Mental Health related deaths

Noted (AI summary) Farnham Park GP Practice conducted a Serious Event Audit on 31 May 2022 and identified a clinical psychologist to provide mental health training. Unexpected deaths will be discussed at weekly clinical meetings. NHS England highlights existing educational resources and guidance for GPs and outlines planned future actions including the rollout of the Learn from Patient Safety Events (LFPSE) service and implementation of the Patient Safety Incident Response Framework (PSIRF), and sharing the report with Regional Mortality Boards. NHS Frimley ICB will share the coroner's concerns with GP practices, focusing on documentation of suicide/self-harm risk and mental health assessments. They will also update the local formulary to highlight national guidance on the increased risk of suicidal behavior when starting antidepressants, with a point-of-prescribing alert, to be completed by August 2022. CQC contacted Farnham Park Health Group and received evidence of a significant event analysis and action plan implemented in response to the death, with 7 of 10 actions already completed. They also raised the failure to notify CQC of the death with the provider and will consider further action. The GMC has reviewed the concerns and decided not to investigate further, but will share them with the doctor's responsible officer for discussion during their revalidation. The Department acknowledges the concerns and notes actions taken by other bodies, emphasizing the clinical responsibility of GPs in prescribing decisions and referencing NICE guidelines. It provides general context and reiterates existing guidelines without committing to specific new actions.

Noted (AI summary) Cumbria, Northumberland, Tyne and Wear Foundation Trust has implemented several measures to proactively engage families, including integrating family support as a core offer, providing family therapist assessments, and reviewing and implementing systems to ensure carers are offered intervention. The Trust also plans further improvement work in 2022/23 to increase staff time with service users and carers. The Department of Health and Social Care acknowledged concerns about mental health workforce capacity. It noted an increase in the mental health workforce and highlighted ongoing national plans to expand the workforce by an additional 27,000 professionals by 2023/24 through significant investment.

Noted (AI summary) Sheffield Health & Social Care NHS Foundation Trust outlines a plan to develop a protocol for working with older adults with a forensic history, ensure thorough risk assessments when removing a service user from detention, improve communication with service users and families, ensure complex clinical decisions are multidisciplinary, and deliver online training on the Mental Health Act. The Government Legal Department, on behalf of the Probation Service, acknowledges the concerns but states it's a matter for the sentencing Judge to determine Restriction Orders. They will obtain the Court transcript of Mrs Grayson's sentencing hearing and share concerns with the Ministry of Justice colleagues in the Mental Health Caseworker team.

Noted (AI summary) The Department highlights resources such as Practitioner Health for healthcare workers and mentions national efforts to prevent suicide, including the cross-government strategy and investments in local prevention plans and bereavement services. They also reference the wellbeing support offer for healthcare staff and mental health hubs. The RCGP acknowledges the issue of suicide among health professionals and details the support and resources available, including Practitioner Health, The Doctors' Support Network, HHP Wales and the Sick Doctors Trust. They also collaborate with other stakeholders and are piloting a project supporting teams affected by sudden bereavement.

Noted (AI summary) GMP has revisited its Graded Response Policy (GRP), implementing a new GRP on 1 February 2022 using the THRIVE framework for risk assessment. They are also implementing a new IT system called 'Sherlock' by August 2022 to improve information storage and access in the FCC. The IOPC acknowledges the report and highlights its power to make organisational learning recommendations to relevant bodies. They state that GMP has a legal obligation to respond to the recommendations in writing by 20 July 2022.

Noted (AI summary) The consultant psychiatrist will now email his secretary of planned follow-ups for patients and advise her to remind the patient two weeks before the scheduled time to make an appointment. If they do not respond, the GP will be informed that they are no longer attending the clinic. No actions or stance were discernible from the provided text.