Mental Health related deaths

Concerns summary Care home staff failed to recognise and appropriately act on serious mental health deterioration, made inaccurate records, and did not follow GP advice, compounded by inadequate post-death investigation and training.

Concerns summary Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support for addiction and mental health.

Concerns summary A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed to guide the junior doctor on challenging this decision, leading to premature discharge and the patient's death.

Concerns summary Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also concerns about uncoordinated care between different agencies.

Concerns summary The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if they believe others are informed, risking a fragmented multi-agency approach.

Concerns summary Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling issues, increasing the risk of harm to vulnerable patients.

Concerns summary Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police delays, expose individuals to significant harm before assessment.

Concerns summary Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing and failures in escalating deteriorating mental health, medication reviews, and proper risk assessment.

Concerns summary Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase suicide risk, while local bridge safety measures fail to meet current guidance.

Concerns summary A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient observation on wards raises concerns about insufficient monitoring.

Concerns summary Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for neurodiverse patients.

Concerns summary The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified and no record of the rationale, posing a serious safety failure.

Concerns summary Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable for those with disabilities, exacerbated by potential funding cuts.

Concerns summary The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and risks obscuring future threats to life.

Concerns summary The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied to acute mental health patients.

Concerns summary Patients with undiagnosed or untreated ADHD face excessively long waiting lists, leading to potential deterioration, harmful behaviors, and increased risk of death.

Concerns summary A lack of formal communication frameworks between different NHS specialties and Trusts, especially in complex mental health and pain cases, resulted in fragmented patient care.

Concerns summary Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait times and an unsuitable environment, alongside service gaps for high-risk individuals.

Concerns summary Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E waits, where the environment was unsuitable and exacerbated mental health conditions.

Concerns summary A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced mental health professional, family, and patient's wishes for admission, led to a denied hospitalisation.

Concerns summary There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted or adequately documented.

Concerns summary Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing a simplistic assessment approach. Critically, risk assessments for unaccepted patients are not audited, creating a safety net gap.

Concerns summary A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient was inappropriately burdened with resolving the pharmacy's error.

Concerns summary A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there were delays in accessing the patient's record, preventing adherence to her care plan and leaving staff unaware of her significant self-harm history.

Concerns summary The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in crisis to contact multiple services. This is compounded by out-of-hours issues and restrictions on certain medications.