Mental Health related deaths

Concerns summary The 'triangle of care' approach, which facilitates family involvement with patient permission in mental health care, is not consistently applied, potentially limiting crucial support for patients.

Concerns summary Concerns relate to the flawed operation of the dual diagnosis policy, inadequate development and implementation of the delivery plan, and a poor working relationship between Addaction and the Community Mental Health Team.

Concerns summary A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute inpatient mental health beds led to further self-harm and suicide attempts.

Concerns summary Drugs too easily entered the secure mental health unit due to unchecked external food orders, inadequate searches of residents returning from leave, and staff not being searched upon entry.

Concerns summary Dangerous discrepancies exist between national and local ambulance guidance on the 15-minute timeframe for resuscitation, creating ambiguity and potential misinterpretation regarding when cardiac arrest officially begins.

Concerns summary Smoke-free hospital guidance forces detained mental health patients who smoke into unescorted 'off-grounds' leave without staged assessment, significantly increasing risks of absconding, self-harm, and harm to others.

Concerns summary Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.

Concerns summary Police received incorrect name spelling and unclear instructions for a welfare check, indicating critical communication failures and a lack of agreed protocols between ambulance and police services.

Concerns summary Multiple failures in a missing persons investigation, including incorrect closure due to severe understaffing and high workload in the police missing persons unit.

Concerns summary Police issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to communicate the decision to drop the investigation.

Concerns summary Lack of commissioned services for autism management and local inpatient provision forces out-of-area mental health placements, hindering family contact and local support.

Concerns summary Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies in primary care, exacerbated by staff training issues and limited communication options.

Concerns summary The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.

Concerns summary The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient care, especially for mental health needs. Additionally, underfunding has led to inadequate out-of-hours mental health staffing.

Concerns summary Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient GP medication reviews created an overdose risk.

Concerns summary A patient died from pregabalin toxicity after consuming excess prescribed medication post-discharge, raising concerns about managing medication risks for individuals with a history of misuse.

Concerns summary The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking missed safeguarding opportunities.

Concerns summary Observation policies for vulnerable patients were unclear, staff lacked training on safeguarding and reporting crimes, and nurses misunderstood their powers to detain informal patients. Confusion also existed regarding family involvement in care planning.

Concerns summary Poor record-keeping, inadequate preparation and attendance at multidisciplinary meetings, and staff unfamiliarity with Clozapine's significance hindered patient care. Inaccuracies in serious incident reviews also compromised learning.

Concerns summary Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising the alarm due to chaotic ward conditions and lack of CCTV review policy contributed to the incident.

Concerns summary Misdiagnosis of ASD was linked to over-reliance on questionnaires and less experienced clinicians, compounded by a lack of services for chronic, complex conditions.

Concerns summary Stationary ambulance doors that cannot be locked pose a risk to police containment of individuals detained under the Mental Health Act, potentially allowing egress from the vehicle.

Concerns summary Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator caseloads, causing delayed follow-ups and inadequate risk assessments.

Concerns summary Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of timely patient follow-up, which created a risk to life.