Mental Health related deaths

Concerns summary Poor communication and coordination between private ADHD clinics and NHS GPs led to duplicate prescriptions for different medications, risking patient confusion and potential harm.

Concerns summary Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.

Concerns summary A high-risk falls patient was discharged home before a careline/lifeline pendant was provided, delaying assistance when the patient subsequently fell.

Concerns summary Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the police via emergency channels.

Concerns summary A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.

Concerns summary Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on acute paediatric wards unsuitable for their care.

Concerns summary Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also lacked dedicated resources and IT integration.

Concerns summary Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, where their needs cannot be fully met, posing a risk of death.

Concerns summary Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing mental health service contact.

Concerns summary CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially dangerous delay in support.

Concerns summary An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There are no guidelines for fire escape protections in such settings.

Concerns summary A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate discharge without medication review or escalation.

Concerns summary Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking inappropriate care for vulnerable mothers.

Concerns summary A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to an avoidable suicide.

Concerns summary Failures in information sharing, incomplete care plans, and inadequate risk assessments led to an inappropriate discharge placement that was not adequately monitored, despite repeated crises and professional warnings.

Concerns summary A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient clinicians, create significant risks for deaf mental health patients.

Concerns summary The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating a gap between practice and documented policy, with no review expected until 2026.

Concerns summary There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to support patients at home.

Concerns summary Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex needs.

Concerns summary There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist regarding the door-locking system's reliability and staff guidance for its failure.

Concerns summary Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a poor understanding of Mental Health Act aftercare provisions.

Concerns summary Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management of critical side effects, increasing psychosis relapse risk. Additionally, a car park's penultimate floor lacked adequate safety barriers.

Concerns summary A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both psychiatric and physical healthcare.

Concerns summary A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise patient safety.

Concerns summary Concerns exist about emergency services' reliance on problematic terms like 'ABD', criticized for their potential to perpetuate racial bias and discrimination, despite rejection by psychiatric bodies.