Mental health ward clinical decision policy
33 items
1 source
Lack of rigorous policies for critical clinical decisions on mental health wards, such as safe return of personal items.
Cross-Source Insight
Mental health ward clinical decision policy has been flagged across 1 independent accountability source:
33 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (33)
Shannon Lee
Concerns: There is persistent staff confusion regarding the exact timing of 15-minute observations, with no clear national standard, risking inconsistent patient monitoring.
Response: The Trust states its Level 2 intermittent observation policy is unambiguous and clearly specifies 15-minute intervals with no reference to 30 minutes. It describes existing electronic observation (eObs) system functionality …
Responded
Charlotte Tetley
Concerns: A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, risking patient safety.
Responded
Azroy Dawes-Clarke
Concerns: The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and the Mental Capacity Act, leading to unclear responses during medical emergencies and conveyance.
Responded
Luke Worrell
Concerns: Clinical staff lacked awareness of potentially fatal Clozapine side effects and inappropriately used a community treatment order when a higher level of Mental Health Act section was necessary.
Overdue
Kevin Ince
Concerns: There was insufficient consideration and utilisation of legal powers under the Mental Health Act and Mental Capacity Act to ensure a detained patient received necessary treatment and nutrition.
Responded
Aaron Deeley
Concerns: Patients held under Section 5(2) MHA in acute wards lack a Responsible Clinician or Mental Health Liaison assessment. Acute staff lack specialist mental health training, and policy for 1:1 observation is confusing, leaving a critical protocol gap.
Responded
Adrian James
Concerns: The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for predicting and preventing impulsive acts of self-harm.
Responded
Roberto Bottello
Concerns: Failures in mental health service follow-up and assessment, alongside significant delays in Mental Health Act assessment at hospital, despite clear signs of acute psychosis.
Responded
Paz Ogbe-Millar
Concerns: Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
Responded
Michelle Whitehead
Concerns: Staff lacked sufficient training and awareness of the Rapid Tranquilisation policy, which was also unclear on monitoring unconscious patients and deviated from national guidelines, alongside a lack of guidance for Psychogenic Polydipsia.
Responded
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
Mollie Stansfield
Concerns: There was a significant failure in understanding and correctly implementing Section 5(2) of the Mental Health Act, coupled with inadequate awareness and training for medical staff on essential holding powers.
Overdue
Yuksel Ismail
Concerns: Bedford Hospitals NHS Trust failed to implement recommendations for mental health patient transfers, with an inadequate new policy and staff confusion regarding powers to detain 'at-risk' patients lacking mental capacity.
Responded
Maziellie Mackenzie
Concerns: The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.
Responded
Angela Frost
Concerns: The Trust lacks formal guidance for seeking second psychiatric opinions and consultants demonstrate poor understanding of confidentiality when communicating with family members regarding patient care and risk planning.
Responded
Emma Dorman
Concerns: Non-clinical staff inappropriately influenced patient leave decisions, overriding clinical judgment. Additionally, the ward lacked psychologist input for over three years due to persistent recruitment failures.
Responded
Christopher Swain
Concerns: Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a failure to provide staff escorts for sectioned patients being transferred.
Responded
Claire Lilley
Concerns: Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.
Responded
Thiago Araujo
Concerns: The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Responded
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
Andrew Wells
Concerns: The Trust's Root Cause Analysis was flawed due to a lack of psychiatric expertise, resulting in an inadequate review of clinical decisions. Clinicians also failed to appropriately apply the Mental Health Act, using "de-facto" detention without proper safeguards.
Overdue
Rebecca Marshall
Concerns: The provided text is largely boilerplate and does not detail specific safety concerns beyond the general risk of future deaths related to hospital and mental health care.
Responded
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
Francesca Whyatt
Concerns: Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and the failure to automatically treat ligature incidents as Serious Untoward Incidents (SUIs), despite the rapid risk of death.
Overdue
Dominic White
Concerns: A robust protocol is lacking to ensure all personnel are aware of patient observation levels. An approved mental health professional showed a lack of recognition regarding the absconding risk when allowing a detained patient leave.
Overdue
Leslie Matthews
Overdue
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
Kimberley Parsons
Concerns: Unjustified advice on 'assisted self-harming' was given without research backing, consultant approval, or documentation, indicating a lack of clear protocols for novel treatments and training failures.
Responded
Rafel Delezuch
Concerns: Emergency department staff lacked awareness and training on restraint policies, the dangers of prone restraint, and suitable medications for rapid tranquilisation, leading to unsafe practices.
Responded
Dale Proverbs
Concerns: Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, which could lead to future fatalities. Higher observation standards previously in place would likely have prevented the death.
Responded
Keiran Toman
Concerns: Psychiatric services failed to adequately assess patient capacity to refuse family contact, leading to isolation and increased risk of deterioration, especially when patients disengaged without follow-up to next of kin.
Overdue
Natasha Raghoo
Concerns: Critical failures included inadequate staff training in resuscitation, sporadic and incomplete patient observations, and failure to perform essential diagnostic tests like ECGs. Poor communication during staff handovers and with families also compromised care.
Overdue
Kirabo Kiwanuka
Concerns: Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.
Overdue