Mental Health related deaths

Concerns summary (AI summary) Therapeutic observations were not accurately recorded due to Wi-Fi signal issues, and there was no care plan in place to address the physical health conditions, such as sleep apnoea, associated with long-term mental health medication.

Concerns summary (AI summary) The coroner raises concerns that the £250 per week allowance for reasonable living expenses under Proceeds of Crime Act Restraint Orders, which has not been reviewed since 2009, is insufficient given the increased cost of living, especially for those with dependents.

Concerns summary (AI summary) The coroner noted that non-urgent referrals to the Single Point of Access (SPA) for mental health support may take up to 14 days to triage, and referrals could come from individuals without mental health experience.

Concerns summary (AI summary) Front line police officers receive regular refresher training on first aid, but no similar provision is in place for mental health first aid training.

Concerns summary (AI summary) The initial Patient Safety Incident Investigation lacked robustness and did not appear to have been revisited in light of emerging family concerns; proactive communication to families of issues or obstructions to bed availability and reinforcement of safety plans should be a central feature of daily Patient Flow Meetings; it remains unclear how a lack of face-to-face psychiatric review can be escalated.