Mental health ward clinical decision policy
Lack of rigorous policies for critical clinical decisions on mental health wards, such as safe return of personal items.
81 items
10 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
93match
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: decision, health, mental
Committee recommendation
90match
#33 - Eighth Report - Children and young people’s mental health
In addition to our recommendations on the use of restraint that we set out in our report on the treatment of autistic people and people with learning disabilities, the use of prone restraint on children and young people should be banned in all inpatient settings and in transit. Further action should be taken with all inpatient and transport...
Matched on
terms: health, mental, ward
PFD report
89match
Andrew Wells
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.
Matched on
terms: clinical, decision, health, mental
PFD report
89match
Maziellie Mackenzie
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.
Matched on
terms: health, mental, policy
PFD report
89match
Aaron Deeley
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.
Matched on
terms: health, mental, policy, ward
PFD report
85match
Emma Dorman
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.
Matched on
terms: clinical, decision, ward
PFD report
85match
Yuksel Ismail
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.
Matched on
terms: health, mental, policy
PFD report
85match
Luke Worrell
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.
Matched on
terms: clinical, health, mental
PPO recommendation
81match
The Head of Healthcare
The Head of Healthcare should ensure that where a patient has a confirmed history of a serious mental illness and there is evidence of risk to others, the mental health team should: • document whether they have considered detention under the appropriate section of the Mental Health Act; • if this is not felt to be appropriate, record...
Matched on
terms: clinical, decision, health, mental
LGO / SPSO decision
77match
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: clinical, health, mental, policy
PFD report
73match
Dale Proverbs
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.
Matched on
terms: health, mental
PFD report
73match
Leslie Matthews
Date of report: 26 July 2016 Ref: 2016-0276 Deceased name: Leslie Matthews Coroners name: Crispin Oliver Coroners Area: County Durham and Darlington Category: Hospital Death (Clinical Procedures and medical management) related deaths; Other related deaths This report is being sent to: Patient Safety Lead, County Durham and Darlington NHS Foundation Trust; Medicines and Healthcare Products […]
Matched on
terms: clinical, health
PFD report
73match
Dominic White
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.
Matched on
terms: health, mental
PFD report
73match
Rebecca Marshall
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.
Matched on
terms: health, mental
PFD report
73match
Claire Lilley
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.
Matched on
terms: health, mental
PFD report
73match
Paz Ogbe-Millar
Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
Matched on
terms: health, mental
PFD report
73match
Kevin Ince
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.
Matched on
terms: health, mental
PFD report
73match
Charlotte Tetley
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.
Matched on
terms: health, mental
Scottish FAI
72match
Kerry Ann Finnigan
Recommendation One: All patients admitted to a psychiatric ward within NHS Lanarkshire should be reviewed by a senior clinician within at least 24 hours of admission, a policy, which has been seen to work successfully in other NHS areas such as NHS Grampian. Such a policy would ensure that admitted patients to hospital would have a senior review...
Matched on
terms: clinical, health, mental, policy
PHSO casework decision
72match
P-004433 - Barts Health NHS Trust
Dr G complains about the treatment provided to her son, Mr K. She says that Mr K was not given his medication or any food while on the mental health inpatient ward. She also says that he was unnecessarily sectioned.
Matched on
terms: health, mental, ward
Scottish FAI
72match
Dr Sara Lilian Macrae
(i) When staff in a secure mental health ward are presented with evidence that a patient has vocalised suicidal ideation and demonstrated means to complete suicide by presentation of a ligature, urgent action to search that patient's room and person for any other potential ligatures ought to be taken. In addition, consideration should be given to placing the...
Matched on
terms: clinical, health, mental, ward
PFD report
69match
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: health, mental
PFD report
69match
Christopher Swain
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.
Matched on
terms: health, mental
PFD report
69match
Mollie Stansfield
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.
Matched on
terms: health, mental
PFD report
69match
Roberto Bottello
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.
Matched on
terms: health, mental
PHSO casework decision
68match
P-001556 - Wrightington, Wigan and Leigh NHS Foundation Trust
Mr A complains that the Trust did not provide proper treatment on the Mental Health Ward and discharged him in a psychotic state of mind. He also complains the Trust has failed to send him copies of his medical records.
Matched on
terms: health, mental, ward
PHSO casework decision
68match
P-003123 - Oxleas NHS Foundation Trust
Mr A complains about the Trust’s decision to transfer him back to prison without properly considering his mental health.
Matched on
terms: decision, health, mental
PPO recommendation
65match
The Governor and Head of Healthcare
identify what training is needed so there is clear understanding of the lawful authority of prison staff, and when the Mental Capacity Act should be used instead, or in parallel.
Matched on
terms: health, mental
LGO / SPSO decision
65match
PSOW-202406503 - Cwm Taf Morgannwg University Health Board
Mrs B complained about the care and treatment provided by the Health Board for her mental health and neurological condition. In addition, Mrs B raised concerns about not receiving responses from the relevant team involved in her care. The Ombudsman found that although the Health Board had provided a response to Mrs B, she remained unclear as to...
Matched on
terms: health, mental
PHSO casework decision
65match
P-003375 - Greater Manchester Mental Health NHS Foundation Trust
Miss H complains that Greater Manchester Mental Health NHS Foundation Trust failed to properly manage her lithium medication.
Matched on
terms: health, mental
PFD report
61match
Francesca Whyatt
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.
Matched on
terms: ward
PFD report
61match
Michelle Whitehead
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.
Matched on
terms: policy
IMB recommendation
60match
Foston Hall (2021)
Are there plans to address: the inadequate provision for mental health throughout the criminal justice system, which is a serious concern? This is manifested in Foston Hall in a high level of unmet need for mental health treatment and delays in transferring prisoners to secure hospitals
Matched on
terms: health, mental
IMB recommendation
60match
Bullingdon (2021)
There are some prisoners in Bullingdon whose state of mental health is such that the prison is not equipped to cope with them; it is very likely that they need to be sent to secure psychiatric institutions. Some of these prisoners have spent far longer in the SSCU than 42 days, after which continued segregation has to be...
Matched on
terms: health, mental
IMB recommendation
60match
Oakwood (2024)
Could the Director work with the healthcare unit to try to ensure that a mental health professional is present during CSU GOoD reviews when the prisoner concerned has serious mental health concerns?
Matched on
terms: health, mental
IMB recommendation
60match
Isle of Wight (2024)
When prisoners in SARU fail the algorithm and are transferred to the IHU either for observation or anticipated transfer to a secure hospital facility what therapeutic engagement with the mental health team is provided for under the contract with Practice Plus Group?
Matched on
terms: health, mental
PFD report
57match
Rafel Delezuch
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.
Matched on
classifier match
PFD report
57match
Azroy Dawes-Clarke
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.
Matched on
terms: mental
Committee recommendation
56match
#10 - Fifth Report - The treatment of autistic people and people with learning disabilities
We welcome the Government’s announcement that it will bring into force the Mental Health Units (Use of Force) Act 2018 in November 2021. This will go some way to reducing the use of restricted practices in inpatient facilities. However, we remain concerned that the use of restrictive practices remains commonplace in many inpatient facilities and therefore still presents...
Matched on
terms: health, mental
IMB recommendation
56match
Downview (2021)
End the current severe lockdown regime in prisons, taking into account its significant and long-term impact on the mental health of prisoners.
Matched on
terms: health, mental
IMB recommendation
56match
Liverpool (2022)
Strengthen and enhance legislation to prevent prisoners being segregated for long periods of time, particularly those experiencing mental health difficulties.
Matched on
terms: health, mental
IMB recommendation
56match
Heathrow Immigration Removal Centre (2022)
We would support broader use of the Colnbrook care suite for short term respite, particularly for detainees with deteriorating mental health conditions. We also urge the Contractor to replicate the Colnbrook care suite facility in Harmondsworth.
Matched on
terms: health, mental
IMB recommendation
56match
Low Newton (2025)
For some years, the IMB at HMP/YOI Low Newton has raised the issue of women presenting with severe mental ill health and challenging behaviour. Given the disruption this creates, the resources required to manage them and the toll this takes on everyone around them, when can we expect that they will be re-directed to a more suitable environment,...
Matched on
terms: health, mental
PHSO casework decision
56match
P-002520 - South London and Maudsley NHS Foundation Trust
Ms H complains the Trust deliberately moved her to a block of flats and wrongly sectioned her under the Mental Health Act.
Matched on
terms: health, mental
PHSO casework decision
56match
P-002945 - Manchester University NHS Foundation Trust
Miss U complains about the care and treatment when she was sectioned under the Mental Health Act. She said staff used inappropriate physical force and did not tell her about several aspects of her treatment.
Matched on
terms: health, mental
PFD report
53match
Natasha Raghoo
The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on antipsychotics with raised blood pressure, inconsistent communication during staff handovers, and unclear policies on family involvement in care planning.
Matched on
classifier match
PFD report
53match
Lee Bates
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.
Matched on
classifier match
Committee recommendation
53match
#21 - Government risks land value capture by announcing New Town sites without policy.
There is significant potential to use land value capture as part of funding the proposed New Towns, especially on green field sites. However, we are concerned that the Government has announced substantial detail of the 12 potential sites without a planning policy to protect land value, contrary to the recommendation of the New Towns Taskforce. It appears that...
Matched on
terms: policy
Committee recommendation
53match
#12 - Update national policy to encourage minimum affordable housing targets in Local Plans.
As part of its ongoing review of the viability planning practice guidance, the Government must consider how different types of developer contribution could be re-negotiated following a viability assessment, to protect affordable housing contributions. The Government must also update national policy to encourage all local authorities to set a minimum percentage target for affordable housing in their Local...
Matched on
terms: policy
PFD report
49match
Kimberley Parsons
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.
Matched on
classifier match