are currently setting up a working group with key partner agencies, including mental health agencies and professionals, to discuss and design a joint missing person protocol. They anticipate that these discussions will take into account the circumstances of Mr Hamilton's case.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Report sections

Investigation and inquest

On 18 January 2022 I commenced an investigation into the death of Leroy Patrick HAMILTON. The investigation concluded at the end of the Inquest. The conclusion of the Inquest was: Drowned whilst suffering an acute psychotic relapse

Circumstances of the death

Mr Hamilton was known to suffer from reactive depression and psychosis and had been under the care of the mental health team since 2017 when he was detained under the Mental Health Act having deliberately self-harmed by stabbing. Since that time, he had been under the care of the community mental health team with a period of care under the home treatment team in July 2021 following a short admission for a relapse in his condition. At his last review in September 2021, he was noted to be well but concern was expressed about lack of compliance with medication due to some side effects. On 02/12/21 he was noted by a resident at his shared accommodation to be hallucinating, having smashed a window and threated to eat the glass. Police and paramedics attended and he was taken to Good Hope Hospital emergency department where he arrived at 01.45. He was assessed by the mental health liaison service and a psychiatric doctor as needing a full Mental Health Act assessment which was undertaken at 11.30 on 03/12/21. The assessment concluded that he did require further treatment due to a relapse in his condition caused by non-compliance with his medication. He agreed to a voluntary admission, further assessment and recommencement of his medication. He remained in the Emergency department whilst attempts were made to find a bed. At the time there was a national shortage of mental health beds. Staff from the hospital notified the police that he had left the department at 13.41 and that he was at risk of harming himself. There was a failure to treat Mr Hamilton as a missing person at this time, a failure by the mental health services to refer him to the home treatment team for a safe and well check and he was not assessed by the street triage team. At 18.58 police were notified by his landlord that he had left his property following a mental health episode and he was reported to have drunk bleach. No action was taken in relation to this log. At 19.51 police found Mr Hamilton walking on the footpath alongside the dual carriageway near The Fort shopping village after a member of the public reported seeing a man walking in the road. Mr Hamilton reported to officers that he suffered from depression and was out walking to clear his head. Police noted that he was cold and wet and had recently been assessed at Good Hope Hospital and he agreed to be taken to Birmingham Heartlands hospital for further assessment. At the hospital he was triaged by a nurse and noted to be suicidal. He was taken to the escalation room to wait to be assessed. He was not seen again and was noted to be missing from the department at 05.28 on 05/12/21. It is not known when he left the department. There was a failure to report him missing at this time. On 06/12/21 the deceased was found by a member of the public who was walking his dog, in the middle of the river Stechford lying on his back on a rock. He was confirmed deceased at the scene by at 12.20. His whereabouts since he left the emergency department on or around 4/5th December 2021 are unknown and whilst he had previously indicated suicidal ideation, his intentions at the time of his death are unknown. There were several failures in his care which amount to missed opportunities to help Mr Hamilton; however, it is not possible to say whether the outcome could have been different. Following a post mortem, the medical cause of death was determined to be: 1a Drowning 1b Psychosis 1c 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. –
1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU. Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
2. Safe space: The inquest heard how it is often the case that due to the lack of inpatient beds and PDU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed. This means that acutely ill mental health patients are often left for long periods without any specialist care, support or observation. Consideration should be given to setting up a safe space where patients can wait for a bed or PDU space which is able to cater for their special needs and keep them safe.
3. Multi agency protocol for informal missing patients: The inquest heard how there is no agreed protocol to deal with informal patients who abscond from emergency departments. Consideration should be given to setting up an agreed protocol so that all agencies involved understand their respective roles and responsibilities.
4. WMP Missing person investigations: The inquest heard how on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr Hamilton as a missing person when he was reported as missing. On both occasions he should have been treated as a high risk missing person. This raises a serious concern that staff do not understand when people should be classified as missing. Consideration should be given to ensuring staff properly understand how to assess if someone should be treated as a missing person and WMP should consider whether further training is required.
5. WMP risk assessments for missing persons: When Mr Hamilton was first reported as missing no risk assessment was undertaken about his level of risk to himself. The call had confirmed he was at risk of harming himself. The leads to a concern that staff do not understand when and how to risk assess incidents and when to identify high risk incidents.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2023-0013Deceased
Date of report: 11 January 2023
Coroner: Louise Hunt
Coroner area: Birmingham and Solihull

Responses identified

Responses identified 3 of 5

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Mar 2023.

Sent to

Birmingham and Solihull Integrated Care Board

Birmingham and Solihull Mental Health NHS Foundation Trust

Department of Health and Social Care

University Hospital Birmingham NHS Foundation Trust

West Midlands Police

Source links

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