Sussex Partnership NHS Trust

PFD Addressee
Reports: 34 Earliest: Aug 2013 Latest: 13 May 2025

100% 2-year response rate (above 83% average). 49% of classified responses show concrete action taken.

PFD Reports
20 results
Margaret Reeves
All Responded
2025-0227 13 May 2025 West Sussex, Brighton and Hove
Alcohol, drug and medication related deaths Suicide
Concerns summary (AI summary) Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant safety concern.
Action Planned (AI summary) The Trust will migrate to a new Electronic Patient Record system (SystmOne) in November 2025, which will integrate with GP surgery systems and facilitate two-way sharing of information. They are also working to establish electronic prescribing, prioritising community electronic prescribing to coincide with the SystmOne adoption. NHS Sussex is in the process of rolling out the shared care record to primary care in this financial year (2025/2026), and in the coming years the information NHS providers will be able to access about a patient will be replaced by the national Shared Care Record which NHS England is currently developing.
Harry Southern
All Responded
2025-0034 20 Jan 2025 West Sussex, Brighton & Hove
Mental Health related deaths Suicide
Concerns summary (AI summary) Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable for those with disabilities, exacerbated by potential funding cuts.
Action Taken (AI summary) Sussex Partnership Foundation Trust has taken local action to improve access to support. They cite the NHS national plan to deliver the '24/7 Neighbourhood Mental Health Centre model' and the NHS 111 mental health option.
Morgan Betchley
All Responded
2025-0004 2 Jan 2025 West Sussex, Brighton & Hove
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide
Concerns summary (AI summary) The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied to acute mental health patients.
Action Planned (AI summary) NHS England highlights national work on moving away from risk stratification and supporting personalised safety planning, and that NHS Sussex ICB is seeking updates from the Trust on actions including raising staff awareness of care plan and therapeutic observation importance, care plan audits, and developing a training package on the needs/risks associated with care experienced individuals. Sussex Partnership NHS Foundation Trust provided the coroner with a copy of the Ligature Anchor Point Risk Reduction Policy and a Patient Safety Briefing, launched refreshed ligature risk, assessment and awareness training in July 2024 (becoming mandatory in April 2025), completed installation of new anti-ligature alarmed bedroom doors on Rowan Ward, and commenced work on Maple Ward.
Ryan Ouslem
All Responded
2024-0511 24 Sep 2024 West Sussex, Brighton and Hove
Suicide
Concerns summary (AI summary) Police officers lacked crucial mental health training and understanding of their powers, failed to conduct thorough inquiries, and there was inadequate timely information sharing and joint working protocols between police and mental health services.
Action Planned (AI summary) From 7th October 2024, staff on DCU will become part of Neighbourhood Policing Teams and therefore mandatory training will become aligned. Sussex Police has offered 1:1 training to PC, and the planned roll out of "Mental Health and the Police" will ensure mandated mental health training is provided to all officers and staff that may be required to attend incidents where mental health could be a factor. Sussex Police is introducing Mental Health First Aider training to all new recruits from January 2025. SPFT partners are developing a Standard Operating Protocol for the RRS to provide guidance to officers who contact them for advice & assistance. A trust wide Standard Operational Procedure for the RRS is being developed which will provide guidance to staff working within the RRS. Immediately following the inquest, the Trust contacted Sussex Police to open the door to discussions about how we may approach cross training and these discussions are ongoing.
Jack Taylor
All Responded
2022-0029 28 Jan 2022 West Sussex
Alcohol, drug and medication related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.
Action Planned (AI summary) Sussex Police is co-developing a Missing Persons Template with SPFT to improve information sharing and is reviewing existing training for Sergeants on missing person investigations, with potential enhancements. The force also plans to review the structure of the Missing Persons Team to enhance support to colleagues. Sussex Partnership NHS Foundation Trust, working with Sussex Police, established a working group to improve the joint response to patients absent without leave, proposing solutions including a Missing Persons Template and updated risk assessment processes. An improved escalation process has been implemented and added to the AWOL Policy and the AWOL reduction project is being rolled out across the Trust.
Henry Holcombe
All Responded
2021-0257 15 Jul 2021 Brighton & Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.
Action Taken (AI summary) The Trust has strengthened internal monitoring, enhanced training (including for agency/bank staff), and now reviews policy compliance weekly by the Ward Manager and monthly by the Matron. They are also undertaking a Quality Improvement programme for therapeutic observations and considering technological aids for patient monitoring, expected to be completed by December 31st, 2021.
Rodney Dixon
All Responded
2021-0209 21 Jun 2021 East Sussex
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent clinicians, poses risks to patient risk management.
Action Planned (AI summary) Sussex Partnership NHS Foundation Trust will discuss changes made by East Sussex County Council with their Deputy Chief Nurse to ensure the Trust's doctors working as independent s.12 doctors are informed of ESCC's changes in practice and to identify any difficulties with information access processes. East Sussex County Council updated their Mental Health Act referral and Risk Assessment Forms to include a section on dynamic risk assessment, arranged yearly risk management training with Brighton University for AMHPs, and updated the AMHP warranting and re-warranting process.
Hannah Bampfylde
All Responded
2021-0136 5 May 2021 Surrey
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide
Concerns summary (AI summary) Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy lacked clarity on re-booking appointments and escalating non-attendance, allowing newly referred patients to slip through the system.
Action Taken (AI summary) Since September 2020, the Referral Co-ordinator is the person who books any further initial assessment appointments and not the Team Administrator. The requirement to notify the GP is stated in their Active Engagement Did Not Attend (DNA) Management Policy; weekly administration support is in place to ensure that all DNA cases have been identified and our Referral Co-ordinator oversees the rebooking of assessments and/or informs the GP of discharge from Horsham ATS.
Christopher Swain
All Responded
2020-0284 14 Dec 2020 West Sussex
Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths Suicide
Concerns summary (AI summary) Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a failure to provide staff escorts for sectioned patients being transferred.
Noted (AI summary) The Trust acknowledges failings in care and outlines previous actions taken following the death, including an internal investigation and sharing of learning. The Trust states that policies for Section 17 leave were in place, but not followed, and weekly audits are now conducted to ensure compliance.
Elena Wells
All Responded
2020-0248 23 Nov 2020 Brighton and Hove
Emergency services related deaths Mental Health related deaths
Concerns summary (AI summary) Mental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a lack of in-person checks when the patient's condition worsened.
Action Planned (AI summary) The Trust and BHCC are developing a joint policy and guidance to improve communication and define responsibility between the organisations to improve the safety of voluntary patients waiting for acute mental health beds. Actions include reviewing existing policies and protocols, implementing new documentation procedures, and providing staff training, to be completed by April 2021.
George Rogers
All Responded
2019-0484 27 Nov 2019 West Sussex
Suicide
Concerns summary (AI summary) The absence of a designated Lead Practitioner during patient transfers between mental health teams causes delays in treatment and leaves patients unmonitored during a critical transition period.
Action Taken (AI summary) A new process was introduced to allocate a Lead Practitioner which resulted in a 95% reduction in unallocated patients at the point of transfer between teams.
Bethany Tenquist
All Responded
2019-0178 21 Mar 2019 Brighton and Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights critical deficiencies in self-harm prevention protocols.
Action Planned (AI summary) Sussex NHS Trust will improve communication pathways with the Police and improve guidance to staff regarding contacting the Police following serious incidents.
Paul Hanton
All Responded
2018-0021 18 Jan 2018 West Sussex
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Concerns involve inadequate information sharing during 999 calls for AWOL patients, limited hospital CCTV access for police, and a discernible difference in police response to informal versus sectioned patients, despite similar risks.
Action Taken (AI summary) The police force updated its missing person policy in September 2017, including new call handling guidance with mandatory risk level recording, and delivered related training to staff between January and March 2017. They also have a joint policy with Sussex Partnership NHS Foundation Trust regarding absent patients, which is currently under review with planned consultation with Safeguarding Boards. The Trust created a checklist of information needed by police during 999 calls about AWOL patients, which is being incorporated into the Trust's AWOL policy. Instructions for accessing CCTV have been positioned next to the computer, and staff have been trained on using the system.
Sabrina Walsh
All Responded
2017-0449 14 Jul 2017 East Sussex
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The absence of CCTV in corridors and communal areas at the acute care facility delayed locating vulnerable patients, risking timely intervention.
Noted (AI summary) NHS England provides context regarding the use of CCTV in mental health units, referencing relevant guidance and the Sussex Partnership NHS Foundation Trust's consultation with patients and staff. They note the Trust's agreement to install CCTV in entrance areas. The Trust is implementing the installation of CCTV in the entrance areas of all 12 of its acute inpatient/PICU wards, including Woodlands.
Janet Muller
All Responded
2017-0441 4 Jul 2017 West Sussex
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.
Action Planned (AI summary) NHS England is implementing enhanced governance arrangements to monitor QVH's action plan, engaging with the Trust to promote networking with BSUH, and assessing the suitability of QVH for specialized services. The CQC will assess protocols, and a monthly CCG-regulated quality forum will oversee the action plan's implementation.
Matthew Roberts
All Responded
2017-0028 9 Feb 2017 West Sussex
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) There was no policy to log and scrutinize faxes, leading to potential loss of information, and staff often delayed reading referral details, hindering timely risk assessment. The organization also failed to conduct a formal review of the death.
Action Taken (AI summary) Sussex Partnership NHS Foundation Trust supplemented Information Governance training for EIP staff with posters on fax receipt. The EIP service developed a transition proforma, a best-practice tool for use by EIP practitioners at the point of transitions into and out of EIP service. The Trust has developed a new Serious Incident Policy.
Alice Mead
All Responded
2015-0239 24 Jun 2015 Brighton and Hove
Suicide
Concerns summary (AI summary) Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication review, and an unacceptably delayed, "hands off" response to urgent concerns for a vulnerable patient.
Action Taken (AI summary) Sussex Partnership NHS Trust implemented an improved system for reviewing care coordinator caseloads, especially when a care coordinator leaves. Staff in East ATS and MHRRS have undergone Applied Suicide Intervention Skills Training (ASIST), and a new approach to calls is underway in East ATS.
Bruce Longden
All Responded
2015-0149 21 Apr 2015 Brighton & Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The Sussex Partnership Trust demonstrated a critical lack of awareness regarding its own internal protocols.
1 response from Response Brighton and Sussex University Hospitals NHS Trust
Danuta Corbett
All Responded
2014-0150 3 Apr 2014 Brighton & Hove
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.
Action Taken (AI summary) The consultant psychiatrist now carefully reviews notes taken during ward review. The Trust has reinforced with staff that should extraordinary circumstances arise again, a retrospective note must be completed, and the nurse responsible will ensure proper handovers take place in the future.
John Walker
All Responded
2013-0213 21 Aug 2013 West Sussex
Mental Health related deaths
Concerns summary (AI summary) Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.
Action Taken (AI summary) The Trust has revised the documents clinicians are asked to complete to ensure they are less repetitive and better support succinct recording of relevant issues and the fences throughout Langley Green Hospital have been altered to make it much more difficult to get over.