Mental Health related deaths

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 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.

Action Planned (AI summary) Swansea Bay University Health Board acknowledges concerns about treating individuals with both addiction and mental health diagnoses. They are developing a Standard Operating Procedure (SOP) and care pathway to address this, starting meetings in May 2025 to review practices and integrate mental health and substance use services.

Action Planned (AI summary) NCASP will require teams across the partnership to feedback when newly introduced policies and guidance, including those on self-neglect have been discussed and the changes to practice that will follow. The SAR Framework and Practice Guidance has been updated to reflect improvements to processes for identifying cases that may warrant review and a further requirement will be added that the partnership must review the impact of the learning one-year post completion of a SAR.

Action Planned (AI summary) The MPS is reviewing its corporate process for s.135 warrants and will incorporate the matters raised in the PFD report and learning identified into this review. HMCTS has reiterated arrangements for applications to magistrates’ courts in London and held a meeting with NHS colleagues to explore concerns, committing to continued communication and partnership working.

Action Planned (AI summary) The MPS corporate process for s.135 warrants is being reviewed, and the PFD report's matters and learning will be incorporated into this review. HMCTS has reiterated the arrangements for applications to be made to magistrates’ courts in London whether routine, urgent or out of hours. They also arranged a meeting with NHS professionals to explore concerns.

Action Planned (AI summary) Hertfordshire and West Essex ICB notes long waiting times for ASD assessments and outlines actions including pathway investment, implementing a service model redesign, providing additional funding, and creating resource packs for parents and carers. NHS England published the National Framework and Operational Guidance for Autism Assessment Services in April 2023, setting out expectations for integrated autism assessment pathways and that referrers must not omit providing assessment or intervention for health-related needs. The council erected notices signposting to the Samaritans immediately after the death and will assess the feasibility of raising or replacing bridge parapets with new, higher versions once a Principal Inspection is complete, after liaising with Network Rail to undertake the Principal Inspection at the first opportunity.

Action Planned (AI summary) Mid South Essex NHS Trust is working with partners to develop clear and straightforward pathways for mental health care in the Emergency Department, with a rollout programme and training planned for ED staff after final approvals. EPUT reports that the Mental Health Liaison team now has access to all key systems including SystmOne, and the Inpatient and Urgent Care Divisional Directors of Quality and Safety are establishing regular quality forums with Directors of Nursing in Acute hospitals.

Action Planned (AI summary) The Royal College of Psychiatrists will communicate risks and best practices regarding cross-titration to its members through newsletters and other communications, raise the issue with mental health organizations, and use the PFD to inform their priorities. It also advocates for more research on the use of video technology in observing patients, and has worked with NHS England to publish principles for trusts considering this technology.

Action Planned (AI summary) NHS England highlights national work on moving away from risk stratification and supporting personalised safety planning, and that NHS Sussex ICB is seeking updates from the Trust on actions including raising staff awareness of care plan and therapeutic observation importance, care plan audits, and developing a training package on the needs/risks associated with care experienced individuals. Sussex Partnership NHS Foundation Trust provided the coroner with a copy of the Ligature Anchor Point Risk Reduction Policy and a Patient Safety Briefing, launched refreshed ligature risk, assessment and awareness training in July 2024 (becoming mandatory in April 2025), completed installation of new anti-ligature alarmed bedroom doors on Rowan Ward, and commenced work on Maple Ward.

Action Planned (AI summary) NHS England acknowledges the long waits for ADHD services and describes a national programme to improve access, including exploring digital options for diagnosis and support, and moving to a needs-based approach. They have also developed guidance for systems to manage medication shortages. The RPS published a report on medicines shortages in Nov 2024 and will consider how to raise awareness of these issues through future communications and engagement and with professional bodies for pharmacy.

Action Planned (AI summary) NHS England will continue to support provider Trusts to deliver appropriate training and support to staff to deliver reasonable adjustments and accessible communication for patients. NHS England’s South East regional colleagues have also engaged with NHS Sussex ICB, the responsible commissioner for the services described, on the concerns raised. The DHSC is rolling out the Oliver McGowan Mandatory Training on Learning Disability and Autism and NHS England is rolling out further training for staff working in mental health services to upskill staff in supporting autistic people in contact with those services.