Khalif Mohammed: Prevention of future deaths report
Alcohol, drug and medication related deathsSuicide (from 2015)
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Date of report: 04/09/2025
Ref: 2025-0452
Deceased name: Khalif Mohammed
Coroner name: Louise Hunt
Coroner Area: Birmingham and Solihull
Category: Suicide (from 2015) | Alcohol, drug and medication related death
This report is being sent to: Home Secretary
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: The Home Secretary | |
| 1 | CORONER I am Louise Hunt, Senior Coroner for Birmingham and Solihull |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 16 January 2025 I commenced an investigation into the death of Khalif MOHAMMED. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Suicide |
| 4 | CIRCUMSTANCES OF THE DEATH Khalif Mohammed was suffering from severe paranoid schizophrenia which first had been diagnosed in 2017. Khalif’s symptoms included hallucinations, delusional beliefs and negative symptoms of lack of motivation and isolation. Which he was being treated with medication to reduce his symptoms. His mental health relapsed in August 2024 in which he was readmitted to the hospital and detained under section 3 of the mental health act. On the 5th December 2024 he was transferred to Eden ward at Highcroft hospital. Where he gradually started to improve. As he improved, Khalif was granted escorted leave then to unescorted leave only to the local area. Khalif did not express or say he had suicidal thoughts. On the 6th January 2025 Khalif had unescorted leave at 10 am for 30 minutes to the local area from the Eden ward. He returned at 10:30 am to the Eden ward with no issues. In the afternoon on the 6th January 2025 Khalif had unescorted leave to the local area but failed to return back. Staff done various checks around the hospital and surrounding areas. Police were then notified at 15:03 who confirmed further checks needed to be done. However Khalif was still missing. Another call was made to police at 17:32 who then created a missing person’s case which was categorised as a priority case. Police officers made background checks including speaking to his family who said he would likely be at his flat and attended the ward to obtain further information. On the 7th January 2025 when resources became available police officers went to Khalif’s flat at 10:10 who were let into the flat by accommodation staff. Khalif was found lying on the floor [REDACTED] and was confirmed by paramedic as deceased at 10:26. Following a post mortem, the medical cause of death was determined to be: 1a Haemopericardium and Haemothorax 1b Stab wound [REDACTED] |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. The inquest heard that West Midlands Police had insufficient resources to allocate police officers to deal with Khalif’s case on 06/01/25 which was classed as a priority case with expected allocation of resources within an hour. As a result, there was a significant delay in officers being allocated to the case. Whilst it could not be shown that this affected the outcome for Khalif, there is a risk of future deaths if the available resources are not sufficient to deal with the large numbers of cases received each day and in my view, action should be taken. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 October 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Khalif’s family Birmingham and Solihull Mental health Foundation Trust West Midlands Police I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | 4 September 2025 Signature: [REDACTED] Louise Hunt Senior Coroner for Birmingham and Solihull |