Suicide

Noted (AI summary) NHS England acknowledges the concerns and highlights existing national guidance on liaison mental health services. They note actions taken by the Trusts involved, including a joint working group, and describe internal processes for reviewing PFD reports. The trust has reviewed the Mental Health Liaison SOP to provide clearer direction for staff in supporting patients awaiting assessment under the Mental Health Act, focusing on risk management. A Joint Working Protocol is being put in place and the SLA between MSE and EPUT is being addressed at a senior level. The trust has reviewed its policy on the admission and treatment of patients with mental health disorders in acute settings, reinforcing mental health support available in ED. They have also provided guidance on assessing patient capacity and detaining patients under Section 5(2) of the Mental Health Act, including notification procedures and patient rights.

Noted (AI summary) NHS England highlights the Mental Health, Learning Disability and Autism Inpatient Quality Transformation programme, designed to localize and realign care. They have published a Commissioning Framework and required ICBs to develop 3-year plans to cease sending people to distant or outdated inpatient services and are working with the Greater Manchester ICB re oversight of The Priory Cheadle. The DHSC acknowledges concerns about mental health service funding, reliance on independent providers, and availability of specialist units. They highlight existing initiatives to improve patient flow, localise care, and ensure quality regardless of provider.

Noted (AI summary) NHS England highlights increased access to CYPMH services, with 758,000 children and young people receiving support in the 12 months to January 2024. They cite a 46% increase in the CYPMH workforce since January 2019 and mention the NHS Long Term Plan's ambition for 100% access to specialist support. They also note discussion of all PFD reports by a working group. The DHSC acknowledges concerns about long waiting times for assessment and treatment in children and young people’s mental health services, and the importance of early intervention and support. They highlight the government's plans to increase mental health staff and improve access to services, and state NHS England will address concerns about the “keeping in touch team”.

Noted (AI summary) NHS England will issue guidance to health systems on reviewing Serious Incident investigations to ensure lessons are learned and changes agreed upon. A national oversight group has been set up to review concerns and issues with RCRP, and this group feeds into a ministerial working group. This is an appendix to the BSMHFT response, specifically the Trust's Missing Patient Policy. It outlines the actions to be taken when a patient is missing or AWOL, relating to Informal inpatients, Detained patients who are AWOL and patients in the community, read in line with National Partnership Agreement: Right Care, Right Person (RCRP). West Midlands Police (WMP) has provided additional RCRP training to call handlers and officers and produced an exhibit detailing the escalation point of contact for partner agencies to West Midlands Police. WMP has also emphasised the need for officers to gather information from all sources and record the rationale for decisions made, particularly regarding vulnerable people. The National Police Chiefs' Council clarifies the aims of Right Care Right Person (RCRP) and states that it appears the situation concerning Mr. Bari was treated as a missing person case from the outset by West Midlands Police, and therefore RCRP principles would not apply. BSMHFT has updated their Missing Persons Policy in line with Right Care Right Person (RCRP) changes, incorporating feedback from the inquest, and a new Executive Director of Quality and Safety/Chief Nursing Officer will be accountable for the policy. The updated policy includes a revised Appendix C form focusing on the reasoning for critical concern and requires formal notification from the police with their decision and reasoning if they have decided not to deploy immediately. The APCC provides background on its role and the role of PCCs in local policing, noting that it has developed guidance for members on the Right Care, Right Person approach. It states that the NPCC is reviewing the report to identify relevant national learning. The Department of Health and Social Care acknowledges the concerns raised, noting that local policies should align with the Mental Health Act Code of Practice and that local partners should reassess joint processes on risk assessment, communication, and escalation. They emphasise the importance of collaboration between policing and health partners. The College of Policing is undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process. They are also working to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. The Home Office outlines the rationale and purpose of the National Partnership Agreement (NPA) and notes that decisions on implementation of Right Care Right Person (RCRP) are for individual Chief Constables. They state that missing persons cases are outside the scope of RCRP and existing police procedures should continue to operate.

Noted (AI summary) NHS England is responding to 'The Long Wait' HMIP report, and is working with HMPPS nationally and regionally to support the ACCT process. HMP Guys Marsh issued guidance to healthcare staff and relevant training was provided to induction and reception staff who conduct first night interviews. NHS England South West region supported the development of e-learning training for healthcare staff on safeguarding in secure and detained settings. Unilink will raise the issue of prisoner transfer information with the Ministry of Justice to explore the possibility of sharing relevant information to better manage and redirect communications. The response is a cover letter forwarding the PFD response, but contains no details itself. The Department of Health and Social Care acknowledges concerns about mental health treatment equity in prisons and delays in transferring mentally unwell prisoners. They mention the Mental Health Bill, which will introduce a 28-day statutory time limit for transfers from prison to hospital, and that they expect other recipients of the report to address concerns around national guidance, ACCT processes and engagement with family members.

Noted (AI summary) CYP staff will be reminded that a referral ought to be made, staff will be reminded that a referral ought to be made, nonetheless. This aspect of identified learning shall become a dedicated focus within our annual PLO training for CYP colleagues working across our operational services to raise awareness of presenting significant MH issues, Legal Services, when accepting a new case from CYP, shall be required to discuss with social workers any relevant vulnerabilities relating to the parent(s) and a referral has been sent to the Community Safety Partnership for consideration for a domestic homicide review of this case. NSFT has asked all clinicians that receive referrals into services to identify those where treatments have been recommended by non-NSFT clinicians in order to offer an assessment prior to signposting elsewhere. Norfolk and Waveney ICB states that they have reviewed their Mental Health Individual Funding Request records and have not been able to identify any Individual Funding Request being made to them on behalf of Ms Madden, for Schema-based Cognitive Behavioral Therapy. Suffolk Constabulary notes the concerns raised but states that they conduct their own risk assessments when delivering Claire’s Law disclosures, which would include the wellbeing of the recipient of that disclosure and the delivery was conducted in accordance with policy and appropriate aftercare. The ICB will work with partners to ensure that learning and action is taken forward from this case, and the Trust has asked all its clinicians that receive referrals into mental health services to identify those where treatments have been recommended by clinicians from outside the Trust in order to offer an assessment prior to any decision being made on the most appropriate way forward. The Home Office acknowledges receipt of the report and restates commitment but describes no specific actions taken or planned.

Noted (AI summary) NHS England acknowledges the concerns about mental health bed shortages and highlights ongoing investment in mental health services and the Better Care Fund. They are seeking further information from the North West region and will discuss the report at the Regulation 28 Working Group.

Noted (AI summary) NHS England highlights the Suicide Prevention Strategy and guidance to improve the culture of care for mental health inpatient services. Oxleas has designed a clinical risk training workshop, and participates in the Royal College of Psychiatrists’ Culture of Care Programme. The Department acknowledges concerns about the use of risk assessment tools and refers to NICE guidance and the 5-year Suicide Prevention Strategy for England. It highlights NHS England's work to improve risk management within mental health services, including guidance published in April 2024. The Trust will issue a blue light bulletin reminding clinical staff to update risk assessment documents, and will audit risk assessments using the 'Tendable' system. The Trust will also work with the National Culture of Care team to adapt the risk assessment and formulation tool.

Noted (AI summary) The Department says that patients should not lose their right to access NHS services by accessing private services, and that NHS England has signposted relevant guidance to ICBs. The Priory has detailed how and when to refer patients to NHS services.