“Staff had not been completing the comments section during therapeutic observations as the…”
Dated 14 Apr 2026, from the coroner for Birmingham and Solihull. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 9 Jun 2026.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated14 Apr 2026
- Deadline9 Jun 2026
- Published on judiciary.uk17 Apr 2026
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Birmingham and Solihull Mental Health NHS Foundation Trust | Response publishedPublished on judiciary.uk in April 2026. |
The coroner’s concerns
– 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.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2026-0216
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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