Suicide

Concerns summary When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance funding, leaving high-risk individuals without immediate alternative treatment or support.

Concerns summary Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.

Concerns summary A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from patient and staff, leading to his tragic death.

Concerns summary Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and inadequate facilities, compounded by mishandling a missing person's report.

Concerns summary A psychiatrist failed to inform a patient about Lamotrigine's self-harm/suicide side effect due to a lack of awareness, exacerbated by inconsistent or absent warnings in reputable pharmacological guidelines, posing patient safety risks.

Concerns summary Critical medication changes for a patient with cognitive impairment were not communicated to the next of kin, causing confusion. A lack of clear policy and systemic investigation into this communication breakdown risks future harm to vulnerable patients.

Concerns summary Mental health assessment failed to gather corroborative history and discharged patient to GP care without adequately considering suicidal ideation or providing a proper safety plan. The Root Cause Analysis was unreliable, failing to identify these critical care problems.

Concerns summary Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted to opiates, creating an inequality in healthcare provision compared to England.

Concerns summary Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential psychological services, which poses a risk of preventable deaths.

Concerns summary Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with potentially fatal consequences.

Concerns summary Valuable non-crime domestic abuse information is fragmented and not available as a national police resource, hindering effective safeguarding of potential victims.

Concerns summary The absence of arrangements or guidance for the safe collection and disposal of unused end-of-life prescription medication creates risks of misuse or environmental harm.

Concerns summary Inadequate interagency information sharing and a crisis team clinician's failure to contemporaneously record assessments and decision-making rationale posed risks to patient safety.

Concerns summary A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient understanding of autistic prisoners' needs pose significant risks.

Concerns summary Critical failures include outdated care plans, poor record-keeping and information compilation, lack of psychiatrist reviews, inconsistent risk assessment policies, and inadequate handover procedures, all contributing to a fragmented care system.

Concerns summary Failures in checking medical records upon prison admission led to missed antidepressant medication, exacerbated by staff shortages, heavy workloads, and the absence of a "red flag" warning system for suicide risk.

Concerns summary Policy violations in patient observations, inadequate handover procedures, and a prolonged, unsuccessful search for appropriate alternative placement negatively impacted the patient's mental state and ability to manage self-harm risks.

Concerns summary Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue with tracking and ensuring current staff competence.

Concerns summary Significant delays in accessing mental health services and support, along with the adverse psychological impact on patients of missed contact attempts, raised serious concerns.

Concerns summary An urgent GP mental health referral was downgraded without documented rationale, patient/GP discussion, or identification of the decision-making staff, indicating no system for clear documentation and accountability in clinical triage.

Concerns summary The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.

Concerns summary The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, unpopulated summary sections, and a non-functional keyword search.

Concerns summary An inadequate mental health assessment, lacking robust information gathering and documentation, failed to properly diagnose and treat the patient, with no clear evidence of lessons learned or staff training.

Concerns summary Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial safeguards, contributing to toxic drug interactions.

Concerns summary Repeated mental health appointment cancellations by administrators, without clinical follow-up, left patients at risk. The "formal position" for duty worker contact after cancellations lacks proper policy, training, or consistent application.