Mental Health related deaths

Noted (AI summary) Amicus Health will flag high-risk patients prescribed medications for closer monitoring with regular reviews and shorter prescriptions. They have eliminated non-auditable messaging systems for clinical information to ensure transparency and accountability in prescription management. The Royal Pharmaceutical Society acknowledges the concerns raised. They will consider how to raise awareness of these important issues through future communications and engagement with the wider pharmacy sector and will raise these issues with colleagues at the professional and representative bodies for pharmacy. Pharmacy2U will monitor inbound contact channels to ensure prompt responses. The superintendent pharmacist has discussed the case with the senior clinical management team and will continue to work internally and with healthcare colleagues in other parts of the NHS.

Noted (AI summary) Norfolk and Suffolk NHS Foundation Trust states that the NHS 111 Mental Health Option telephone support line is not commissioned to provide medication prescriptions and refers to its Management of Medicines Policy; it also says it has implemented a new Standard Operating Procedure for mental health liaison teams within acute hospitals. DHSC states that the NHS England National Specialty Advisor for Mental Health Pharmacy will write to mental health Chief Pharmacist colleagues across England requesting that they ask local systems and prescribing committees to review their local mental health prescribing policies.

Noted (AI summary) NHS England acknowledges the concerns and provides context on the Summary Care Record (SCR), the Royal College of Emergency Medicine (RCEM) guidance, and the National Record Locator (NRL), and states reports are discussed by the Regulation 28 Working Group. NHS Dorset will enforce the use of the Dorset Care Record in line with contractual commitments in 2025/2026 and will monitor progress of the issue directly via their Corporate Risk Register. They will also share the Regulation 28 Report with NHS partners and wider system partners at the Pan Dorset Mortality Group.

Noted (AI summary) NHS England acknowledges concerns about smoke-free policy application in mental health settings but refers to existing NICE guidance and states that individual NHS Trusts are responsible for local implementation. They also note that regional colleagues are seeking assurances from the relevant system regarding local arrangements. NICE acknowledges the concerns but states that the issues raised regarding national policy contradictions are outside their remit and best addressed by NHS England and the CQC. They highlight their guideline NG209 on tobacco dependence. The Department of Health and Social Care acknowledges the concerns regarding the smoke-free policy's impact on mental health inpatients and refers to the legal requirement for smokefree hospital premises. They expect NHS organisations to support patients who smoke through cessation measures or safe leave arrangements, and note that NHS England will address concerns around national guidance.

Noted (AI summary) GTD Healthcare has implemented changes to the standard templates used by Assistant Practitioners and provided hard copies to clinicians for use during IT issues. They have also implemented safeguards to ensure appointments with Assistant Practitioners are booked after a triage by a registered clinician and have audited and reviewed their prescribing practices. The DHSC acknowledges the concerns, states they fall under the provider's remit, and notes that NHS England and the CQC have been contacted to address them. It provides context on supervision guidance for PCNs but offers no concrete actions.