Suicide

Concerns summary Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.

Concerns summary Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment processes that do not sufficiently account for mental health vulnerabilities.

Concerns summary Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general practice professionals to make direct referrals for high-risk patients, created dangerous gaps, particularly over weekends.

Concerns summary Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used for vulnerable prisoners, allowed access to ligature material which was missed during daily checks.

Concerns summary Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.

Concerns summary There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. Also, not all police forces have implemented trauma education campaigns.

Concerns summary Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, risking critical information being missed in missing person reports.

Concerns summary Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature deaths.

Concerns summary HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing with Probation Services.

Concerns summary Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the police via emergency channels.

Concerns summary Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and ongoing close care.

Concerns summary Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on acute paediatric wards unsuitable for their care.

Concerns summary Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk evaluation for suicidal patients due to gaps in training and policy.

Concerns summary The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among vulnerable inmates, posing a risk of future deaths where still implemented.

Concerns summary Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining further information from callers were not followed.

Concerns summary An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised vulnerabilities, without attempting to reduce associated risks.

Concerns summary The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds also prevent private disclosure of family concerns regarding risk.

Concerns summary Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental health beds, and inadequate facilities for appropriate waiting.

Concerns summary Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance for managing potential conflicts of interest when staff recognise patients outside of personal relationships.

Concerns summary Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns were not actioned promptly or effectively.

Concerns summary The self-exclusion scheme (GamStop) fails to protect individuals from unlicenced overseas gambling sites, which target vulnerable users. There is a critical lack of public health information regarding these risks.

Concerns summary No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion and patient safety risks.

Concerns summary A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding medication changes, risking patient safety due to uncoordinated treatment.

Concerns summary Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the patient's mental health.

Concerns summary The electronic sensor system provides only a brief, visual CCTV alert without an audible alarm, making it easily missed by operators and risking lost opportunities for intervention.