Mental health access for alcohol addiction
272 items
2 sources
Significant barriers to timely mental health support for patients with alcohol addiction due to service and awareness gaps.
Cross-Source Insight
Mental health access for alcohol addiction has been flagged across 2 independent accountability sources:
1 inquiry rec
271 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (271) — showing 100 most recent
Micheala Finch
Concerns: Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse and not deploying escalated home-based treatment.
Pending
Oliver Robinson
Concerns: A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.
Response: Curaleaf Clinic has implemented several changes following an internal investigation, including requiring specialist consultants prescribing cannabis-based medicinal products to provide evidence of competencies across all clinical practice areas. They also …
Responded
Diana Grant
Concerns: Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, where their needs cannot be fully met, posing a risk of death.
Response: NHS England has established Single Points of Contact (SPoCs) across all 15 Secure Provider Collaboratives to streamline mental health bed admissions from prisons, and these SPoCs are implementing robust referral …
Overdue
Lynsey Dearden
Concerns: A patient allocated community mental health support received no appointments for months. Critically, there was no policy or framework guiding the timing or process for appointments or initial assessments.
Response: NHS England has shared draft national guidance, the Personalised Care Framework, with systems for early adoption, which sets out core principles for care plans, therapeutic relationships, and access to secondary …
Response: The Trust has implemented new Standard Operating Procedures (SOPs) for patient contact and appointments, mandating initial contact within 48 hours and assessment within 14 days of referral. A new process …
Responded
Andrew Dodds
Concerns: Police failed to provide next of kin details to the s136 suite and crucial information about prior s136 detention was missing from police systems, preventing mental health service contact.
Response: South Yorkshire Police has implemented a new Standard Operating Procedure (SOP) and developed enhanced briefings for officers regarding the transfer of individuals detained under Section 136 of the Mental Health …
Responded
Ethel Robertson
Concerns: A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their patients' ED admissions for non-mental health issues, risking delayed care and missed links to mental health decline.
Response: The Trust clarifies that Mental Health Liaison Teams already notify the Older People's Mental Health Service (OPMH) if mental ill health is evident in the Emergency Department. They dispute the …
Responded
Suzanne Ellerby
Concerns: A lack of universal safety netting guidelines for transferring vulnerable mental health patients from secondary to primary care leaves patients unsupported, leading to gaps in essential follow-up.
Response: NHS England has drafted the Personalised Care Framework (PCF) guidance, which sets out specific recommendations for transferring and receiving services to ensure effective care transitions for mental health patients. This …
Response: The Department for Health and Social Care acknowledges the concerns and, following enquiries with NHS England, highlights that NHS England has developed draft Personalised Care Framework (PCF) guidance. This guidance …
Overdue
Patricia Genders
Concerns: Over-reliance on A&E for mental health crises due to inadequate dedicated placements creates an unsuitable and insecure environment, risking patient deterioration and abscondment.
Response: NHS England has initiated a pilot program for 24/7 neighbourhood mental health centres and implemented a 24/7 Mental Health Crisis Pathway. They have also published updated guidance for mental health …
Response: The Department for Health and Social Care has introduced a mental health option via NHS 111 and expanded 24/7 liaison mental health teams. It plans to deliver 200 more mental …
Responded
Caitlin Imber
Concerns: CAMHS closed a referral for a vulnerable child due to missing contact information without making further enquiries, causing a significant and potentially dangerous delay in support.
Response: CAMHS has changed its standard operating procedure to ensure appointments are offered even when contact numbers are missing from referrals, a change made following the investigation. The service is also …
Responded
Sophie Towle
Concerns: There was a critical lack of joint policy and liaison between physical and mental health teams for complex cases involving foreign body insertion, and the specialist Personality Disorder Hub was disbanded, reducing expert care.
Response: Nottinghamshire Healthcare has collaborated with Sherwood Forest Hospital to create a joint management policy for patients with inserted foreign bodies, which is currently being trialled. The Trust has also published …
Response: Sherwood Forest Hospitals has collaborated with Nottinghamshire Healthcare to develop and ratify a new guideline for the management of deliberately inserted foreign bodies, which has been disseminated to staff. This …
Overdue
Scott Berry
Concerns: Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews or rehabilitative programs, increasing suicide risk.
Response: HM Prison and Probation Service has implemented multiple changes to policy and practice for IPP prisoners, including revisions to release on temporary licence and offender management processes. They have updated …
Responded
Jack Peatling
Concerns: A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to an avoidable suicide.
Response: NHS England has made £75 million available for local systems to improve bed capacity and developed a national mental health and children and young people’s bed management platform. They are …
Response: The Department of Health and Social Care is committing £26 million in capital investment to open new mental health crisis centres. They have also asked integrated care boards to drive …
Responded
Joanna Chamberlain
Concerns: A gap exists in safe spaces for mental health patients needing more support than home teams provide. National guidance is needed for proactively including family and GP input in care plans.
Response: NHS England is trialling neighbourhood mental health centres in six areas to provide community support for mental health patients not in immediate crisis. They have also shared draft 'Personalised Care …
Responded
Imogen Nunn Prevention of future deaths report
Concerns: A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient clinicians, create significant risks for deaf mental health patients.
Response: The Department for Education acknowledges concerns regarding BSL interpreter shortages and procurement, but maintains the government's preference for industry self-regulation. The Minister will raise these issues with the BSL Advisory …
Responded
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
Victoria Taylor
Concerns: Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex needs.
Overdue
Charles Stonley
Concerns: Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their risk of self-harm and death.
Overdue
Chloe Barber
Concerns: Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a poor understanding of Mental Health Act aftercare provisions.
Overdue
Resmije Ahmetaj
Concerns: Mental health services exhibited inadequate clozapine monitoring, poor communication and escalation regarding subtherapeutic medication levels, and delayed management of critical side effects, increasing psychosis relapse risk. Additionally, a car park's penultimate floor lacked adequate safety barriers.
Responded
Jessica Smithson
Concerns: The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void inconsistently, leading to varied support, challenges in police response, and limited integration with NHS mental health pathways.
Responded
Tracey Ostler
Concerns: A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both psychiatric and physical healthcare.
Responded
Dean Bradley
Concerns: Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, leaving vulnerable people at risk.
Responded
Joseph Powell
Concerns: GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable individuals.
Responded
James Sheppard
Concerns: There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to those requiring mental health care.
Responded
Sarah Boyle
Concerns: The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, with slow transfer processes, risking future deaths.
Responded
Imogen Nunn
Concerns: A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial proceedings for deaf patients and witnesses.
Responded
Leanne Carroll
Concerns: The Perinatal Mental Health Service suffers from insufficient awareness among health professionals, inadequate staffing levels, and a lack of documented decisions and discussions in patient records at the Single Point of Access.
Responded
John McLoughlin
Concerns: Peer Support for pilots is inadequate for severe mental health issues and suicidal thoughts, highlighting a lack of robust mental health support for escalating problems within the industry.
Overdue
Matthew Lynch
Concerns: The internal investigation was inadequate, and barriers exist to proper Mental Health Act assessments. There's poor information sharing between agencies regarding residents, and support workers require more focused mental health training.
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
Joshua Weavers
Concerns: Nationally and locally, excessively long waiting times for Autism Spectrum Disorder (ASD) assessments delay crucial care and increase suicide risk, while local bridge safety measures fail to meet current guidance.
Responded
Aeran Taylor
Concerns: Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and insufficient long-term rehabilitation options for veterans with substance abuse were identified.
Responded
Paul Williams
Concerns: Homelessness, forced family separation, and prolonged waiting times for public housing severely impacted mental health, contributing to the deceased's deteriorating condition.
Responded
Robert McGowan
Concerns: Cultural, structural, and systemic barriers prevented a patient with Autism and complex mental health needs from receiving adequate physical health treatment, resulting in only partially treated bacterial endocarditis.
Responded
Joseph Forbes Black
Concerns: Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite the increased risk from potent synthetic opioids.
Responded
Paul Taylor
Concerns: Suspects interviewed on a voluntary basis for relevant offences do not receive automatic mental health nurse referrals, creating a disparity in access to healthcare support compared to those in custody.
Responded
Haydar Jefferies
Concerns: HMP Coldingley lacked systems for recording welfare information, collating prisoner details, checking mental health referrals, and providing out-of-hours clinical mental health support, leading to inadequate crisis management.
Overdue
Oliver Winson
Concerns: Patients with undiagnosed or untreated ADHD face excessively long waiting lists, leading to potential deterioration, harmful behaviors, and increased risk of death.
Responded
Matthew Sheldrick
Concerns: 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.
Responded
Matthew Sheldrick
Concerns: 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.
Responded
Timothy De Boos
Concerns: 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.
Responded
Kayleigh Melhuish
Concerns: HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show deficiencies in ACCT review training. Additionally, a specific ligature point was identified in Residential Unit 3.
Overdue
Amy Butcher
Concerns: 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.
Responded
Kirsten Hocking
Concerns: There is a critical lack of specialist rehabilitation accommodation for women at high risk of self-harm, leading to ineffective post-release support. Probation officers also lack sufficient understanding of available housing options and appropriate release planning.
Responded
Alexander Rogers
Concerns: 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.
Responded
Jagjeet Singh
Concerns: A chronic national shortage of mental health beds meant a patient was repeatedly without a bed upon medical discharge, forcing him into unsuitable accommodation or rough sleeping.
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
Malcolm Taylor
Concerns: 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.
Responded
Aran Bradbury
Concerns: The ambulance triage system incorrectly prioritised a patient with both substance ingestion and mental illness, assigning a lower category response because mental health history overshadowed drug ingestion, delaying critical aid.
Overdue
Declan Morrison
Concerns: A widespread shortage of suitable placements for complex mental health needs led to the deceased's mental health decline, inappropriate detention, and ultimately contributed to his death.
Responded
Paul Chase
Concerns: There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after release. Resources are extremely limited, leading to extensive waiting times for essential treatment and therapy.
Responded
Sean Heath
Concerns: Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.
Responded
Leighton Dickens
Concerns: Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support and unimplemented alternative services.
Responded
Maria Kelly
Concerns: Significant systemic failure in mental health and physical health follow-up, marked by numerous failed contact attempts for reviews and the absence of a welfare check for a vulnerable patient.
Responded
Charne Petit
Concerns: A severe shortage of mental health beds meant the patient could not receive necessary hospital treatment and led to patients being inappropriately detained in general hospitals.
Responded
Ryan Ouslem
Concerns: Police officers lacked crucial mental health training and understanding of their powers, failed to conduct thorough inquiries, and there was inadequate timely information sharing and joint working protocols between police and mental health services.
Responded
Helen Kerr
Concerns: Mental health teams failed to act on repeated information about declining patient mental health, delaying appropriate treatment. Crucially, information sharing between police and mental health services out-of-hours is inadequate, and risks to staff from patients' delusions were not addressed.
Responded
Carol Guest
Concerns: There are inadequate crisis support systems for mental health patients over 65, as existing services are unavailable by age, and general practitioners provide incorrect referral information.
Responded
Joanita Nalubowa
Concerns: Rigid Mental Health Act aftercare criteria lack flexibility, preventing suitable accommodation for patients whose historical residences are inappropriate, risking future harm by limiting discretion in placement decisions.
Overdue
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
Nimo Osman
Concerns: A significant delay in calling an emergency ambulance after a patient's collapse was exacerbated by a senior nurse's continued belief that nurses cannot call 999 without a doctor's approval, undermining training efforts.
Responded
Martyn Stringer
Concerns: A severe and frequent lack of suitable beds for compulsory mental health detention prevents patients from receiving critical care, with beds sometimes denied due to anticipated demand.
Responded
Matthew Braben
Concerns: Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages significantly harmed prisoner mental health.
Overdue
Stephen Lindsay
Concerns: Unclear commissioning responsibilities for mental health support caused critical care gaps for a terminally ill patient. This risks future deaths as patients may not receive necessary support, leading to crises.
Responded
Kieran Lavin
Concerns: Critical suicide risk information was not recorded or shared effectively due to busy shifts. Post-death guidance for informal patient transport risk assessment remains inadequate, lacking specific questions for comprehensive evaluation.
Responded
Nathan Scantlebury
Concerns: There is a critical and long-standing national and local shortage of suitable placements for high-risk children with complex mental health needs.
Overdue
Gemima Christodoulou-Peace
Concerns: Clinicians lack a central resource to identify medications increasing suicidal behaviour, call recordings for remote interactions are limited, and there were significant delays in accessing mental health services and medication reviews despite escalating patient distress.
Responded
Megan Davison
Concerns: A national lack of diagnosis and integrated treatment pathways for Type 1 Diabetes with Eating Disorder (T1DE) and DKA, alongside an inability to share patient records with private providers, impedes comprehensive care.
Responded
Judith Obholzer
Concerns: Insufficient clarity and integration between private and NHS mental health services led to poor information sharing, difficult crisis team referrals, and delayed treatment plans for patients.
Responded
Benjamin Faux
Concerns: The university failed to provide adequate pastoral care for taught research students, lacked processes for monitoring engagement and ensuring follow-through on study suspensions, and staff underestimated mental health risks.
Responded
Miles Hurley
Concerns: Ineffective communication and documentation between police and the Liaison Diversion Service, coupled with a lack of guidelines for mental health assessments of intoxicated individuals, compromised appropriate care in custody.
Responded
Lee McHale
Concerns: The 'bedroom tax' caused significant housing benefit shortfalls, leading to rent arrears and fear of eviction for a former foster parent, contributing to their fatal overdose.
Overdue
Juan Martin
Concerns: Inadequate mental health bed capacity in London leads to prolonged waits for patients in unsuitable environments, directly posing a risk of future deaths.
Responded
Katie Madden
Concerns: Child services lacked systems to treat vulnerable parents (e.g., Claire's Law recipients) as higher risk in child care investigations, failing to assess the mental health impact of child removal processes or provide independent support. Funding for specialist therapy was also problematic.
Responded
Emma Morris
Concerns: 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.
Responded
Benjamin Sulzbacher
Overdue
Brandon Turner
Concerns: 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.
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
Darren Docherty
Concerns: Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks to their health and safety.
Overdue
Carole Mather
Concerns: A lack of overarching national guidance hinders health and social care practitioners in assessing mental capacity and applying legal frameworks for individuals with chronic alcohol dependence, risking their protection.
Responded
Tobias Mannering-Jones
Concerns: Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability and exploitation risks, compounded by poor inter-agency coordination.
Responded
Nicola Rayner
Concerns: A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's death and continues to pose a significant risk to other patients.
Responded
James Day
Concerns: Inadequate and difficult-to-access mental health support for service personnel with PTSD, both during and after service, forces individuals to self-medicate, leading to poor outcomes.
Responded
Abdullah Popalzai
Concerns: Acutely psychotic prisoners requiring transfer for treatment are left untreated and at risk due to a shortage of timely psychiatric hospital bed availability.
Responded
Shahzadi Khan
Concerns: National mental health bed shortages led to out-of-area placements with poor communication and discharge planning. There was also a lack of awareness regarding menopause as a factor in mental health deterioration.
Responded
Rachel Mortimer
Concerns: The family received no support options for a relative's mental state, and no alternative risk mitigation service was provided when the intended one was unavailable.
Responded
Matthew Wickes
Concerns: The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly for neurodiverse students, leading to a gap in pastoral support and risk of overlooking struggling individuals.
Overdue
Amarnih Lewis-Daniel
Concerns: Extremely long waiting lists for Gender Identity Clinics, coupled with a severe lack of local support and specialist knowledge in mental health services, and unclear responsibilities for patient welfare, are intensifying distress.
Responded
Jessica Eastland-Seares
Concerns: Critically inadequate community provision and insufficient financial investment for autistic individuals force unnecessary inpatient admissions and A&E attendances due to a severe lack of suitable support placements.
Responded
Charlene Roberts
Concerns: Systemic failures in managing a complex patient included unquestioned long-term cyclizine prescribing, inadequate supervision, and a lack of specialist dual-diagnosis treatment options, allowing the patient to self-harm.
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
Angela Collins
Concerns: Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health crisis receive insufficient or no support.
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
Philip Malone
Concerns: A persistent and chronic lack of psychiatric bed capacity in Birmingham and Solihull continues to pose a significant risk, despite previous reports and insufficient remedial actions.
Responded
Madeleine Savory
Concerns: There is a national shortage of Tier 4 beds in paediatric mental health facilities, delaying timely access to crucial care for children in need.
Responded
Roger Stevenson
Concerns: A vulnerable adult with chronic mental ill health was "lost in the system" due to inadequate follow-up, delayed access to services, and lack of proactive support. Staffing shortages and poor family engagement further jeopardized care.
Overdue
Kevin Gale
Concerns: DWP procedures, including lengthy forms, long phone queues, and travel requirements, are impractical and exacerbate symptoms for individuals with mental health illnesses.
Responded
Federica Cavenati
Concerns: There is an absence of intravenous antidepressant medication in the UK for patients who cannot take it orally, unlike in Europe, limiting treatment options for vulnerable individuals.
Overdue
Alex Dews
Concerns: School avoided NHS mental health referrals due to excessive waiting lists, instead procuring private support with unclear allocation processes and poor communication between the school and external providers.
Responded
Leighton Dickens
Concerns: Police officers have limited access to qualified mental health advice and clinical records when responding to mental health crises, as urgent support teams are not readily available and a promised service is unimplemented.
Overdue