Mental Health related deaths

Concerns summary Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.

Concerns summary The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.

Concerns summary The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.

Concerns summary Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.

Concerns summary Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without support in a foreign country.

Concerns summary Toxic substances are easily and cheaply obtainable online without safeguards, and are advocated on websites as a method for suicide, leading to multiple deaths.

Concerns summary A psychiatric liaison nurse downgraded a patient's high suicide risk without consulting the referring GP or obtaining a second opinion, highlighting a critical lack of safeguards in risk assessment.

Concerns summary Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" for crucial patient information.

Concerns summary Mental health crisis management failures included delayed bed availability, insufficient overnight support, confusion over professional responsibility, and a lack of in-person checks when the patient's condition worsened.

Concerns summary A website may be illegally promoting suicide methods, and a lethal substance is too easily available online under a misleading description, posing significant public safety risks.

Concerns summary A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.

Concerns summary When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance funding, leaving high-risk individuals without immediate alternative treatment or support.

Concerns summary Risk assessments for patients going on leave were not consistently completed, failing to identify community risks and define staff actions for potential plan breakdowns.

Concerns summary Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's deteriorating mental state.

Concerns summary Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.

Concerns summary A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from patient and staff, leading to his tragic death.

Concerns summary The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, compounded by a lack of observation and CCTV in the garden.

Concerns summary Data sharing and confidentiality rules prevented GPs from disclosing crucial risk factor information to care homes without consent, hindering safeguarding due to a lack of inter-agency sharing.

Concerns summary Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans for a released prisoner.

Concerns summary Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care coordination, poor evaluation of relapse signs, and a lack of assertive community outreach for his advanced addiction and mental health needs.

Concerns summary Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other identified issues having been remedied.

Concerns summary Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal ideation or providing a proper safety plan. The Root Cause Analysis was unreliable, failing to identify these critical care problems.

Concerns summary Open waste paper baskets in communal areas posed a choking hazard, exacerbated by improper disposal of clinical waste. Staff also failed to document or risk-assess a resident's habit of ingesting non-food items, leading to an incomplete understanding of risk.

Concerns summary There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts for psychiatric patients with acute medical problems, hindering optimal integrated care.

Concerns summary Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential psychological services, which poses a risk of preventable deaths.