Suicide

Concerns summary Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked mental health deterioration and disengagement from services.

Concerns summary Opiate medication from a deceased parent on palliative care was not removed by nursing staff, remaining accessible and subsequently used by the deceased to end her life after a previous suicide attempt.

Concerns summary The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient care, especially for mental health needs. Additionally, underfunding has led to inadequate out-of-hours mental health staffing.

Concerns summary The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking missed safeguarding opportunities.

Concerns summary Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.

Concerns summary A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge protocols between agencies and inadequate facilities for mental health crisis intervention were identified.

Concerns summary A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.

Concerns summary Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent individuals from jumping.

Concerns summary The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to improve data access.

Concerns summary Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future suicide attempts.

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 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 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 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 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 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.