Suicide

Concerns summary Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases patient risk upon leaving the facility.

Concerns summary Websites promoting or assisting suicide are easily accessible, and platforms lack adequate independent scrutiny to remove age-inappropriate and harmful content.

Concerns summary The university's examination results system is complex and misleading, with provisional passes and pending marks causing confusion. There is also no system for personal tutors to proactively contact vulnerable students before releasing failed results.

Concerns summary University students face lengthy delays accessing mental health support, even when expressing suicidal ideation and having known risk factors like ASD.

Concerns summary The provided text primarily details the deceased's history and the event, but does not explicitly outline the coroner's specific concerns regarding systemic failures or risks.

Concerns summary The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.

Concerns summary Critical information regarding a prisoner's suicidal intent expressed at court was not communicated to prison staff, leading to inadequate monitoring and a lack of necessary support measures.

Concerns summary Frequent changes in care coordinators and the failure to obtain critical collateral information from other healthcare trusts on admission resulted in a fragmented understanding of the patient's risks.

Concerns summary Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and retention issues, hindering the Trust's ability to manage increased demand for complex cases.

Concerns summary A crisis line clinician failed to adequately assess risk, displayed a lack of empathy, and did not document a crucial call, exacerbated by management advising against proper record-keeping and a general lack of trust cooperation with the inquest.

Concerns summary The absence of dedicated in-patient mental health provision for young people aged 14-25, and the immediate application of adult services at 18, poses risks by not acknowledging developmental needs.

Concerns summary Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not receiving crucial medication. The Trust's internal investigation was also flawed and incomplete.

Concerns summary Poor note-keeping and a lack of clear future care planning during discharge, coupled with insufficient family involvement and unavailable crisis support for the carer, exposed the patient to significant risk.

Concerns summary The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground leave lacked criteria and proper risk assessment.

Concerns summary The rapid closure of an ACCT for newly transferred prisoners, often based on minimal review, poses a risk as it fails to allow adequate time for staff to assess and understand the individual's needs.

Concerns summary Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health staff led to missed opportunities to address escalating suicidal risk, compounded by poor audit and flawed investigation.

Concerns summary A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU led to incomplete observations and a failure to ensure prisoner safety.

Concerns summary Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump within minutes of arrival, indicating current safeguards are insufficient.

Concerns summary Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an emergency appointment or clinical callback, raising concerns about future risk to patients.

Concerns summary Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.

Concerns summary Pandemic-driven telephone consultations for mental health prevented comprehensive assessments, and GPs lacked clear guidance on when to refer patients to crisis teams.

Concerns summary Inadequate systems existed for providing in-depth mental health support to patients with anxiety and non-engagement issues, leaving families as the sole caregivers and preventing necessary intervention.

Concerns summary Methadone prescribed to a care home resident was found in a staff member's possession, raising serious concerns about medication management, security, and auditing protocols.

Concerns summary There was an unacceptable delay in clinical assessment, and no system existed to triage referral acuity, preventing expedited assessment for urgent cases.

Concerns summary Police repeatedly failed to act on reports of neighbour harassment, suggesting incidents are not taken seriously enough and leading to missed opportunities to intervene and potentially prevent future deaths.