Mental Health related deaths

Concerns summary A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because different clinical note systems cannot access each other's records.

Concerns summary The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing patients into unsupervised smoking areas, potentially leading to unnoticed disappearances and suicides.

Concerns summary Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post Injection Syndrome.

Concerns summary There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act to ensure a detained patient received necessary treatment and nutrition.

Concerns summary A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to the failure to apply established NICE guidelines and local policy for comprehensive assessment.

Concerns summary Inadequate communication policies around sensitive accommodation moves created uncertainty for vulnerable service users and supporting teams. The council's failure to conduct an internal review risks inadequate learning and future deaths.

Concerns summary Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, leading to unaddressed discrepancies and potential safety risks during unescorted leave.

Concerns summary The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication breakdown between the college and mental health organizations.

Concerns summary A lack of compulsory training on the Dual Diagnosis pathway, poor communication, and an inefficient system for the Frontline Resolution Team to manage caseloads and follow up referrals led to significant care failures.

Concerns summary A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are left awaiting critical care, posing a risk of future deaths.

Concerns summary Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.

Concerns summary Police officers lacked guidance on using Mental Health Act powers and managing individuals likely missing but not officially reported, hindering their ability to ensure safety in critical situations.

Concerns summary Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled with a lack of comprehensive analysis from the CJLD assessment.

Concerns summary A widespread shortage of suitable placements for complex mental health needs led to the deceased's mental health decline, inappropriate detention, and ultimately contributed to his death.

Concerns summary Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, and reliance on telephone assessments, compromising patient risk assessment.

Concerns summary Procedures for referring clients between the Neighbourhood Mental Health Team and Mind, and for patients returning to NHS care from Mind, lack robustness and transparency.

Concerns summary Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care coordinator then improperly prioritized Oliver's case, failing to ensure timely support before going on leave.

Concerns summary The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, an oxygen bottle ran out during resuscitation efforts.

Concerns summary An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support to the Crisis Resolution and Home Treatment Team, leading to critical delays over a weekend.

Concerns summary The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and failed to implement new national risk assessment training.

Concerns summary A severe lack of communication and coordination between multiple health services resulted in significant delays, repeated referral rejections, and missed opportunities for treatment for a patient with complex epilepsy and psychotic symptoms.

Concerns summary Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.

Concerns summary Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering coordinated care.

Concerns summary Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support and unimplemented alternative services.

Concerns summary A severe shortage of mental health beds meant the patient could not receive necessary hospital treatment and led to patients being inappropriately detained in general hospitals.