Mental Health related deaths

Concerns summary The deceased lacked ready access to a unified dual-diagnosis service that could holistically assess and treat co-existing mental health conditions and substance misuse issues.

Concerns summary The Home Treatment Team failed to follow clinical guidance to consult the patient's sons about inpatient admission and medication non-compliance. There was also a breakdown in properly recording and communicating the care plan with the family.

Concerns summary Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails to provide mandatory comprehensive mental health assessments, leaving ex-personnel reliant on external services.

Concerns summary Significant underfunding and under-resourcing of CAMHS caused extensive waiting times for child psychiatrist assessments, preventing timely diagnosis and treatment. Exploding referral rates without proportionate resource increases have made the service unsustainable, endangering young people.

Concerns summary There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act assessment, leading to confusion and a failure to progress critical steps like a warrant, delaying further intervention.

Concerns summary Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This prevented staff from knowing significant risks, potentially impacting care decisions and safety measures.

Concerns summary Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and complex mental health conditions pose significant risks.

Concerns summary Inadequate garden fence security at a mental health facility, without national guidance, and a critical breakdown in information exchange at shift handovers led to a failure in appreciating emerging patient risks.

Concerns summary The Care Coordinator role is overburdened and lacks consistent job descriptions or cover during absences, compromising information flow and comprehensive patient assessment within mental health teams.

Concerns summary A systemic void exists for vulnerable individuals with suicidal ideation but no overt psychiatric illness, leading to them being passed between agencies without effective crisis intervention or multidisciplinary planning.

Concerns summary A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.

Concerns summary Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose significant ongoing safety risks.

Concerns summary The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies for prescribing, clinical governance, and learning. Thresholds for referring to secondary mental health services were also unclear.

Concerns summary The patient's discharge plan disregarded clear clinical advice regarding her high suicide risk and risk to family, leading to her returning home alone. There was also a failure to integrate recommendations from previous criminal justice proceedings.

Concerns summary Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks sufficient trauma-informed care.

Concerns summary National shortages of mental health beds led to acute hospital detentions, while significant staffing challenges impacted ward operations, exacerbated by COVID-19's effects on mental health.

Concerns summary A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for other patients is facing significant, unacceptable delays.

Concerns summary Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective inter-provider communication, increasing suicide risk for autistic individuals.

Concerns summary Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment with an insecure courtyard fence and ligature risks. National perimeter fence guidelines are lacking.

Concerns summary Police response was critically delayed by nearly four hours due to escalation failures, compounded by a lack of readily available entry equipment and poor document management practices.

Concerns summary Insufficient staffing, failure of a duty doctor to assess a patient, unapproved medication administration without proper tracking, and significant inaccuracies in clinical records led to compromised care.

Concerns summary The coroner highlighted a general concern about the appropriateness of reviewing an unspecified practice, suggesting a need for internal re-evaluation.

Concerns summary "Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the product remain in circulation, requiring urgent action.

Concerns summary Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such harmful online content.

Concerns summary Inadequate support and psychosocial interventions were provided for a child with Prader Willi syndrome and high-risk behaviours. Poor communication between agencies also prevented coordinated care.