Mental Health related deaths

Noted (AI summary) NHS England and Improvement acknowledges the concerns about waiting times for specialist eating disorder inpatient beds. They describe the optimal service model and ongoing transformation work, including investment in community services and early intervention models.

Noted (AI summary) NHS England and NHS Improvement acknowledge concerns about individuals obtaining excess medications and checking prescriptions across providers. They cite GMC guidance on prescribing practices and describe ongoing programs to improve information sharing and mental health services.

Noted (AI summary) The Trust has strengthened links between community and forensic social work teams, secured funding for a Local Authority assigned social worker to join the community forensic team, and developed a protocol to address placing people outside of the Trust’s geographical area. CQC describes enforcement action taken culminating in the closure of Annette's Care. It states that an internal review found no gaps or areas for improvement in CQC's processes and that the CQC will participate in a 'learning event' with the local authority and Devon Partnership Trust. The PSAP will commission a multi-agency learning review, independently facilitated, to identify multi-agency learning in terms of strengths and weaknesses related to the case. This review will involve the engagement and participation of the family.

Noted (AI summary) The Metropolitan Police Service will develop additional training on recording property, especially regarding risk, and implement it in the "Street Duties" course for probationer constables. The officer involved in the incident has been spoken to and advised on recording property and circumstances for seizure. The Trust has discussed the concerns with Borough Lead Nurses and sent letters to nursing staff, highlighting expectations for patient searches, observations, and rapid tranquilisation monitoring. The Trust now requires formal training and competency assessment for staff conducting searches and observations, with Registered Nurses exclusively performing RT monitoring within eyesight for the first hour post-administration. The Department acknowledges the concerns and outlines actions taken by the East London NHS Foundation Trust (ELFT), NHS England and NHS Improvement (NHSE & NHSI), and the Care Quality Commission (CQC). It highlights ongoing monitoring and planned inspections of ELFT.

Noted (AI summary) The Department acknowledges the concerns and outlines national initiatives to improve mental health services and suicide prevention, including investments in community mental health care and digital information sharing. It notes local action by the Stockport CCG and offers condolences to the family.

Noted (AI summary) Practice Plus Group has mandated training on the identification of hypostasis and rigor mortis, using scenario-based simulations, and will raise concerns about confusing terminology in existing guidance with NHS England. Resuscitation Council UK acknowledges the concerns but states that detailed training in the recognition of rigor mortis and hypostasis is outside the scope of RCUK training courses, though they encourage starting CPR unless irreversible death is certain. They have shared the response with relevant bodies.

Noted (AI summary) MPFT acknowledges the concerns about commissioning difficulties for patients living near county boundaries, explains how they have worked with other trusts to provide care, and states that the matter has been forwarded to commissioners for consideration.

Noted (AI summary) The Trust has taken steps to reduce risk from ligatures, including installing pressure sensor alarms on en-suite bathroom doors, removing door furniture, and establishing a rolling capital programme for ligature works. They are also reviewing therapeutic observational practice, staffing levels, and care plans. HSE states that the safety of the environment for patients, including management of ligature points, falls within the remit of CQC, not HSE, according to a Memorandum of Understanding. NHS Birmingham and Solihull ICB provides supplementary information to the Coroner, in support of the information provided by Birmingham and Solihull Mental Health Foundation Trust, in response to the Regulation 28 Report. The CQC has asked for weekly reports on ward improvements, sought an independent review from NHS England, and will share learning from the inquest with inspectors and registered persons. They are monitoring the trust and will use enforcement powers if regulations are not met.