Mental Health related deaths

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 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 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 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 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.

Concerns summary Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information and incorrect prioritisation for referrals.

Concerns summary Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition and risk mitigation.

Concerns summary A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within mental health facilities.

Concerns summary Police failed to leave voicemail messages when attempting to contact family members during a critical emergency, potentially delaying location and aid for a critically ill individual.

Concerns summary The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge his refusal to inform his mother about discharge, contrary to GMC guidance.

Concerns summary The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision to withhold discharge information from his mother, and record-keeping was deficient.

Concerns summary Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities to gather critical information. A lack of professional curiosity and poor record-keeping also contributed.

Concerns summary A severe shortage of available housing in Cornwall, with high demand and low supply, contributed to the deceased's homelessness and exacerbated his mental health issues.