Suicide

Concerns summary Police safeguarding teams lack established links with NHS mental health services and officers need further training to appropriately assess and refer individuals requiring urgent mental health support.

Concerns summary Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving many officers untrained in critical situations.

Concerns summary Police misinterpreted Section 136 of the Mental Health Act, believing they lacked power to detain a suicidal individual in a hotel room. This highlights a need for clearer guidance on how such temporary accommodations are classified under the Act.

Concerns summary A patient at high risk was repeatedly denied monitoring by the Home Based Treatment Team due to rigid protocol adherence, creating a significant gap in supervision for vulnerable individuals falling between service remits.

Concerns summary Staff lacked critical understanding of patient confidentiality breaches for safety, efficient patient flow, and clear roles in risk management and leave authorization. Decision-making for self-discharge and Mental Health Act detention also lacked sufficient senior input.

Concerns summary Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.

Concerns summary Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward doors, specifically regarding access to hinge pins, at a mental health facility.

Concerns summary Scammonden Bridge is a notorious suicide location, and previous recommendations to Kirklees Council and Highways England for suicide prevention measures may not have been fully implemented.

Concerns summary Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due to resource constraints.

Concerns summary Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a suicidal patient. There was also no clear guidance for advising patients in crisis about driving restrictions.

Concerns summary There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.

Concerns summary Lack of a formal process to guide practitioners on appropriate mental health support routes and insufficient flagging of self-harm/suicide risk on referral forms contributed to inadequate scrutiny.

Concerns summary Inadequate family engagement and a lack of clear policy for it post-discharge compromised patient support. Flawed care transfer procedures between borough teams resulted in no follow-up appointments or consistent community contact.

Concerns summary The university's non-mandatory tutorials and homework in Mathematics made it difficult to identify struggling students, allowing some to go without face-to-face contact for nearly a year and delaying support until exam failures.

Concerns summary Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT training meant officers lacked understanding of their crucial responsibilities.

Concerns summary Inconsistent information sharing and a lack of multi-agency collaboration between mental health and social care led to inadequate risk assessment and slow referral processes for a patient with escalating mental health needs.

Concerns summary The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an ongoing risk of future deaths from falls.

Concerns summary An online suicide forum provided dangerous advice, enabling individuals to mislead mental health professionals and perfect suicide methods, thus frustrating necessary assessments and interventions.

Concerns summary Repeated cancellation of consultant psychiatrist appointments without clinical input on patient urgency meant individuals at serious need could "fall through the net," as a preventative system was not yet operational.

Concerns summary The absence of a designated Lead Practitioner during patient transfers between mental health teams causes delays in treatment and leaves patients unmonitored during a critical transition period.

Concerns summary Police guidance for missing person risk assessments lacks clarity, potentially leading to inconsistent decision-making by officers in complex cases.

Concerns summary The probation service failed to refer mental health concerns to medical practitioners. Supported accommodation exhibited poor documentation, unclear welfare check protocols for security staff, and inadequate risk assessment updates, without policy for GP contact.

Concerns summary Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, and a lack of mechanisms for schools to receive assessment data further compromised child safeguarding.

Concerns summary The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care practices, or national guidance documents like ACCT.

Concerns summary ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was not consistently used when new ones were opened.