“Enhanced Supervision Levels training is not included on mandatory training programmes”
Dated 30 May 2023, 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 25 Jul 2023.
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 dated30 May 2023
- Deadline25 Jul 2023
- Published on judiciary.uk2 Jun 2023
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Birmingham Community Healthcare NHS Foundation Trust | Response publishedPublished on judiciary.uk in June 2023. |
The coroner’s concerns
- 1. Enhanced Supervision Levels training is not included on mandatory training programmes. Whilst some training sessions have been delivered by the trust to current staff members following this incident, I am concerned that new staff members joining will not be suitably trained in this area. 2. Falls risk assessment training is on the essential role training programme, however, I am concerned that this area is not covered suitably on induction of staff to the centre. This leaves a gap, particularly with agency staff, and I am not satisfied that with the current processes, agency staff will be fully versed on the completion of these risk assessments. 3. I was told that since this incident, falls risk assessments are being audited for compliance. I was also told that they are not being audited for correctness. I am therefore concerned that errors, and consequently, staff training needs, would not be picked up in these audits.
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, 2023-0175
- 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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