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Publication of independent external quality assurance review in respect of mental health service users Mr A and Mr B in Birmingham

NHS England has today published the independent external quality assurance review in respect of mental health service users Mr A and Mr B in Birmingham.

Mr A was charged and convicted of murdering his mother on 3 July 2012. Mr B was charged and convicted of murdering his mother on 20 July 2011. Sincerest sympathies are offered to all the people who have been affected by these tragic events.

Dr David Levy, Medical Director at NHS England – Midlands and East said: “We would like to offer our sincere sympathies to the people who have been affected by this tragic incident.

“Thankfully, events such as this are rare. However, when they do occur, we work closely with the relevant organisations to ensure that lessons are learned and any necessary improvements are put in place to ensure patient and public safety.”

The independent review was  commissioned by NHS England, specifically to review the outcomes of the Birmingham and Solihull Mental Health NHS Foundation Trust’s (BSMHFT) internal review and the Birmingham Community Safety Partnership’s Domestic Homicide Review following the two homicides, to ensure the  recommendations and actions identified have been implemented and are being sustained.

The aim of this review is not to investigate the circumstances of the offence, but to enable the providers of care, and the whole of the NHS, to learn lessons and make improvements for the benefit of future patients, their carers and the public. We commission these reports so that the NHS is open and transparent with the families involved and the wider public about what took place and what the NHS is doing to fix it.

The review acknowledges changes made by the mental health services since these tragedies happened in 2011 and 2012 and will help the whole of the NHS to learn the lessons and ensure services for patients continue to improve. However, this recent review identifies two areas in which if a similar incident or circumstances, such as outlined in the Domestic Homicide Review of Mr A, occurred today that the current systems would potentially not prevent a reoccurrence. The availability of inpatient mental health beds, though increased in number, remains a concern. Despite notable progress being made by the Birmingham system to address this national problem, further local work is necessary and underway including a deep-dive meeting of Birmingham Mental Health commissioners and providers in early November to further understand the needs of the population. The review also notes that although a new Approved Mental Health Professional (AMHP) service has been implemented in Birmingham, mental health staff remain confused about the service and are still to feel the benefits.

The independent review team did not make additional recommendations in respect of their findings because a further review is planned to assess progress against the key lines of enquiry and the recommendations cited in the previous reviews.

NHS England continues to work with both Birmingham and Solihull Mental Health Foundation Trust, Forward Thinking Birmingham, Birmingham City Council and commissioners to ensure appropriate and sustainable actions continue to be implemented.

A copy of the full independent investigation report is available on our website.