Mental Health related deaths

Noted (AI summary) NHS England acknowledges the coroner's concerns regarding connectivity between mental health services abroad and in the UK, but notes that information sharing cannot be mandated for overseas healthcare providers. They highlight the work of the Regulation 28 Working Group in sharing learnings from PFD reports. The Home Office outlines the Right Care, Right Person (RCRP) approach, which GMP is rolling out, to ensure the right agencies respond to people in need of support, but defers to the College of Policing and GMP for specific issues. NWAS has provided feedback and reflection to the Mental Health Practitioner involved in the incident. They continue to deploy mental health Trust practitioners in NWAS control rooms and directly employ mental health practitioners for triaging calls. The DHSC acknowledges concerns about training for police officers, notification of carers for Mental Health Act admissions, connectivity between international and UK mental health services, GP practice list removals, and communication between mental health agencies, deferring to other bodies on some points and explaining existing policy on others. GMMH has emphasized the notification of carers following admission under the Mental Health Act through daily staff huddles and implemented a process to ensure written information is provided to carers within 72 hours of admission. GMMH will also carry out an audit to ensure staff are following guidance on safe transfers between teams by the end of March 2025. The College of Policing highlights the national 'Right Care Right Person' (RCRP) framework, supported by Authorised Professional Practice (APP) and a toolkit, along with a bespoke e-learning training package. They are in contact with Greater Manchester Police, who are implementing RCRP. The CQC acknowledges the concerns but states that they fall outside of its regulatory remit, particularly regarding GP practices and information sharing between agencies. It outlines its inspection methodology but takes no direct action. Trafford Council has reinforced expectations within Adult Social Care that staff must verify if the Police are responding to a call, reviewed and strengthened safeguarding processes, and invested in mental health management and practitioner capacity. Single agency recommendations from the Safeguarding Adults Review have been actioned. Response contains only blank pages.

Noted (AI summary) NHS England highlights existing funding and initiatives to improve mental health services and reduce pressure on inpatient beds, including investment through the NHS Long Term Plan and Better Care Fund. They are supplementing this with further recurrent investment to recommission inpatient care. The Trust acknowledges the concerns about bed shortages and the need for adequate medicalization, and outlines work within the Mind & Body Transformation program to better integrate physical and mental healthcare. They state this issue requires resolution at a national level.

Noted (AI summary) Surrey Council explains that the SCARF process is not designed for emergency referrals and that a clear process exists for officers to contact the Emergency Duty Team out of hours. The Trust updated its website with referral routes, enhanced collaboration with families, and revised the SBAR tool to include carer/family views. They have also implemented mandatory training for staff on the referral pathway to mental health services, with 86% completion to date and the remainder scheduled for completion soon. Surrey Police is reminding all officers to undertake research as soon as practicable when dealing with members of the public, including asking the Force Control Room to do so on their behalf when it is impracticable to do so themselves; this message will be conveyed via force emails and a reminder on the daily briefing to response officers.

Noted (AI summary) The Royal Pharmaceutical Society explains that the BNF provides a general overview and may not include all information necessary for prescribing, recommending referral to a specialist for bipolar disorder. They will continue to monitor for additional information around the management of bipolar disorder for future updates. BMJ acknowledges the coroner's concerns regarding BMJ Best Practice's content on bipolar disorder treatment. They state that the tool is a reference for medical professionals and that content is regularly reviewed and updated, but the decision on treatment remains with the prescribing clinician. They highlight the importance of consulting multiple sources and checking product information sheets for medications. NICE acknowledges the coroner's concerns regarding their bipolar disorder guideline (CG185) and its consideration of the two polarities of bipolar disorder in long-term treatment. They will discuss this area with their topic experts and review any new evidence, updating recommendations if necessary.

Noted (AI summary) NHS England acknowledges the concerns raised, noting the national Liaison and Diversion service specification requires timely information sharing with police. They also describe national NHS England work on reviewing PFD reports to identify emerging trends. Midlands Partnership NHS Trust, which now provides Liaison and Diversion services in Sussex, has introduced a Custody Pathway Standard Operating Procedure. They are also considering extending their service hours and introducing an on-call service and are working with Sussex Police and Mitie to agree on the content of a revised MOU. Sussex Police references existing College of Policing guidance on handover procedures, risk assessments, intoxication, and mental vulnerabilities. They state they will not create a separate MOU due to concerns it could conflict with or become outdated compared to national guidance. The NPCC is considering a nationally recognised pre-arrival risk assessment to communicate risks and concerns to custody. They also plan to raise concerns regarding a lack of 24-hour LDS service and NHS Trust information sharing with NHSE. Mitie acknowledges the coroner's concerns regarding communication and documentation but states that they are not involved in mental health assessments in police custody and that the concerns should be addressed by the Police, NHS England and its local mental health and liaison and diversion services teams. However, Mitie has liaised with Sussex Police and the L&D Trust to understand their role in any formal process that they may wish to put in place.

Noted (AI summary) SWR expresses condolences and explains a miscommunication regarding inquest information. They describe existing measures at Bracknell Train Station such as staffing, training, signage, and tactile paving. They also note that Network Rail is responsible for the lineside fencing issue. The Trust has updated training and guidance for staff on handling service users declining a 72-hour review meeting, clarifying the decision-making process and emphasizing patient-centered care. They have also provided pre-discharge guidance for staff on including the detail, expectations and importance of 72-hour reviews within the discharge safety plan.

Noted (AI summary) NHS England acknowledges the concerns and refers to actions taken by Norfolk and Suffolk NHS Foundation Trust, including a Quality Improvement Programme, re-evaluation of training, a new SOP, and changes to the Patient Safety Screening Form. They also describe the PSIRF and its aims. Following concerns raised, the Trust has added prompts to the patient safety screening form to consider retrieving patient calls for investigation and inquest purposes. Additionally, they have extended their current recording facility in one of their CRHTT areas which went live on 15th May 2024 and have enabled phone lines designated as requiring a recording facility.