“One mental health service, FTB crisis team, transferred necessary mental health care to a…”
Dated 14 Sep 2018, from the coroner for Birmingham and Solihull. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Report put online after its 56 daysOrganisations 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.
judiciary.uk put this report online on 7 Jan 2019, after the 56 days for replies had ended (9 Nov 2018). These dates can’t tell us whether a reply was due before it went online. A reply may have been sent and not yet published.
- Report dated14 Sep 2018
- Deadline9 Nov 2018
- Published on judiciary.uk7 Jan 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Birmingham Women's and Children's NHS Foundation TrustNamed in the report as “Birmingham Women’s and Children’s NHS Trust” | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 7 Jan 2019, after the 56 days for replies had ended (9 Nov 2018). These dates can’t tell us whether a reply was due before it went online. |
| Birmingham and Solihull Clinical Commissioning Group | Report put online after its 56 daysNo response published on judiciary.uk. judiciary.uk put this report online on 7 Jan 2019, after the 56 days for replies had ended (9 Nov 2018). These dates can’t tell us whether a reply was due before it went online. |
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well Consortium (LWC)}, putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “4t is part of their recovery, empowers them and gives them choices”. FTB crisis team did nat alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action.
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, 2018-0283
- 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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