Mental Health related deaths

Concerns summary A critical gap in mental health service provision in Norfolk and Waveney meant high-risk patients did not meet criteria for available support, leaving them without appropriate care.

Concerns summary Fragmented inter-agency communication and a lack of clear discharge protocols led to a vulnerable patient being sent to an unsuitable care home. There was also no escalation process for medication refusal, exacerbated by a national bed shortage.

Concerns summary There is an inadequate provision of mental health support for prison officers, which needs urgent review.

Concerns summary Patients living near county boundaries face difficulties accessing consistent secondary psychiatric care, as crisis and long-term treatment services are split across different jurisdictions.

Concerns summary A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, or adequate risk assessment, failing to follow Care Programme Approach guidelines.

Concerns summary The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral status and plan, failing to account for their specific needs.

Concerns summary Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a need for improved documentation processes and staff training.

Concerns summary Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.

Concerns summary Failures in mental health care include inappropriate decisions to decline treatment, a lack of dual diagnosis services, poor family liaison, and insufficient autism awareness leading to misinterpretation of needs.

Concerns summary Failures included not seeking family consent for contact, an unreviewed outdated medical alert, lack of formal mental health assessment, and absence of an overall care coordinator, hindering comprehensive mental health care.

Concerns summary The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.

Concerns summary There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a hospital setting.

Concerns summary There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and ensuring effective patient referral to community mental health teams.

Concerns summary The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.

Concerns summary DWP call handlers lacked training for mentally ill claimants, and brief, inaccurate call records hindered decision-making. The assessment process was inflexible, preventing correction of errors or flexible appointment management.

Concerns summary Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. This creates a potential for prisoners to self-harm.

Concerns summary Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant placements. Health professionals also misunderstood patient confidentiality, hindering crucial information gathering from families.

Concerns summary Police failed to record an assault as a crime, preventing the provision of appropriate victim support and signposting for a vulnerable individual with known vulnerabilities.

Concerns summary HMP Belmarsh's immediate needs form inadequately assesses self-harm risk for new prisoners without existing care plans. The nightly roll check system lacks robust auditing, risking missed checks and compromising prisoner safety.

Concerns summary Mental health care plans and risk assessments were not updated with critical information regarding the patient's multiple medication overdoses, including a doctor's warning about the severity.

Concerns summary A care home failed to prevent a vulnerable resident from accessing plastic bags, despite staff awareness of self-harm risk, indicating a systemic failure in removing means of harm.

Concerns summary Mental health professionals lack awareness of "Shamanic" hallucinogenic drugs, leading to inadequate assessment and treatment for psychosis caused or exacerbated by their use.

Concerns summary A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the hospital, leading to a missed opportunity for assessment.

Concerns 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.

Concerns summary The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.