“2”
Dated 19 Nov 2019, 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
Deadline passedReplies were due by 14 Jan 2020. A reply may have been sent and not yet published.
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.
- Report dated19 Nov 2019
- Deadline14 Jan 2020
- Published on judiciary.uk27 Dec 2019
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Midlands Partnership University NHS Foundation TrustNamed in the report as “Midlands Partnership NHS Trust” | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 14 Jan 2020. A reply may have been sent and not yet published. |
The coroner’s concerns
– 1. 2. The Trust’s Internal Root Cause Analysis investigation reviewed the decision making of the clinicians including the role of the treating consultant psychiatrist, the unit’s Responsible Clinician. However, on one on the investigation team was a psychiatrist, or of a similar status to the Responsible Clinician. The RCA report agreed with the Responsible Clinician that the decision making around Mr Wells’ informal status and observation levels was appropriate. The draft RCA report went through a governance exercise, and a member happened to be a consultant psychiatrist, but this did not involve scrutiny of the evidence. I agreed with the evidence from an independent expert consultant psychiatrist that the decision making of the clinicians, including the Responsible Clinician, was not appropriate. Therefore, my on-going concern is that the Trust’s RCA process is not robust or effective enough to learn lessons from serious incidents. The expert witness also stated the Mental Health Act was not applied appropriately. Namely, whilst Mr Wells was technically an informal patient, the clinicians recognised that he would be detained if he tried to leave i.e. he was ‘de-facto’ detained without the additional resources and safeguards applicable to a detained patient being put in place. The expert witness said ‘de-facto’ detention was contrary to the Code of Practice to the Mental Health Act and Mr Wells should have been detained. Therefore, my on-going concern is that the Trust’s clinicians are not applying the Mental Health Act appropriately.
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, 2019-0389
- Added to Minute Book
- 8 Oct 2026
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- 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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