Mental Health related deaths

Concerns summary A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing a significant risk.

Concerns summary Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing assessment, observation setting, and safeguarding measures.

Concerns summary Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's death.

Concerns summary Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged without assessment by an Approved Mental Health Professional, increasing risk of self-harm or suicide.

Concerns summary An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. Lack of guidance for publishing reports in "exceptional circumstances" led to arbitrary decisions.

Concerns summary A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an urgent need to review S.136 procedures.

Concerns summary Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate risk grading and no plan to rectify this critical issue.

Concerns summary Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases patient risk upon leaving the facility.

Concerns summary Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing person's psychotic relapse were not recorded or relayed to other officers or agencies.

Concerns summary A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure vehicle without restraints, a practice accepted by the transport company, likely contributing to respiratory arrest.

Concerns summary The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.

Concerns summary Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.

Concerns summary Mental health professionals operated in silos without information sharing protocols. Pandemic-related telephone assessments and unsupported solo A&E visits hindered comprehensive risk assessment and family involvement.

Concerns summary National guidance is needed for VTE risk assessment when bilateral leg swelling obscures DVT, and inconsistencies exist in VTE assessment forms and discharge letters across trusts.

Concerns summary Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families as the sole caregivers and preventing necessary intervention.

Concerns summary Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.

Concerns summary A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting risk assessments. Incompatible electronic systems prevent routine access to full medication records between primary and secondary care.

Concerns summary There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding child protection investigations and providing appropriate mental health support to parents.

Concerns summary Delays in resolving Care Programme Approach (CPA) issues between authorities and the inability of a mentally ill person to register with a GP due to a lack of documentation pose ongoing risks.

Concerns summary Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated by fragmented and inconsistent application of the Care Programme Approach (CPA).

Concerns summary Mental health clinicians failed to consider or routinely monitor the significant impact of hormonal changes as a contributory factor to depression in peri-menopausal women.

Concerns summary Failures in mental health care included serious underestimation of suicidality, delayed psychiatric assessment, and inadequate medication. The Home Treatment Team failed to visit and assess risk despite police warnings and neglected family concerns.

Concerns summary There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of a full medical picture.

Concerns summary Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to search police systems for relevant history, and did not reflect on their procedural errors.

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.