Mental Health related deaths

Action Planned (AI summary) Cardiff and Vale University Health Board has worked to co-produce guidance on information sharing with families, revised a patient information leaflet, and commissioned a co-produced family engagement project to enhance family involvement.

Action Planned (AI summary) MFT has held discussions with GMMH to improve escalation processes for patients whose discharge is being organised by the CMHT. GMMH is in the process of appointing a new Manager for Community Flow and a clearer escalation pathway has been developed between GMMH and MFT. GMMH and MFT have agreed to internally review Ms. Anderson’s patient journey through a Learning Multi-Disciplinary Team Meeting. GMMH will move to a more proactive approach to discharge and will review all admissions of CMHT patients ensuring discharge planning is considered from admission. Inquiries between the acute trust staff relating to an inpatient and the MHLT will be documented in GMMH electronic patient record and will be included in the Trust wide Standard Operating Procedure for MHLT’s, plan to be in operation across all MHLT’s by 1st September 2025. An escalation policy for Mental Health patients who are CRFD is due to be rolled out system wide by quarter 3 which prescribes actions and timescales at each level to ensure all options have been considered.

Action Planned (AI summary) NHS Greater Manchester Integrated Care is developing a comprehensive plan to improve access to psychological therapies, with key areas including Workforce Expansion, Enhanced Commissioning Models, and Enhanced Community Crisis Support, including out-of-hours community support, a 24/7 mental health crisis line, and digital support commissioned from Kooth and Qwell.

Action Planned (AI summary) BCUHB is raising awareness of the Perinatal Mental Health Service, delivering mandatory training, and reviewing the 'SPOAA Referral Checklist' for consistency across the division, with implementation planned from 26th May 2025.

Action Planned (AI summary) NHS England required ICBs to review community mental health services by September 2024. NHS England understands that NHS Dorset would actively support the expansion of this work to support sharing of mental health care plans. The DCR Partnership is looking to have the capability to share information with others using the NRL from March 2026 onwards. The College of Policing acknowledges concerns about the lack of a bespoke risk assessment tool for violence in MOSOVO units. They will consult with the NPCC Lead for MOSOVO and relevant subject matter experts to improve guidance and direction and will liaise with Dorset Constabulary to ensure they are fully sighted on current guidance. The NPCC will request the College of Policing to review APP and training material to highlight violence risk assessment more strongly within risk management plans; they have also reiterated a request for a full review of the ARMS process. NHS Dorset supported a learning event led by NHSE regarding mental health needs, and will work with SWAST to enable access to the Dorset Care Record. They have also opened a risk on the system risk register to scrutinise the accessibility of information across system partners. HM Prison and Probation Service acknowledges concerns about sharing risk information from prison with sentencing courts and highlights the establishment of immediate release pathfinders in three prisons to develop multi-agency approaches. They will task the Safety Group in HMPPS to consider this specific area when reviewing the Prison Safety Policy Framework later in 2025-26.

Action Planned (AI summary) The Civil Aviation Authority will instruct inspectors to encourage operators and Approved Training Organisations to improve mental health support to pilots, including upskilling peer supporters and supporting escalation of concerns to mental health professionals, and is reviewing its Pilot Health Safety Sense Leaflet.

Action Planned (AI summary) The Trust conducted a system-based investigation into the death, identifying weaknesses in change of address and medication compliance management. Actions include a written reminder to clinical staff about recording address changes in Rio, and a review of the standard operating procedure for non-contact with appointments to ensure consistent escalation to the MDT. Birmingham City Council, having had no prior involvement with the deceased, will add guidance clarifying the use of Section 2 versus Section 3 of the Mental Health Act to Birmingham and Solihull Mental Health Foundation Trust's Mental Health Policy. The Council details its information-sharing practices with landlords, noting that the extent of information provided depends on how the resident accesses accommodation.