Suicide

Action Planned (AI summary) • The Trust is developing a new private care protocol to guide clinicians on how to approach circumstances when a patient is accessing care from a private healthcare provider. • The protocol will operate within the existing policy framework, linked to existing policies and procedures for information sharing and record keeping. • Work to develop this new protocol is underway and will be completed by the end of this month, applying to new and existing patients.

Action Planned (AI summary) • The approach to monitoring service users following changes to antipsychotic medication has been strengthened and is being implemented, with full standardisation across all relevant services to be completed by 1 March 2026. • Any request for enhanced monitoring following medication changes is now formally logged and reviewed at the first daily multidisciplinary planning meeting. • The process includes a structured clinical discussion to confirm the level of risk and the intensity of monitoring required, clear allocation of responsibility to a named clinician, and formal recording within the clinical diary system.

Action Planned (AI summary) NHS England has invested £20 million to connect care records across England by March 2026 and is updating its Healthy Child Programme guidance to include requirements for information sharing and record keeping related to maternal and family health. Regional Chief Nurses will cascade this updated guidance to Trusts. Derby and Derbyshire ICB is working to remove barriers to information sharing by establishing system-wide information governance agreements and applying for Section 251 agreements by Q1 26/27. The ICB will also work with partner Trusts to ensure relevant guidance on information sharing and cross-referencing mother and baby notes is provided by Q1 26/27. Sett Valley Medical Centre has implemented screen alerts on mother/child notes where the mother is under perinatal care and ensures these patients are discussed at monthly MDT and child safeguarding meetings. They also completed suicide prevention training and plan to request acknowledgement of referrals from the perinatal team. Derbyshire Healthcare NHS Foundation Trust has audited GPs not using SystmOne and added an 'alert' to patient records for awareness. They have drafted an information leaflet for GPs about different electronic record systems and added an additional page to e-referral documents for contextual information sharing. Derbyshire Community Health Services NHS FT has incorporated guidance into their Perinatal Mental Health SOP for cross-referencing child and parent records when information is relevant to parental mental health, and implemented an auto-consultation function in SystmOne for this purpose. Locality Managers have been briefed, and a one-page document on record keeping has been shared with staff.

Action Planned (AI summary) HMPPS is nearing completion of a project to convert fifty cells across thirteen establishments to ligature resistant cells, and are hopeful that further installations will be possible in 2026/27. They use the Assessment, Care in Custody, and Teamwork (ACCT) case management approach to support individuals at risk of self-harm or suicide.

Action Planned (AI summary) The Trust is revising its Rapid Response Standard Operating Procedure to ensure senior clinical oversight of referrals, revising its CAMS policy, considering a dedicated CAMS workforce, and promoting the use of the Urgent Mental Health Helpline.

Action Planned (AI summary) HMPPS is reviewing national prison officer training, developing interim upskilling sessions on recognising risks and triggers, and considering upgrading Victorian-style windows to anti-ligature designs. They are concluding a project to convert 50 cells across 13 locations to a fully ligature‑resistant standard. HCRG is retraining reception nurses, introducing an Early Days in Custody (EDiC) Nurse role, improving identification and escalation of urgent mental health referrals, and reviewing the Mental Health Operational Standard Operating Procedures and referral processes.

Action Planned (AI summary) GMP is undertaking a review of policies, delivering updated training to call handlers, reinforcing escalation protocols, and implementing quality assurance measures through supervisory reviews. The FCCO's in-house guidance system, Sherlock, will be updated and new training will incorporate these revisions.

Action Planned (AI summary) NHS England has shared draft guidance with systems, the Personalised Care Framework. North Staffordshire Combined Healthcare NHS Trust has implemented a process to contact patients awaiting Standard Assessment Framework assessments, requires key workers to have confirmed appointment dates before allocation, and clarified transition timescales. North Staffordshire Combined Healthcare NHS Trust is implementing a mandatory electronic alert system for Community Psychiatric Nurses when a service user is newly allocated or has not received an appointment within a specified timeframe, and is also transitioning to co-produced care planning and move away from Care Programme Approach (CPA).

Action Planned (AI summary) Practice Plus Group is advertising for a Principal Psychologist, Clinical Assistant Psychologist and two Assistant Psychologists, and has interviewed candidates for the Principal Psychologist post. They are exploring sharing psychological resources with a neighboring prison in the interim.

Action Planned (AI summary) The practice will amend their risk assessment template to include a mental health medication review code and free text advice regarding stockpiled medications, patient safety with medication quantity, reducing medication amounts, and safety plans. They will relaunch the amended policy in January 2026 and add the recording of medication review and consideration of reducing amount of medication on each issue as part of the annual audit program.