Suicide

Concerns summary Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.

Concerns summary Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment processes that do not sufficiently account for mental health vulnerabilities.

Concerns summary Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general practice professionals to make direct referrals for high-risk patients, created dangerous gaps, particularly over weekends.

Concerns summary Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used for vulnerable prisoners, allowed access to ligature material which was missed during daily checks.

Concerns summary Discharge assessment processes led to an unrealistic impression of the patient's mobility, potentially compromising patient safety.

Concerns summary There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. Also, not all police forces have implemented trauma education campaigns.

Concerns summary Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, risking critical information being missed in missing person reports.

Concerns summary Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature deaths.

Concerns summary HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing with Probation Services.

Concerns summary Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the police via emergency channels.

Concerns summary Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and ongoing close care.

Concerns summary Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk evaluation for suicidal patients due to gaps in training and policy.

Concerns summary The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among vulnerable inmates, posing a risk of future deaths where still implemented.

Concerns summary A lack of protocol for patients receiving both NHS and private psychiatric care leads to poor communication regarding medication changes, risking patient safety due to uncoordinated treatment.

Concerns summary The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also no national guidance clarifying the required components for S.117 plans.