‘Staff holidays’ delay death review by up to nine months

A coroner has expressed ‘serious concern’ after a trust-wide safety review – prompted by the death of a young mother – was delayed by up to nine months due to ‘staff holidays’.

An inquest heard that 25-year-old Natasha Adams, who died by suicide in August 2021, had had her level of care downgraded by Birmingham and Solihull Mental Health Foundation Trust a month earlier, in July, something her family suggested had a “dramatic impact”.

She was moved from a “care programme approach” (known as CPA, which involves enhanced care for people with complex needs and/or safety concerns) to “care support” (a non-clinical programme for people with lower-level concerns and complexities).

An earlier investigation into her death by the trust, finalised in December, said the trust should audit other cases to check whether the trust’s 2019 “care management and CPA/care support policy” was being complied with.

Now Birmingham and Solihull coroner James Bennett has criticised a delay in carrying out the trust-wide audit – writing in a prevention of future deaths report that, as of last month, four months after the report investigating Ms Adams’ care was completed, “no action has been taken”.

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Source: HSJ, 5 May 2022