Conflicting mental health care plans
92 items
2 sources
Care plans for high-risk mental health patients containing contradictory instructions, incompatible with legal duties.
Cross-Source Insight
Conflicting mental health care plans has been flagged across 2 independent accountability sources:
1 inquiry rec
91 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (91)
Edward Hands
Concerns: Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and delayed medical assessment.
Pending
Stephen Taylor
Concerns: Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns were not actioned promptly or effectively.
Response: Vita Health Group reviewed and updated its Duty Standard Operating Procedure in November 2025 to mandate same-day actioning of routine referrals and emphasize careful consideration of family information in clinical …
Response: Kent and Medway Mental Health NHS Trust has updated its Urgent Mental Health Helpline Standard Operating Procedure, including clearer high-risk categories, faster triage (from 72 to 24 hours), and new …
Responded
Mohammed Choudhury
Concerns: Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known risks.
Response: The Trust has reinforced operational policies for medication non-concordance, requiring formal MDT discussion and documentation of missed depot injections, and embedded an audit cycle for compliance. All relevant staff have …
Responded
Wendy Eyles
Concerns: No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion and patient safety risks.
Overdue
Mark Vidler
Concerns: Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also lacked dedicated resources and IT integration.
Response: Kent and Medway NHS Mental Health Trust has delivered refresher training focusing on patient-centred care and introduced regular service user/carer feedback. They are revising their Rapid Response Standard Operating Procedure …
Responded
Timothy Reading
Concerns: 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.
Pending
Christopher Bird
Concerns: Concerns were raised about the reliability of the nhs.net email system for transmitting critical mental health information to GPs, leading to systemic communication breakdowns between secondary and primary care.
Overdue
Gareth Jackson
Concerns: Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, contrary to the safety plan. A national bed crisis also delayed transfer.
Responded
Jonathan Hamer
Concerns: Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition and subsequent death by suicide.
Responded
Amy Padley
Concerns: Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support for addiction and mental health.
Responded
Emma Sanders
Concerns: 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.
Responded
Jamie Harding
Concerns: 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.
Responded
Kashim Ali
Concerns: Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.
Responded
George Kyriacos Petrou
Concerns: Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a risk that vulnerable individuals with suicidal intentions may not receive necessary observation.
Overdue
David Power
Concerns: A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy unknown to the referring team. This systemic lack of shared understanding creates a risk of future deaths.
Responded
Parminder Sanghera
Concerns: Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, leading to inadequate risk assessments that missed suicide/self-harm concerns before release.
Responded
Evie Davies
Concerns: 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.
Responded
Tammy Watkins
Concerns: Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 policy, and confusion in emergency call procedures, led to preventable deaths.
Responded
Alice Litman
Concerns: Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient mental healthcare provision for those awaiting gender-affirming treatment.
Responded
Mohammed Akram
Concerns: A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant risk.
Responded
Leya Adris
Concerns: A patient with escalating mental health concerns, including suicidal ideation, did not receive critical psychiatrist input because the GP's urgent referral was incorrectly diverted by the single point of access system.
Responded
Isabela Suciu
Concerns: Conflicting guidelines for newborn hypothermia led to delayed antibiotic administration and create ongoing confusion and risk of missed clinical signs in neonatal units.
Overdue
Girmaye Guyo
Concerns: There's a risk of patients being discharged under the Nearest Relative Power despite still meeting detention criteria, due to a lack of clear procedures and legal tests for clinicians to apply.
Overdue
Vaughan Whalley
Concerns: Deficient suicide and self-harm risk assessments upon release from detention, coupled with poor communication to police and inadequate practitioner-detainee interaction, compromised effective risk management. A manager's review also lacked critical analysis or learning identification.
Responded
Nicholas Stout
Concerns: Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and safeguarding referrals for children are frequently missed.
Responded
Heather Findlay
Concerns: Staff are unprepared for patients absconding, with policies lacking clear guidance on following or police engagement, leading to confusion and potential non-attendance by police for distressed patients.
Responded
Hilary Guedalla
Concerns: Multiple communication failures meant staff were unaware of a patient's high suicide risk and allowed unescorted leave. Inadequate record-keeping, brief un-noted risk assessments, and delayed, confused responses to a missing patient compounded the risk, exacerbated by short-staffing.
Responded
Brenda Shields
Concerns: The patient was discharged without planned follow-up or family involvement, and promised referrals were not made. Inadequate consideration of her alcohol problems led to an incorrect low-risk assessment, mirroring concerns from previous reports.
Responded
Jai Singh
Concerns: Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded by the mental health team's lack of a psychiatrist and ongoing risk assessment documentation.
Responded
Charlotte Comer
Concerns: The Trust suffered from severe understaffing, leading to excessive care coordinator caseloads and fragmented patient care. A senior clinician unilaterally overrode a Multi-Disciplinary Team decision, highlighting a lack of robust procedural oversight.
Responded
Daniel-John Varndell
Concerns: A probation officer unilaterally removed a critical mental health appointment condition from a high-risk individual's license, without consulting MAPPA professionals, posing a risk of future deaths.
Overdue
Stanislav Mucha
Concerns: There was no documented agreement among professionals regarding the outcome and necessary actions following a mental health act assessment, leading to confusion and a failure to progress critical steps like a warrant, delaying further intervention.
Responded
Joshua Rennard
Concerns: Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.
Overdue
Alexandra Tolley
Concerns: The care plan's instruction not to restrain or follow a high-risk patient absconding under Section 2 was incompatible with safety duties. Informal decisions for ground leave lacked criteria and proper risk assessment.
Responded
Jude Lloyd
Concerns: Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental capacity assessments. The Trust's internal investigation was also flawed and incomplete.
Responded
Antony Schofield
Concerns: Inadequate risk assessments, poor communication during patient transfer, and a lack of professional curiosity by community mental health staff led to missed opportunities to address escalating suicidal risk, compounded by poor audit and flawed investigation.
Responded
Katie Locke
Concerns: Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.
Overdue
Fiona Humberstone
Concerns: A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting risk assessments. Incompatible electronic systems prevent routine access to full medication records between primary and secondary care.
Overdue
Rodney Dixon
Concerns: Sub-optimal training for Mental Health Act assessments and assessors, along with inadequate access to patient data for independent clinicians, poses risks to patient risk management.
Responded
Nicholas Rousseau
Concerns: Senior A&E consultants held conflicting views on managing elevated lactate levels and sepsis, with one disregarding NICE guidelines due to perceived inconvenience, indicating a lack of standardized care.
Responded
Katy Samuels
Concerns: The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.
Responded
Kimberley Smith
Concerns: The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.
Responded
Sam Pringle
Concerns: Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with potentially fatal consequences.
Responded
Lee Carpenter
Concerns: An urgent GP mental health referral was downgraded without documented rationale, patient/GP discussion, or identification of the decision-making staff, indicating no system for clear documentation and accountability in clinical triage.
Overdue
Sophie Boothe
Concerns: Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate mental health assessment and referral downgrading.
Responded
Irene Whittingham
Concerns: Conflicting guidance on Vitamin D and Calcium blood level monitoring for high-dose patients and confusing software interfaces allowed prescribing errors that exceeded national guidelines without GP notification.
Overdue
Billy Jenkins
Concerns: An inadequate mental health assessment, lacking robust information gathering and documentation, failed to properly diagnose and treat the patient, with no clear evidence of lessons learned or staff training.
Overdue
Daniel Moran
Concerns: Staff lacked critical understanding of patient confidentiality breaches for safety, efficient patient flow, and clear roles in risk management and leave authorization. Decision-making for self-discharge and Mental Health Act detention also lacked sufficient senior input.
Overdue
Kieran Hubbard
Concerns: Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a suicidal patient. There was also no clear guidance for advising patients in crisis about driving restrictions.
Overdue
Keith Heatley
Concerns: There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no clinical review before high-risk patient leave.
Responded
Neil Black
Concerns: Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.
Responded
Nicky Reilly
Concerns: The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.
Responded
Patricia Chambers
Concerns: Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.
Overdue
Annette Hill
Concerns: An unresolved tension exists between Sepsis 6 guidelines and the BTS COPD care bundle for advanced respiratory disease, potentially leading to inappropriate antibiotic administration.
Responded
Rebecca Romero
Concerns: The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. There was confusion over unit transfers and inconsistent risk assessment terminology among staff.
Overdue
Jonathan Meaney
Concerns: Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately addressed, resulted in the patient's premature release without proper consultation or confirmed follow-up care.
Responded
Matthew Edwards
Concerns: Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up appointments, and significant waits for critical diagnostic scans.
Responded
Janet Muller
Concerns: Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.
Responded
Olaseni Lewis
Concerns: Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged restraint." Additionally, there was a critical lack of clarity and training on inter-agency roles and responsibilities between police and healthcare staff.
Responded
Dean Rowland
Concerns: Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.
Responded
Jonathan Zucker
Concerns: A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.
Responded
Andrew Codling
Concerns: A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm over a weekend.
Responded
Sandra Brotherton
Concerns: Inadequate support for a sole carer, poor information sharing of care plans with Personal Assistants, and difficulties accessing urgent psychiatric appointments and follow-up after concerning incidents.
Responded
John Jones
Concerns: A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear communication protocols for such handovers.
Overdue
Margaret Richardson
Overdue
Oliver Ford
Concerns: The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for patients triaged on Fridays.
Responded
Anthony Preston
Overdue
Rohan Fitzsimons
Concerns: Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals taking their own lives while awaiting necessary detention.
Overdue
Pamela Gressman
Concerns: There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a clear treatment and observation plan for physical symptoms.
Responded
Danny Sweet
Responded
Leslie Morrison
Overdue
Lee Grimes
Concerns: Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by inadequate staff training in managing overdose reports.
Overdue
Tracey Lynch
Concerns: No specific concerns are provided in the truncated text.
Overdue
Dorota Kijowska
Concerns: The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to the patient, leading to a lack of clarity.
Overdue
David Pooley
Concerns: A named nurse was not allocated until the day before death, breaching trust policy and resulting in a failure to carry out essential risk assessments and care plans.
Overdue
Charlotte Bevan and Zaani Malbrouck
Concerns: There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
Responded
Lee Bates
Concerns: A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols for OSA patients receiving sedative medication, creates an ongoing risk of avoidable deaths.
Overdue
Masoud Ghaderi
Concerns: Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward rounds relied on inadequate, brief summaries, risking errors and omissions in care.
Overdue
Mark Daniels
Concerns: The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.
Responded
Tanya Page
Concerns: Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.
Overdue
Michael McCrory
Concerns: The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear training on minimising recurrence risks.
Overdue
Simon Tree
Concerns: The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.
Responded
Katherine Bonaventura
Concerns: The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.
Overdue
Samarjit Singh
Concerns: The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and declined referrals for mothers with severe postnatal depression.
Overdue
Darren Arnoup
Concerns: Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.
Overdue
Samiyo Farah
Concerns: Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric referrals from A&E.
Overdue
Stephen Goodhall
Concerns: A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose risks to patient care.
Overdue
Norma Sheppard
Concerns: Significant confusion existed regarding the terms of Mrs. Sheppard's discharge to a care home, specifically concerning subcutaneous fluids, with conflicting information between the written discharge and verbal understanding.
Overdue
David Chatburn
Concerns: The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.
Overdue
Mena Terefi
Concerns: Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels and insufficient resources, risking future deaths.
Overdue
Khalid Yousef
Concerns: Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This is compounded by misunderstanding of L&D's role and a reduction in qualified Forensic Medical Examiners.
Responded