Suicide

Concerns summary Ineffective communication pathways for sharing information directly with the RDaSH Crisis Team created risks in patient care.

Concerns summary Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. Critical safeguarding advice, like not leaving the patient alone, was not properly documented or communicated.

Concerns summary Lack of a protocol for contacting social workers led to a failure in obtaining valuable collateral history and sharing crucial information, depriving the patient of support upon discharge.

Concerns summary The significant issue of "lack of connectivity" identified in evidence had not been fully addressed by the Trust.

Concerns summary The long-term use of shorter-acting benzodiazepines, contrary to guidelines, and a failure to review patients on extended prescriptions risked dependence and adverse outcomes.

Concerns summary The lack of local in-patient detox facilities and long waiting lists are unacceptable. A more collaborative approach for dual diagnosis patients is critically needed, as current separation of care increases risk.

Concerns summary Prolonged custody awaiting psychiatric reports led to significant deterioration of the deceased's mental health in a prison assessment unit, resulting in her self-inflicted death.

Concerns summary Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.

Concerns summary A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm over a weekend.

Concerns summary There was a conflict in risk assessment methods for suicide/self-harm between healthcare staff and ACCT policy for prisoners. Staff required clearer guidance and detailed training on the ACCT process's lower threshold.

Concerns summary A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.

Concerns summary Chronic underfunding and staff shortages in mental health services, particularly for doctors in the EIP team, led to precarious patient care and significant delays in treatment.

Concerns summary Multiple systemic failures included premature discharge without effective care transfer, inadequate suicide risk assessment, and medication prescribing without direct psychiatrist assessment, compounded by significant re-assessment delays.

Concerns summary A critical failure to refer the patient back to Mental Health Liaison Services upon hospital discharge meant a further assessment of her mental state and self-harm risk was missed.

Concerns summary A patient with complex physical and mental health issues disengaged from community mental health services post-discharge following medication changes, contributing to low moods and his subsequent death.

Concerns summary Mental health services failed to adequately assess risk, record crucial details, or proactively engage with a vulnerable young person and her parents after an initial declined appointment.

Concerns summary Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.

Concerns summary There was a critical failure to action a psychiatric referral during inpatient care and no follow-up for complex PTSD post-discharge. This highlighted a commissioning gap for suitable services for complex mental health conditions.

Concerns summary The mental health ward failed to review medication despite patient concerns and did not conduct full risk assessments after self-harm incidents. There was also an over-reliance on inpatient status as a protective factor and a lack of clarity in observation policies.

Concerns summary The university failed to effectively use academic advisors to support struggling students and displayed deeply flawed communication between its various departments, health clinic, counsellor, and the student's GP.

Concerns summary Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously described. This critical oversight and its omission from the Trust's investigation risk missing crucial learning opportunities.

Concerns summary Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up support, and no contemporaneous GP notification. These failures left the patient without crucial support post-discharge.

Concerns summary The prison failed to inform family members how to report welfare concerns, potentially leading to missed suicide risk factors for detainees.

Concerns summary Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical emergency protocols.