Conflicting mental health care plans
Care plans for high-risk mental health patients containing contradictory instructions, incompatible with legal duties.
292 items
10 sources
2 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PHSO casework decision
90match
P-002857 - Herefordshire and Worcestershire Health and Care NHS Trust
Mr A complains about the Adult Mental Health Team at the Trust. He specifically complains he was misdiagnosed with a mixed personality disorder in February 2019 when he had bipolar affective disorder. He also says he was not provided with psychological help for anxiety and other mental health issues including not being given a care co-ordinator for over...
Matched on
terms: care, health, mental
PHSO casework decision
86match
P-001717 - Avon and Wiltshire Mental Health Partnership NHS Trust
Mr A complains about the Trust's care and treatment of his fiancée, Ms E. He complains about the communication and its decision-making regarding her anorexia and autism.
Matched on
terms: care, health, mental
PHSO casework decision
86match
P-003508 - Black Country Healthcare NHS Foundation Trust
Miss U complains about the way Black Country Healthcare NHS Foundation Trust and The Royal Wolverhampton NHS Trust managed her father’s mental health medication.
Matched on
terms: care, health, mental
PHSO casework decision
86match
P-003994 - Kent and Medway Mental Health NHS Trust
Ms N complains about the support given to her and her son when he was experiencing mental health crises in the community. This includes a failure to assess his level of risk, review his medication, and support her as his carer.
Matched on
terms: care, health, mental
PFD report
85match
Darren Arnoup
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.
Matched on
terms: care, health, mental
PFD report
85match
Jonathan Zucker
A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.
Matched on
terms: care, health, mental
PFD report
85match
Janet Muller
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.
Matched on
terms: care, health, mental, plan
PFD report
85match
Jonathan Meaney
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.
Matched on
terms: care, health, mental
Inquiry recommendation
85match
BRIS-19 - Require effective communication among healthcare professionals to avoid conflicting patient advice
Healthcare professionals responsible for the care of any particular patient must communicate effectively with each other. The aim must be to avoid giving the patient conflicting advice and information.
Matched on
terms: care, conflicting, health
PHSO recommendation
85match
Discharge from mental health care: making it safe and patient-centred
We note the Department of Health and Social Care's (DHSC) national statutory guidance on discharge from mental health settings. As it is implemented, DHSC and NHS England must engage with people and services to assess the impact the guidance has on them. In particular, they must make sure that Integrated Care Systems account for the different professionals that...
Matched on
terms: care, health, mental
PFD report
81match
Charlotte Bevan and Zaani Malbrouck
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.
Matched on
terms: care, health, mental, plan
PFD report
81match
Lee Grimes
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.
Matched on
terms: care, health, mental
PHSO casework decision
81match
P-001064 - Pennine Care NHS Foundation Trust
Ms O’s complains about a letter she received from the Trust’s Healthy Minds service which she says was sent to her 18 months after a telephone assessment following which she was discharged, and it was therefore completely out of the blue. She feels it should have been sent following the assessment in three years before. Ms O also...
Matched on
terms: care, conflicting, health
PPO recommendation
81match
The Head of Healthcare at Lewes
The Head of Healthcare at Lewes should ensure that a formal clinical handover is arranged for all complex mental health prisoners before transfer to a new prison.
Matched on
terms: care, health, mental
PHSO casework decision
81match
P-002748 - Surrey and Sussex Healthcare NHS Trust
Mrs L complains the Trust incorrectly stopped medication to treat her mental health condition which led to a long hospital stay and affected her mobility and mental health.
Matched on
terms: care, health, mental
PHSO casework decision
81match
P-004388 - Gloucestershire Health and Care NHS Foundation Trust
Mr C complains the Trust's Child and Adolescent Mental Health Service (CAMHS) delayed prescribing him medication which was recommended in July 2024. He also complains about its decision to decline his referral to its eating disorder services in August 2024.
Matched on
terms: care, health, mental
LGO / SPSO decision
81match
22-009-742d - Northamptonshire Health Care NHS Foundation Trust (22 009 742d)
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did not make reasonable adjustments when communicating with Mr...
Matched on
terms: care, health, mental
LGO / SPSO decision
81match
22-009-742c - Northamptonshire Health Care NHS Foundation Trust (22 009 742c)
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did not make reasonable adjustments when communicating with Mr...
Matched on
terms: care, health, mental
LGO / SPSO decision
81match
23-017-445a - South West London & St. Georges Mental Health NHS Trust (23 017 445a)
Summary: We will not investigate Mr X’s complaint about the decision to detain him under Section 2 of the Mental Health Act 1983. This is because Mr X appealed this decision to the First Tier Tribunal (Mental Health). This means we are prevented from investigating this complaint.
Matched on
terms: care, health, mental
LGO / SPSO decision
81match
23-012-177a - Avon & Wiltshire Mental Health Partnership NHS Trust (23 012 177a)
Summary: Avon & Wiltshire Mental Health Partnership NHS Trust did not appropriately record Miss X’s reasonable adjustments during a meeting. That did not cause her an injustice but the Trust should still take action to stop similar fault happening to others. Also, an Approved Mental Health Professional for North Somerset Council did not inform Mr X of his...
Matched on
terms: care, health, mental
LGO / SPSO decision
81match
24-009-187a - Derbyshire Healthcare NHS Foundation Trust (24 009 187a)
Summary: Ms X complains about Derbyshire County Council and Derbyshire Healthcare NHS Foundation Trust. She says the organisations acted with fault when she was detained in hospital under the Mental Health Act in 2022. Ms X’s complaint is late and there are not enough good reasons for the Ombudsmen to investigate it now.
Matched on
terms: care, health, mental
PHSO casework decision
77match
P-003585 - Nottinghamshire Healthcare NHS Foundation Trust
Mrs R complains that in the months leading up to her father’s death in May 2022, the Trust discharged him despite him saying he was suicidal. She complains it did not allocate face to face appointments, it cancelled scheduled appointments and did not liaise with other services to ensure his individual mental health needs were met.
Matched on
terms: care, health, mental
Committee recommendation
74match
#16 - Publish clear guidance on key worker roles to ensure care coordination for service users.
In some areas, the emphasis on care coordination may have been lost through the rollout of the CMHF. We recommend that NHS England publish clear guidance on the role of key workers to ensure all service users have access to a named individual responsible for coordinating their care. (Recommendation, Paragraph 110)
Matched on
terms: care, health
PFD report
73match
David Chatburn
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.
Matched on
terms: health, mental
PFD report
73match
Samiyo Farah
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.
Matched on
terms: health, mental
PFD report
73match
Samarjit Singh
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.
Matched on
terms: health, mental
PFD report
73match
Katherine Bonaventura
The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.
Matched on
terms: care, mental
PFD report
73match
Leslie Morrison
No formal mental capacity assessment or consideration of a DoLS authorisation was undertaken in the community, and details of the patient's mental health condition did not accompany him to the hospital; the coroner suggests policies to ensure up-to-date information is provided upon admission or discharge.
Matched on
terms: health, mental
PFD report
73match
Rohan Fitzsimons
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.
Matched on
terms: health, mental
PFD report
73match
John Sloan
Mental health professionals failed to inquire about suicidal ideation and did not record concerns from the patient's daughter, representing missed opportunities to provide supportive measures.
Matched on
terms: health, mental
PFD report
73match
Kieran Hubbard
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.
Matched on
terms: health, mental
PFD report
73match
Lee Carpenter
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.
Matched on
terms: health, mental
PFD report
73match
Billy Jenkins
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.
Matched on
terms: health, mental
PFD report
73match
Daniel Moran
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.
Matched on
terms: health, mental
PFD report
73match
Sam Pringle
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.
Matched on
terms: care, mental
PHSO casework decision
72match
P-002767 - Hampshire and Isle of Wight Integrated Care Board
Mrs A complains the Hampshire and Isle of Wight Integrated Care Board did not ensure her son had the mental health care he needed, as it had agreed to following a tribunal. She also complains it delayed psychiatric funding for both her sons.
Matched on
terms: care, health, mental
PHSO casework decision
72match
P-002332 - Nottinghamshire Healthcare NHS Foundation Trust
Mr A complains the Trust failed to put a plan in place for his brother when it was clear his parents could not care for him, failed to make sure his brother was taking his medication correctly and made no effort to contact his brother shortly before his death.
Matched on
terms: care, health, plan
LGO / SPSO decision
72match
PSOW-202305228 - Cardiff and Vale University Health Board
Ms A’s complaint centred on whether the care and treatment provided to her by the Health Board, and specifically its assessment and management of her risk of suicide and self-harm, on specified dates was appropriate. The Ombudsman’s investigation found that broadly the assessment and management of Ms A’s risk of suicide was reasonable. It is recognised that in...
Matched on
terms: care, health, mental
PFD report
69match
David Pooley
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.
Matched on
terms: care, plan
PFD report
69match
Sandra Brotherton
A sole carer did not have a contingency plan in place for emergencies, a personal assistant's care plan was not clearly documented or provided, and an urgent consultant psychiatrist appointment was difficult to obtain.
Matched on
terms: care, plan
PFD report
69match
Olaseni Lewis
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.
Matched on
terms: care, health
PFD report
69match
Dean Rowland
Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.
Matched on
terms: health, mental
PFD report
69match
Patricia Chambers
Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.
Matched on
terms: health, mental
PFD report
69match
Sophie Boothe
Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate mental health assessment and referral downgrading.
Matched on
terms: health, mental
PHSO casework decision
69match
P-001907 - Mersey Care NHS Foundation Trust
Mrs E complains the Trust changed its mind about helping her get specialised funding to treat her son's obsessive compulsive disorder (OCD). She says the Trust discharged her son without putting a treatment plan in place.
Matched on
terms: care, plan
LGO / SPSO decision
69match
23-017-881a - Gloucester Health & Care NHS Foundation Trust (23 017 881a)
Summary: Mrs A complains about the section 117 aftercare being provided to her sister, Ms B. We should not investigate this complaint because the Trust has already admitted fault and taken steps to remedy the injustice to Ms B. Further investigation would not achieve anything more.
Matched on
terms: care, health
Inquiry recommendation
68match
SP51 - GMMH local structured risk assessment responsibility
At the local level, Greater Manchester Mental Health NHS Foundation Trust should liaise with all of the relevant community healthcare organisations (including Child and Adolescent Mental Health Services and Criminal Justice Liaison Services) to ensure that there is clarity about who is responsible for conducting complex structured risk assessments for children and young people who present a risk...
Matched on
terms: care, health, mental
PHSO casework decision
68match
P-002575 - George Eliot Hospital NHS Trust
Mr M complains the Trust dismissed his mental health diagnosis that he has had for over ten years. He also complains the specialist nurse he has been under the care of for HIV treatment also said there was nothing in his records about a mental health diagnosis.
Matched on
terms: care, health, mental
PHSO casework decision
68match
P-003363 - East London NHS Foundation Trust
Mr O complains about aspects of the care provided to his brother by the Trust’s Community Mental Health Team between December 2021 and May 2022.
Matched on
terms: care, health, mental
LGO / SPSO decision
68match
PSOW-202000537 - Hywel Dda University Health Board
Ms D complained that the Hywel Dda University Health Board (“the Health Board”) failed to provide her partner, Mr B, with appropriate care and treatment. In particular, Ms D complained that the Health Board failed to provide Mr B with appropriate mental health support and treatment and that Mr B experienced delays and difficulties in obtaining a dual...
Matched on
terms: care, health, mental, plan