“To Birmingham and Solihull Mental health Trust 1”

The coroner’s concerns

To Birmingham and Solihull Mental health Trust 1. Internal investigation: The internal investigation did not address how and whether the offender’s use of medication should have been monitored after the clinic visit on 12/05/23. This was important as non compliance with medication was a risk factor for relapse. In addition, during the inquest the trust confirmed they had not spoken to the CPN who attempted to visit the offender on 24/05/23 to verify whether they had attended the old or new address. This was a critical issue as the new address had not been updated on the clinical notes. This raises a concern about the quality of the investigation and whether the Trust is adequately learning from incidents. 5 To Birmingham and Solihull Mental Health Trust and Birmingham City Council 2. Mental Health assessments: The inquest heard evidence that there were barriers to the use of S2 and S3 of the Mental health Act due to AMPH resistance, administrative challenges and resourcing. This raises a concern that incorrect MHA assessments are taking place and patients may be detained on an inappropriate section impacting patient care. A copy of a report prepared by is attached. To Birmingham and Solihull Mental Health trust, Birmingham City Council and Provident housing 3. Information sharing between agencies and support worker training: The inquest heard evidence that Landlords have to rely on the information given to them by the residents and do not have access to other key information held by other agencies. This means the landlord is often not aware of key information about an individual. Given the potential for harm for residents and support workers consideration needs to be given to how best to share information to ensure residents are receiving the right care and landlords have sufficient information to be able to monitor residents and undertake risk assessments. The inquest heard evidence that support workers need more focussed training on mental health conditions and how to manage and help residents with enduring mental health conditions.

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, 2025-0119

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0