• Coroner criticised gaps in 0 to 25 mental health service in Birmingham
  • Comes in response to death of a young man lost between services
  • Provider says referral system has been changed in response to the death

A “unique” mental health model for children and young adults has again been criticised for gaps in its service following the death of a patient.

Assistant coroner James Bennet issued a prevention of future deaths report this week regarding Daniel Hubert Collins, who took his own life in April last year.

Mr Collins, 22, had mental health issues and had recently been treated by Forward Thinking Birmingham, a consortium led by Birmingham Women’s and Children’s Hospital Foundation Trust responsible for 0 to 25 mental health services in the city.

The coroner said FTB crisis nurses visited Mr Collins in his home in April, weeks before his death. They discharged him to a counselling service, Living Well Consortium, leaving Mr Collins to contact the service himself.

However, Mr Collins never contacted the service and FTB failed to follow up with Living Well Consortium, or Mr Collins, to ensure he had.

The coroner said: “There was/is no system in place [requiring] the FTB crisis team to notify LWC about the transfer or trigger a follow up with either LWC/the patient. Therefore, patients are at risk of being lost to the mental health service while in crisis/only recently out of crisis.”

The FTB service was set up in 2016 in controversial circumstances, by moving 18 to 25 year old services from the local mental health provider, Birmingham and Solihull Mental Health FT, to a newly established consortium of private and public providers led by the children’s trust.

At the time, trust chief executive Sarah-Jane Marsh said the “unique” model would improve patient access but an independent assessment also warned it could have “catastrophic” consequences for mental health services in the city.

FTB has struggled since, with parts of the service rated “inadequate” by the Care Quality Commission, a shortfall on inpatient beds and staffing shortages.

In April 2017, a coroner found that “no co-ordination of care at a time of crisis” between FTB and other mental health services was a factor in another young person, Leah Abby Ratheram, taking her own life.

Mental health services in Birmingham more broadly have come under recent coronial scrutiny after a coroner last year linked underfunding to the death of seven mental health patients in the city (although most of these deaths were in adult services).

In a response to HSJ, FTB’s mental health services director, Marie Crofts, said referral pathways had been changed in response to Mr Collins’ death, following the inquest and internal investigation.

“Young people who receive support from both our urgent care team, and our voluntary sectors partners the Living Well Consortium, now have their appointments at Living Well made for them by our urgent care staff rather than the young person themselves and a system is in place to pick up non-attendance, automatically triggering a referral back to our urgent care team,” she said.

The report into Mr Collins’ death was also sent to Birmingham and Solihull clinical commissioning group, which commissions FTB, and NHS England.

CCG interim chief nurse Martin Fahy said the commissioner would be monitoring changes made in the service following Mr Collins’ death.

Both Mr Fay and Ms Crofts offered their condolences to Mr Collins’ family and friends.