Suicide

Concerns summary A lack of formal communication frameworks between different NHS specialties and Trusts, especially in complex mental health and pain cases, resulted in fragmented patient care.

Concerns summary Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait times and an unsuitable environment, alongside service gaps for high-risk individuals.

Concerns summary Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E waits, where the environment was unsuitable and exacerbated mental health conditions.

Concerns summary A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced mental health professional, family, and patient's wishes for admission, led to a denied hospitalisation.

Concerns summary There were no recorded mental health or medication reviews for a patient over almost four years, raising concerns about whether these essential reviews were conducted or adequately documented.

Concerns summary Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing a simplistic assessment approach. Critically, risk assessments for unaccepted patients are not audited, creating a safety net gap.

Concerns summary The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for welfare officers is not mandatory. Inadequate information sharing and documentation between medical and command personnel further hinder support and risk reduction.

Concerns summary A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient was inappropriately burdened with resolving the pharmacy's error.

Concerns summary A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there were delays in accessing the patient's record, preventing adherence to her care plan and leaving staff unaware of her significant self-harm history.

Concerns summary The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in crisis to contact multiple services. This is compounded by out-of-hours issues and restrictions on certain medications.

Concerns summary A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because different clinical note systems cannot access each other's records.

Concerns summary The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing patients into unsupervised smoking areas, potentially leading to unnoticed disappearances and suicides.

Concerns summary DWP systems failed to properly assess and safeguard a vulnerable adult receiving a large arrears payment, resulting in a lack of clear communication and exacerbating the patient's paranoia about the money.

Concerns summary The increasing use of for self-harm is not centrally monitored, and current legislation fails to control the import and availability of substances used for poisoning, despite known risks.

Concerns summary Inadequate controls and verification processes allowed a veterinary surgeon to easily access a lethal controlled drug, enabling him to misuse it for self-harm without scrutiny.

Concerns summary NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary antidote for certain ingestions, causing critical treatment delays.

Concerns summary A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to the failure to apply established NICE guidelines and local policy for comprehensive assessment.

Concerns summary A prevalent "cancel culture" among students, involving social ostracism without formal process, severely impacts mental health. This 'self-policing' is linked to a lack of trust in formal reporting mechanisms.

Concerns summary Section 17 leave conditions are not always thoroughly reviewed or clarified before a service user is signed out, leading to unaddressed discrepancies and potential safety risks during unescorted leave.

Concerns summary The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication breakdown between the college and mental health organizations.

Concerns summary A lack of compulsory training on the Dual Diagnosis pathway, poor communication, and an inefficient system for the Frontline Resolution Team to manage caseloads and follow up referrals led to significant care failures.

Concerns summary A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are left awaiting critical care, posing a risk of future deaths.

Concerns summary Significant and unexplained delays in an internal police disciplinary process are concerning, failing to meet the expectation of timely resolution and potentially contributing to a future death.

Concerns summary Electronic custody records contained inadequate detail regarding mental health concerns and suicide risk from police and family, coupled with a lack of comprehensive analysis from the CJLD assessment.

Concerns summary An unsubstantiated assumption that something could not be removed led to a failure to even attempt its removal, which could have been crucial.