Mental Health related deaths

Noted (AI summary) Maidstone Hospital has implemented an action plan, recorded in their incident reporting system (DATIX), and taken steps to strengthen multi-professional working with Kent and Medway Social Care Partnership Trust. They have also commissioned an audit into consent and capacity practices and appointed a new clinical advisor and practitioner for capacity. Kent and Medway NHS and Social Care Partnership Trust have improved joint working with Maidstone and Tunbridge Well NHS trust, strengthened Mental Capacity Assessment monitoring, closely monitored Mental Capacity Act training and signed a Service level agreement with MTW to support patients detained under the Mental Health Act. The DWP outlines its procedures for vulnerable claimants, including reasonable adjustments for those unable to attend in person. They state that they are satisfied that appropriate support is available and do not propose to take any specific actions or make any changes at this time.

Noted (AI summary) The DHSC acknowledges concerns raised and outlines the roles of the CQC, NHS England, and NHS Digital in ensuring patient safety and appropriate training and supervision of healthcare staff, particularly Health Care Assistants, and refers to guidance on clinical risk management for health IT systems.

Noted (AI summary) Humankinds, the incoming provider of Addictions Services within Cumbria, describes actions already taken since taking over the service, including weekly provider meetings, clinical handover for high-risk cases, data transfer of all active service user’s relevant information, and review of all service users at a face-to-face appointment. Greater Manchester Mental Health (GMMH) acknowledges the concerns and apologizes, highlighting that the death occurred during the COVID-19 pandemic, and refers to a meeting with the new service provider, Humankind, regarding the transfer process. GMMH offers to meet with the coroner to discuss the transfer of services.

Noted (AI summary) NHS England highlights that the Digital Person Escort Record (DPER) has been live across the prison estate since November 2020, and all reception healthcare staff should have access to the DPER prior to arrival of persons at the site; further a review and update of the reception and secondary screening templates for healthcare is ongoing. NHS Digital is considering the coroner's concerns about SystmOne in prisons when developing the capabilities for the HJIS re-procurement in 2022/23 and will consider adopting GP IT related products such as GP2GP and the Primary Care Registration Management system in FY22/23. The Department of Health and Social Care acknowledges the concerns raised, highlights the National Partnership Agreement for Prison Healthcare, and notes actions NHS England is taking regarding substance misuse in prisons. HMPPS is considering a national rollout of local initiatives (including those from HMP Guys Marsh) to improve welfare checks on prisoners under the influence of psychoactive substances, and is developing a new version of the ACCT (Assessment, Care in Custody and Teamwork) processes with revised training modules being rolled out nationally for all staff involved in the delivery of ACCT.

Noted (AI summary) The GMC updated its prescribing guidance in February 2021 to place greater emphasis on good practice principles regardless of consultation method and highlights the need for dialogue with patients and obtaining adequate history, including current medication use. The GPhC outlines its role in setting standards for registered pharmacies and pharmacy professionals and taking enforcement action when standards are not met, including actions against online pharmacies supplying high-risk medicines and referrals to Fitness to Practise process. CQC has been in formal discussion with DHSC and submitted proposals for legislative changes to improve risk management of online primary care providers, and is working with regulatory partners to ensure that gaps in regulation are mitigated. DHSC acknowledges the concerns and describes the regulatory framework for medicines, including the roles of MHRA and GPhC, without outlining specific actions beyond existing oversight.

Noted (AI summary) The Home Office acknowledges the concerns and states that police forces are operationally independent and it is for Greater Manchester Police, the NPCC and the College of Policing to address the issues raised. The NPCC and College of Policing note the concerns and explain that the Victims Code was updated in April 2021. They state that forces are not encouraged to give out mobile phone numbers and provide guidance for officers receiving emergency calls.