Suicide

Concerns summary A high-risk mental health patient could not access an inpatient bed due to national shortages, forcing discharge despite immediate safety concerns and an unwillingness to wait in A&E.

Concerns summary Mental health unit admissions during staff handovers led to confusion over task allocation and risk assessment responsibility, exacerbated by the lack of a formal policy to manage or avoid admissions at these times.

Concerns summary An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially misleading patient risk assessments, hindering effective management.

Concerns summary Student accommodation staff lacked mandatory first aid training despite residents' self-harm, and mental health teams failed to effectively gather crucial information from private psychiatrists for risk assessment, hindering comprehensive care.

Concerns summary Delays in resolving a workplace investigation, combined with the public disclosure of allegations among colleagues, caused severe distress. The system failed to accelerate the process despite the evident harm.

Concerns summary Severe staff shortages in mental health services, a lack of crisis care alternatives for complex PTSD/EUPD patients, and a two-year waiting list for autism assessments pose significant risks.

Concerns summary A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments and poor information sharing.

Concerns summary Safety measures, including fencing and barriers, were only partially implemented at the car park, leaving areas where the parapet wall remained easily climbable.

Concerns summary Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and CAMHS being unaware of new national support offers, risking patient safety.

Concerns summary Police lacked understanding of coercive control and its link to suicide, alongside insufficient knowledge of when and how to apply for Domestic Violence Protection Notices.

Concerns summary A critical lack of independent investigation for deaths of patients detained under the Mental Health Act results in ineffective reviews, lost learning, and no consistent oversight for rectifying systemic issues.

Concerns summary Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to prolonged unsupervised periods.

Concerns summary A significant commissioning gap leaves high-risk 17-year-olds without essential sensory occupational therapy, as child services end at 16 and adult services only accept from 18.

Concerns summary Student accommodation windows lacked adequate restrictors, enabling a fatal fall from a sixth-story, highlighting a failure to address the known risk of students falling from windows.

Concerns summary A national lack of clear guidance and multi-agency understanding for vulnerable young people transitioning from child to adult mental health services leads to inadequate support and patients falling through service gaps.

Concerns summary Inappropriate grading of vulnerable person incidents and severe lack of police resources led to significant delays in response and oversight, failing to provide timely assistance.

Concerns summary The indefinite nature of IPP sentences traps prisoners, leading to feelings of hopelessness and challenging behaviours, raising concerns about inhumane treatment and future deaths if not reviewed.

Concerns summary Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not escalated despite the patient becoming unresponsive.

Concerns summary The Trust seriously failed to recognize a patient's prolonged refusal to eat or drink as an active suicide attempt and an elevated suicide risk, indicating a systemic failure in risk assessment.

Concerns summary Clinicians and practitioners involved in mental health inpatient discharge lack adequate training in the discharge process, particularly concerning complex issues arising from out-of-area admissions.

Concerns summary Concerns persist regarding inadequate mental health discharge decisions, insufficient crisis team risk assessments, and downgrading of urgent referrals, with many identified safety measures remaining prospective or unimplemented by the Trust.

Concerns summary A system flaw allowed a patient to submit concerning questionnaire responses after cancelling an appointment, but there was no protocol to alert clinicians to review these urgent responses outside the standard timeframe.

Concerns summary The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, and exclude family input, indicating a lack of thorough investigation and learning.

Concerns summary Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness of its potential for harm and a previous coroner's intervention.

Concerns summary Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental health care.