Mental Health related deaths

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 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. 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 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.

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.

Noted (AI summary) NHS England acknowledges the concerns, points to the NHS Long Term Plan and the Humber and North Yorkshire ICB's contracts requiring reasonable adjustments for individuals with autism and mental health conditions, and highlights the role of the Regulation 28 Working Group in sharing learnings.