Suicide

Noted (AI summary) The response consists of the organisation's name only.

Noted (AI summary) Scape Operations Ltd states that window restrictors were installed in 2018 per the National Code of Standards and are inspected quarterly, with any remedial works immediately undertaken, and therefore they propose no further action.

Noted (AI summary) NWAS has reviewed the use of NHS Pathways for overdose calls, implementing an automatic prompt for an advanced questionnaire if 'risk of suicide' or 'accidental poisoning' is recognised, leading to an automatic upgrade to Category 2 for patients who have taken higher-risk medications. Clinicians in the Clinical Navigation, CSD, and CCD teams have undergone extended training and will use TOXBASE to support decision-making. The Minister acknowledges the concerns raised and explains that national guidance is in place for ambulance services regarding overdose calls, including clinical intervention within 30 minutes or automatic upgrade to Category 2. NWAS is best placed to respond on specific local actions.

Noted (AI summary) SWR expresses condolences and explains a miscommunication regarding inquest information. They describe existing measures at Bracknell Train Station such as staffing, training, signage, and tactile paving. They also note that Network Rail is responsible for the lineside fencing issue. The Trust has updated training and guidance for staff on handling service users declining a 72-hour review meeting, clarifying the decision-making process and emphasizing patient-centered care. They have also provided pre-discharge guidance for staff on including the detail, expectations and importance of 72-hour reviews within the discharge safety plan.

Noted (AI summary) NHS England acknowledges the concerns and refers to actions taken by Norfolk and Suffolk NHS Foundation Trust, including a Quality Improvement Programme, re-evaluation of training, a new SOP, and changes to the Patient Safety Screening Form. They also describe the PSIRF and its aims. Following concerns raised, the Trust has added prompts to the patient safety screening form to consider retrieving patient calls for investigation and inquest purposes. Additionally, they have extended their current recording facility in one of their CRHTT areas which went live on 15th May 2024 and have enabled phone lines designated as requiring a recording facility.

Noted (AI summary) Cygnet will hold a conference to share actions on improving discharge processes, start a quality improvement project to explore a working arrangement with the Samaritans, and already has a Cygnet Social Worker on Byron Ward to coordinate discharges. Reading Borough Council outlines its Standard Operating Procedure for psychiatric hospital discharges, noting that social care practitioners are required to know and act in accordance with it. In the case of Sarah Adams, Adult Social Care were not informed of the discharge. The Trust has revised clinical risk training to increase focus on high-risk situations such as transitions of care, out-of-area placements, clear communication in discharge plans, and the 72-hour follow-up process. They have also strengthened guidance to teams on the 72-hour follow up process.

Noted (AI summary) Amazon has reviewed the book against its content guidelines and decided not to remove it from sale. They display a banner on the product detail page offering information on how to access free and confidential advice from the Samaritans.

Noted (AI summary) NHS England is working with private sector organisations to trial the use of Summary Care Records in settings where they have previously been unavailable and will continue this work throughout 2024. They also note the responsibility of providers to share information under the Health and Social Care (Safety and Quality) Act 2015. The CQC states they cannot comment on the regulation of the private psychotherapist as the practice is not registered with CQC. They welcome the action taken by Surrey and Borders Partnership NHS Foundation Trust and will continue to monitor the trust and any new information received but state this is outside the scope of their regulatory powers. The UK Council for Psychotherapy outlines its role and regulatory responsibility, noting its register of psychotherapists and Complaints and Conduct Process. They state they will not take action in relation to the coroner's first concern, but note work with the Professional Standards Authority and the NHS in discussing opportunities for collaboration in support of suicide prevention strategies.

Noted (AI summary) The Department of Health and Social Care highlights the role of Integrated Care Systems (ICSs) in planning and delivering integrated health and care services. It notes a Joint Action Plan is being developed to improve mental health treatment for people using drugs and alcohol, and DHSC and DLUHC will write to Directors of Housing, Adult Social Services, and Chairs of Safeguarding Adult Boards to emphasize their role in the homelessness system. The Tameside Adults Safeguarding Partnership Board (TASPB) is developing an action plan based on a Safeguarding Adults Review, with a workshop planned and an Action Plan Review Group monitoring progress. Additionally, TASPB launched the TASPB-Tiered-Assessment-and-Management-(TRAM) Protocol in November 2023 to support practitioners working with adults at high risk. The response contains no text.

Noted (AI summary) The NPA will raise concerns with the DHSC about Zuclopenthixol dihydrochloride (clopixol) packs and special container status at upcoming meetings, suggesting the DHSC is a more appropriate body for the report. Lundbeck states it does not classify Zuclopenthixol as requiring special container status, but has queried the NHS Business Authority and provided supportive stability data. The General Pharmaceutical Council acknowledges the concern and will consider whether to issue communications to pharmacy professionals to raise awareness about exceptions to the rules around quantity to supply for special containers. The MHRA confirms that the GPhC led on the response to the report, shared on 7 May 2024, and that the response is supported.

Noted (AI summary) The Department acknowledges the concerns about mental health bed capacity and refers to NHS England's work on improving community mental health services and oversight of the relevant Trust, but does not commit to specific actions beyond raising awareness.

Noted (AI summary) NHS England expresses condolences and outlines its commitment to improving community mental health services nationally, but states that responding to the specific concerns raised by the coroner is the remit of the named NHS Trust. They confirm the concerns have been shared with their national Mental Health Team and Regulation 28 Working Group. The Trust outlines actions taken and planned, including issuing additional guidance on managing suicide risk, sharing learning with the team, updating policies, and reminding staff of the need for communication amongst professionals involved in treatment.