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

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”.

In his report, addressed to the trust’s CEO, he put the delay down to the organisation’s clinical governance committee needing to approve the audit process.

“[Approval] is unlikely to happen until the summer of 2022, and possibly not until as late as September 2022, because of staff holidays,” he wrote.

“In my view, such a delay is of serious concern, and action should be taken to bring forward the audit.”

The trust said it was committed to completing the audit by the end of June and delays in completing it were due to capacity constraints caused by omicron and its impact on staff sickness.

Evidence from Ms Adams’ family during the inquest suggested the decision to downgrade the 25-year-old’s community mental healthcare had a “dramatic impact on Natasha’s mental health”, the coroner added.

He said the delay in approving the audit process had meant other patients had not yet had their cases reviewed, which he considered could pose a risk of future deaths.

A trust spokeswoman expressed condolences to Ms Adams’ family and added: “We are working to ensure we implement all of the recommendations and actions highlighted by the coroner and are committed to completing this audit by the end of June.”

Last year, NHS England and Improvement released a position statement on the use of Care Programme Approach  in mental health services, stating in July that “with the publication of the Community Mental Health Framework, the Care Programme Approach has now been superseded”.

It meant that specific references to the CPA in the 2021-22 NHS standard contract  were removed.

The July 2021 document was clear that “those currently on CPA should be gaining access to high-quality care through the transformation of services and additional investment”.

But it added that the “new system of care envisaged in the framework should be pulling up the standard for all”.

BSMHFT has until 22 June to formally respond to the report.