Benjamin Pesian: Prevention of future deaths report 

You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 September 2026. I, the coroner, may extend the period if  an appropriate application is made. 

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The medical cause of death was 1a) Multiple Injuries
 
Conclusion: Narrative Conclusion
 
The deceased, Benjamin Pesian died after jumping from the terrace  balustrade on the [REDACTED] in Birmingham on the 7 June 
2025. He sadly died from the fatal multiple injuries sustained. On the evidence available it is not clear if he intended to take his own life and it is likely at the  material time he was displaying behaviours associated with a psychotic  episode. 

Benjamin Pesian had been diagnosed with schizoaffective disorder and bipolar affective disorder. His initial onset of his illness occurred in 2020 while he was  living in France. He had hospital admissions in France and also in Hamburg in  Germany.  

In April 2025 he stopped taking his medication, Aripiprazole and had a relapse. He travelled to Sussex area where he was detained by Police and then  transferred to Dorothy Pattison Hospital. He presented with episodes of mania  and psychosis. 

He was initially detained under Section 2 of the Mental Health Act on 11 May  2025 following a psychiatric assessment. The multidisciplinary team (MDT)  discussed options of various antipsychotic medication and ultimately decided  that Cariprazine medication should be used in conjunction with Promethazine  as required. Although he tolerated and reacted well to Risperidone medication, this wasn’t given on this occasion.  
 
On the 5 June 2025, MDT discussions led to the removal of his detention and converting him to an informal patient status. He was subsequently granted  accompanied leave with his family.  
 
On the 7 June 2025 whilst on leave with his family, they attended level 25 of the Cube Hotel, Marquet Pierre White Steakhouse and Bar and Grill in  Birmingham. Mr Pesian then climbed onto the balustrade on the terrace  [REDACTED] and jumped. He sustained multiple traumatic injuries and  sadly died at the scene. 

The MATTERS OF CONCERN are as follows:
 
I have concerns about the Trusts organisational learning from these incidents  and timely implementation of the recommendations made by the external  investigation report author. In addition, I have concerns about the quality and  timely preparation of risk assessments.  I heard evidence during the inquest that risk assessments weren’t always updated and instead reliance was played on handover discussions between staff. 
 
Whilst I recognise there have been action plans put in place by the Trust there is still some lack of clarity around timescales and implementation. As stated  earlier, an additional factor is the CQC involvement and their findings which  also mirror some of the findings from the external investigation. 

I also may send a copy of the report to any other person who I believe may find it useful or of interest. 
 
I can confirm I have sent the report to:
 
1.Family of Mr Pesian c/o Harding Evans Solicitors 
2.Mills and Reeve Solicitors representing Black Country Healthcare NHS  Foundation Trust. 
3.Clyde and CO Solicitors representing MSHA Global Investments Limited.
 
I also have a duty to send a copy of the report to the Chief Coroner.
 
You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy  (2026). Any representations will be sent to the Chief Coroner alongside the  report. Please refer to box 4 above for additional information relating to the  publication of reports and responses.