Mental Health related deaths

Concerns summary Sanctuary Housing failed to properly investigate cuckooing and property damage for a vulnerable tenant, leading to an eviction notice instead of support, and lacked a clear policy for such situations.

Concerns summary A prolonged dispute between a social housing provider and the Council over rehousing a cuckooed tenant remained unresolved, highlighting a failure to support vulnerable individuals and inconsistent council policies on homelessness applications.

Concerns summary Police implemented the "Right Care, Right Person" policy without inter-agency consultation or a clear, agreed protocol for emergency services to respond to mental health welfare concerns, a known recurring issue.

Concerns summary Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter locked premises, and leading to dangerous delays in supervisor reviews.

Concerns summary The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about patient contact, delaying risk review and family notification.

Concerns summary Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.

Concerns summary Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.

Concerns summary Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately explain these processes.

Concerns summary A prolonged hospital stay due to inadequate community placement and poor inter-trust collaboration, coupled with poor documentation, significantly contributed to the patient's decline.

Concerns summary Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit Wi-Fi lacks filters, allowing vulnerable patients access to self-harm websites, increasing suicide risk.

Concerns summary Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of priority cases. ASC lacks robust oversight and auditing to prevent such systemic failures, risking future harm.

Concerns summary Significant waiting lists for mental health therapies, including Interpersonal Therapy, are preventing patients from accessing essential support in a timely manner due to demand exceeding commissioned capacity.

Concerns summary Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition and subsequent death by suicide.

Concerns summary Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, and joint action planning.

Concerns summary The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low priority categorisation and significant delays in ambulance response for at-risk patients.

Concerns summary There is a lack of specific national guidance for assessing mental capacity in adults with Hoarding Disorder and Executive Dysfunction, hindering effective intervention and requiring revised protocols.

Concerns summary Mental health teams exhibited inadequate assertive engagement and poor police liaison for a deteriorating patient, compounded by a lack of mandatory staff training on substance misuse and mental health.

Concerns summary The Perinatal Mental Health Service suffers from insufficient awareness among health professionals, inadequate staffing levels, and a lack of documented decisions and discussions in patient records at the Single Point of Access.

Concerns summary Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to neglect, contributing to the deceased taking his own life.

Concerns summary Officers chairing ACCT reviews at HMP Rochester failed to read all relevant documentation, leading to inaccurate risk assessments, and some did not understand how to properly complete support plan paperwork.

Concerns summary No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. Additionally, national guidance is lacking for ensuring continuity of care for released prisoners with mental health needs.

Concerns summary Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide risk, indicating a systemic failure in communication and risk management.

Concerns summary Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as a solution, these crucial safety measures have not been implemented in a psychiatric unit for over 42 months.

Concerns summary The internal investigation was inadequate, and barriers exist to proper Mental Health Act assessments. There's poor information sharing between agencies regarding residents, and support workers require more focused mental health training.