Mental Health related deaths

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 There is widespread illegal dealing of prescription drugs to vulnerable individuals, indicating a critical failure in stemming the leakage of medication from lawful dispensing into criminal hands.

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Concerns summary Inadequate mental health care during COVID-19 involved no risk assessment for virtual appointments, outdated care plans, failure to share escalating risks with family, and poor documentation of suicidal disclosures.

Concerns summary A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health training, and poor information sharing protocols hindered effective risk assessment and search efforts.

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 The NHS lacks appropriate safe placements for patients with Asperger's or autism who also have co-occurring mental health conditions.

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 A GP failed to use the approved referral form for psychiatric patients, which risks incorrect prioritization of referrals in other cases, although it did not affect this specific patient's treatment.

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.

Concerns summary Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with potentially fatal consequences.

Concerns summary The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant patient changes, providing adequate pain management, and informing new wings of altered risk profiles.