Mental Health related deaths

Noted (AI summary) NHS England clarifies that while the Liaison & Diversion service model does not directly commission psychiatrists, access can be arranged via urgent referral. They state that a Career and Competency Framework for L&D services, published in 2018, is currently under review, and regional commissioners will consider it for workforce and quality issues. NHS England clarifies that Liaison and Diversion services do not directly commission psychiatrists but are for referral. They are developing a new service specification to clarify expectations for access to psychiatry and are reviewing the L&D career and competency framework. West Midlands Police will create a formal escalation process for custody staff disputing Liaison and Diversion decisions, review mental health training for custody officers, and provide clear advice to frontline staff on the L&D function. These actions are planned within six months. West Midlands Police will create a formal escalation process for custody staff regarding Liaison & Diversion decisions, review mental health training for custody officers/staff, and provide clear advice on the L&D function within six months. Birmingham and Solihull Mental Health Trust plans to discuss liaison clarity with West Midlands Police, develop internal communications about the L&D team's role, and review/update the L&D induction programme and introduce reflective practice groups with psychologists by October 2022. Birmingham and Solihull Mental Health Trust plans to discuss liaison clarity with West Midlands Police, develop internal communications about the L&D team's role, and review/update the L&D induction programme and introduce reflective practice groups with psychologists by October 2022. NHS England clarifies that the Police Custody Healthcare Service (PCHS) policy and commissioning responsibilities lie with the Home Office and Police and Crime Commissioners (PCCs) respectively, not NHS England. They state their role is advisory, and they will continue to work collaboratively with the National Police Chiefs Council (NPCC) to align PCHS and Liaison & Diversion service specifications. The Home Office clarifies that commissioning for L&D services is for NHS England and police custody healthcare services for PCCs, and it is not their place to intervene. However, Home Office officials are working with the NPCC, NHS England, and DHSC to improve escalation processes and mental health management in custody, with a view to the NPCC issuing new guidance.

Noted (AI summary) The response acknowledges concerns about access to child and adolescent mental health services (CAMHS) in West Sussex. It outlines national initiatives to increase funding for and access to mental health services, including potential waiting time standards, and mentions a public call for evidence.

Noted (AI summary) NHS Dorset will undertake a review of nursing resources in epilepsy care locally, encompassing primary and secondary care for adults and children, and interaction with other specialities. The Regulation 28 Report will be shared and reviewed with NHS partners at the Pan Dorset Mortality Group. BCP Council's AMHP service uses the Mental Health Act 1983 and Code of Practice, monitored through a Quality Assurance Framework, to inform practice. They are actively engaging with Dorset Healthcare Trust to amend the Pan-Dorset Standard Operating Procedure and discussing with AMHPs how to succinctly share information with GPs. The Integrated Care Board (ICB) are carrying out an 8 week review of the entire Epilepsy and Neurology service which started on 11 August 2022. Dorset Council has completed an internal review of its AMHP pathways and recording systems to ensure adherence to the Mental Health Act Code of Practice, focusing on information sharing. The AMHP service managers will ensure review of records before assessment and there is a new mandatory field to notify the allocated social care practitioner of any Mental Health Act assessment. The trust outlines multiple planned actions, including updating policies to address sexual harassment/assaults on inpatient units, reviewing patient observation practices, improving documentation of rationale for observation levels, reviewing guidance on informal patient status, ensuring comprehensive discharge summaries are sent to GPs after Mental Health Act assessments. Dorset Police supports sharing learning about life-threatening illnesses with the College of Policing and has offered to support national training. They have implemented changes to the POLSA/LPSM process, directed staff to use Niche for logging decisions, and are including a session on log keeping in Vulnerability 4 training; revised processes are in place to monitor training activity. The College of Policing believes their current approach to vulnerability training, which focuses on risk management and information gathering, is appropriate. They argue that the complexity and variability of medical conditions make specific training impractical for non-medical personnel. The Trust has introduced a Standard Operating Procedure in May 2022 which covers the provision of information following Mental Health Act assessments. The Association of British Neurologists will communicate suggested actions to improve communication between psychiatry and neurology teams, such as copying communications to the treating neurologist and informing neurologists of psychiatric admissions. They will also discuss these issues with the President of the Royal College of Psychiatrists. The Royal College of Psychiatrists acknowledges the lack of effective communication between neurology and mental health services. They highlight workforce issues in neuropsychiatry and support the development of integrated services in neuroscience centers in ICSs. The Trust has updated its Safeguarding policy to highlight the response needed when an adult discloses they have experienced sexual abuse, with two appendix documents added to the policy setting out further details.

Noted (AI summary) The GM Mental Health System Quality and Safety Group commissioned a whole system peer panel review of the Regulation 28. Key learning points will be presented/shared with the Greater Manchester Mental Health System Quality Group and cascaded to professionals through relevant governance and learning forums. GM will consider the development of a GM standardised set of principles for the role of adult community mental health teams. The Department acknowledges concerns about the Care Coordinator role, referencing increased mental health workforce numbers, and the NHS Long Term Plan's commitment to expand community mental health services. It also highlights that local systems are reviewing CPA processes and investing in mental health crisis care provision.

Noted (AI summary) Priory reviewed shift handovers and found them satisfactory. Additionally, a detailed handover template is being introduced across Priory Healthcare sites and is currently being trialled on Rivendell ward at Altrincham. Risk assessments have been completed on courtyards/gardens and a programme of works is underway to increase courtyard and garden fencing. The Department acknowledges concerns about the security of outside areas in mental health wards and notes actions taken by the Priory Group to improve security around the garden area of Tatton Ward. The response also provides information about national guidance and regulations related to security levels and reporting of unauthorised absences.

Noted (AI summary) The Trust acknowledges the concerns and describes its general approach to suicide prevention, emphasizing collaboration with partner organizations to address social needs but offers no specific changes. The Department acknowledges the concerns, explains the limits of the Mental Health Act, and references existing NHS England initiatives and investment in community mental health services and integrated care.