Suicide

Concerns summary Inadequate mental health assessments failed to gather comprehensive patient information from various sources, lacked proper staffing support, and indicated a lack of clinical insight from the duty doctor.

Concerns summary Patients with suicidal ideation were given a non-free out-of-hours crisis number, creating a financial barrier to accessing urgent mental health support for those with limited means.

Concerns summary Inadequate risk assessments, poor communication between mental health professionals and family, and systemic failures in managing patients of departing staff and accessing home treatment services.

Concerns summary Prison healthcare exhibited failures in medication monitoring, care planning, appointment follow-up, risk flagging, and staff training for ACCT procedures and inter-professional communication.

Concerns summary Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on Aspen Ward are identified and addressed.

Concerns summary National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.

Concerns summary Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.

Concerns summary Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation and hospital attendance, leaving them unaware of his critical mental state.

Concerns summary Systemic failures and inadequate communication processes between police, courts, healthcare, and prison services led to crucial mental health assessment information not being effectively shared or accessed.

Concerns summary The lack of a regulatory body for advanced nurse practitioners, leading to inconsistent appraisal, revalidation, and potential unsupervised practice, poses a significant risk to patient safety.

Concerns summary An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of its recent inclusion and proper use.

Concerns summary Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear regarding active suicide plans, and the NOMIS database inadequately records past ACCT information.

Concerns summary Hounslow Social Services misunderstood their ongoing welfare role for a child placed far from home and failed to assess for support, neglecting family contact issues.

Concerns summary ACCT documents were incomplete, not properly utilized, and closed prematurely. Resourcing issues compromised officers' ability to ensure prisoner safety, especially for vulnerable young men.

Concerns summary The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate compared to other significant bridges.

Concerns summary A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support contacts. GPs also lacked awareness of available psychiatrist consultation.

Concerns summary Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding after a cell observation panel was blocked, indicating a lack of clear training.

Concerns summary Prison healthcare staff and a GP lacked or had insufficient ACCT training, resulting in non-adherence to mandatory ACCT procedures and indicating a clear, ongoing training need.

Concerns summary No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to a breakdown in communication and continuity of care.

Concerns summary Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" without alternative provision, preventing comprehensive support for their distress.

Concerns summary Serious deficiencies in prison mental health care included misdiagnosis, lack of specialist treatment, uncompleted psychiatric care plans, and poor communication during transfers. These systemic failures and inadequate ACCT procedures contributed to the death.

Concerns summary HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was not implemented.