Mental Health related deaths

Concerns summary No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to a breakdown in communication and continuity of care.

Concerns summary Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" without alternative provision, preventing comprehensive support for their distress.

Concerns summary Staff lacked competence and training in NEW Score usage and communication, leading to alarms not being properly responded to by senior staff, and no consideration for alternative patient monitoring.

Concerns summary South West Trains failed to respond positively to a British Transport Police report recommending measures to reduce the risk of people climbing over a footbridge parapet.

Concerns summary A named nurse was not allocated until the day before death, breaching trust policy and resulting in a failure to carry out essential risk assessments and care plans.

Concerns summary Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing suicide/self-harm risk, and communicating risks were identified.

Concerns summary Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.

Concerns summary Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about seamless patient care.

Concerns summary The electronic patient record system (RiO) failed to summarise critical patient history, preventing a comprehensive assessment and potentially altering care decisions.

Concerns summary Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not readily available and observation records lacked detail, hindering timely intervention and oversight.

Concerns summary Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk of deterioration, especially when patients disengaged without follow-up to next of kin.

Concerns summary The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior therapy is discontinued.

Concerns summary The easy online acquisition of dangerous non-prescribed medication, like Pentobarbital, poses a significant risk of future deaths, necessitating government intervention to regulate such websites.

Concerns summary Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living assessment, and an unsuitable unfurnished flat.

Concerns summary Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, especially in elderly patients.

Concerns summary The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were persistent issues, thus hindering learning and preventing future deaths.

Concerns summary Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans not being acted upon, preventing a crucial face-to-face assessment.

Concerns summary Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.

Concerns summary Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination among professionals.

Concerns summary Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient early without a care plan.

Concerns summary A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in care, risking patient abandonment.

Concerns summary Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for future harm.