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
Source spread
Where this theme appears
Mental health ward clinical decision policy has been flagged across 10 independent accountability sources:
33 PFD reports
6 committee recs
1 CQC action
2 PPO recs
20 IMB recs
2 Scottish FAIs
1 detention investigation rec
8 PHSO decisions
5 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
PFD Reports (33)
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
Natasha Raghoo
Concerns: 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.
Response (Partnership in Care): Partnership in Care reports improvements in information flow between PiC and SLaM, including a Liaison Nurse attending The Dene from SLaM several days a week utilizing a VPN link. PiC …
Overdue
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
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.
Response (Department of Health): The Department of Health notes that Partnerships in Care (PIC) redrafted their policies to conform exactly to the 2008 Mental Health Act 1983 Code of Practice. Staff failure in this …
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.
Response (University Hospitals of Leicester): All clinical staff in the Emergency Department are now aware of the Trust's Restraint Policy and the dangers of prolonged restraint in the prone position. The Chief Pharmacist has met …
Responded
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.
Response (CQC): CQC carried out a comprehensive inspection of Avon and Wiltshire Partnership NHS Trust (AWP) in June 2014, leading to enforcement action and four warning notices. AWP addressed the warnings, including …
Response (Avon Wiltshire NHS Trust): The trust does not endorse harm minimisation strategies, but after a staff member mooted 'safe self-harm' they plan to issue an internal safety alert to all clinical staff to remind …
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.
Response (Cambian Group): Cambian Group has met with St Thomas' and agreed a protocol to reduce the possibility of inadequate communication or care in the future.
Overdue
Leslie Matthews
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA has brought the Coroner's concerns to the attention of the manufacturer and requested that they evaluate whether additional clarity in information could be incorporated at the next Instructions …
Response (County Durham and Darlington NHS Trust): All oxygen flowmeters across the Trust have been checked and faults logged. Equipment Controllers/Department Managers are now performing weekly checks of all flowmeters, using a checklist devised by the Medical …
Responded
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.
Response (Whittington Hospital NHS2 Trust): Whittington Health NHS Trust, Camden & Islington NHS Foundation Trust, and Barnet, Enfield and Haringey Mental Health NHS Trust have created a joint protocol to improve mental health observations in …
Overdue
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.
Response (Priory Hospital): The Priory Hospital Roehampton details environmental and health and safety risk assessments undertaken and coordinated with Policy H43 Observation and Engagement throughout the ward. The Incident Management; Reporting and Investigation …
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.
Response: The Royal Free London NHS Foundation Trust notes that the concerns relate to Camden & Islington NHS Foundation Trust (CANDI)'s Mental Health Liaison service, and that CANDI is undertaking a …
Response: Camden and Islington NHS Foundation Trust outlines several actions taken and planned: Clinicians involved have been prevented from working at this level of expertise until the SIR review is complete. …
Responded
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.
Response (Kent and Medway NHS Trust): KMPT has reviewed its Transfer and Discharge of Care policy, developed a shared care protocol with local universities, created a fast-track referral route from universities to the Community Mental Health …
Responded
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
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
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.
Response (Sussex Partnership NHS Foundation Trust): The Trust acknowledges failings in care and outlines previous actions taken following the death, including an internal investigation and sharing of learning. The Trust states that policies for Section 17 …
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.
Response (Oxleas NHS Foundation Trust): Oxleas NHS Foundation Trust will require consistent recording of service users' and carers' feedback in the MDT template, make risk decisions at every MDT meeting, assign responsibility for updating risk …
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.
Response (South West Yorkshire Partnership NHS Foundation Trust): The Trust is reviewing its Patient Flow Procedure, skill-mix for vacant psychology posts, and will update the Job Description and Person Specification for the vacant part-time Psychologist post in Ward …
Responded
Thiago Araujo
Concerns: The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Response (St Pancras Hospital): The Trust has implemented an additional recommendation that discharge of Crisis Team service users due to non-engagement must be discussed in a multidisciplinary meeting with senior overview, and clearly communicated …
Response (Royal Mail): Royal Mail asserts that their processes for handling restricted and prohibited items are adequate and appropriate, given the legal restrictions on interfering with postal packets. They state that they do …
Response (Metropolitan Police Service): The MPS is developing a Suicide Prevention Policy Document and Toolkit. An investigative standards document is also under development as guidance for police first responders.
Response (Dept. of Health and Social Care): The Department of Health and Social Care describes actions taken to limit the availability of chemicals used in suicides, including working with a chemical supplier to identify suppliers on online …
Response (Home Office): The Home Office is aiming to establish a consultation this summer on possible amendments to the Poisons Act, which will include more obligations on online marketplaces including reporting suspicious transactions …
Overdue
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.
Response (Pennine Care NHS Foundation Trust): The Trust has drafted a process for requesting second opinions from consultant psychiatrists, healthcare professionals, patients, families, and carers which will be submitted to the Trust's Quality Group for scrutiny …
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.
Response (Lancashire and South Cumbria NHS Foundation Trust): The Trust developed a written procedure regarding group leave from The Cove, approved it on 3 February 2022, and shared it with staff, suspending group leave until ratification. They also …
Responded
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.
Response (Bedfordshire Hospital NHS Foundation Trust): The Trust updated its Transfer Policy in collaboration with ELFT, adding a section on patient transfers for those at risk of absconding. The Emergency Department and Safeguarding Team reviewed MCA …
Responded
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.
Response (Department of Health): The Department of Health (Northern Ireland) will raise the issue of powers under the Mental Health Order for the detention of patients with HSC Trust Chief Executives and relevant professional …
Response (NHS England): Hull University Teaching Hospitals delivered training to senior nursing teams on mental health and created a five-year Mental Health Learning and Disabilities and Autism Strategy highlighting training as a focus. …
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.
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns regarding the use of Nearest Relative powers under the Mental Health Act. The response notes the Responsible Clinician's powers to bar …
Overdue
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.
Response (Nottinghamshire Healthcare NHS Foundation Trust): Nottinghamshire Healthcare NHS Foundation Trust has taken immediate actions including a teaching session on Psychogenic Polydipsia within the ‘Trustwide 2-day Physical healthcare Training’, sharing learning from Michelle’s inquest, and reviewing …
Responded
Paz Ogbe-Millar
Concerns: Inadequate observation levels for mental health patients waiting in the Emergency Department create significant safety risks.
Response (West Hertfordshire Teaching Hospital): The hospital has replaced the previous proforma with an electronic assessment aligned with the current SOP, approved the PSIRP and PSIRF Policy, is implementing an electronic patient record system, is …
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.
Response (NHS England): NHS England colleagues will be asked to share the learnings from the case within their health and care systems, and will consider whether any further action needs to be taken …
Response (Central and NW London NHS): CNWL has implemented measures including establishing dedicated s136 hubs, improving communication, and maintaining safer staffing levels, and SPA no longer manages calls from the Police or supports locating Health Based …
Response (Metropolitan Police Service): The Metropolitan Police Service reminds recruit police officers about airwave etiquette including the phonetic alphabet and expects them to demonstrate competence through role play activities; the training material is being …
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.
Response (NHS England): NHS England expresses condolences and outlines its commitment to improving community mental health services nationally, but states that responding to the specific concerns raised by the coroner is the remit …
Response (Central and North West London): The Trust outlines actions taken and planned, including issuing additional guidance on managing suicide risk, sharing learning with the team, updating policies, and reminding staff of the need for communication …
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.
Response (NHS England): NHS England acknowledges the concerns and highlights existing national guidance on liaison mental health services. They note actions taken by the Trusts involved, including a joint working group, and describe …
Response (Essex Partnership University NHS Foundation Trust): The trust has reviewed the Mental Health Liaison SOP to provide clearer direction for staff in supporting patients awaiting assessment under the Mental Health Act, focusing on risk management. A …
Response (Mid and South Essex NHS): The trust has reviewed its policy on the admission and treatment of patients with mental health disorders in acute settings, reinforcing mental health support available in ED. They have also …
Responded
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.
Response (Priory Group): The Priory Group has introduced flowcharts at Kemple View for managing declined physical health monitoring and poor diet/fluid intake, including escalation procedures, capacity assessments, and best interest meetings; they have …
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.
Response (NHS England): NHS England has updated the British National Formulary (BNF) and the Summary of Product Characteristics on the Electronic Medicines Compendium (EMC), updated the Specialist Pharmacy Service website page on Clozapine, …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA acknowledges concerns about awareness of clozapine side effects and is reviewing product information for clozapine, including warnings for healthcare professionals, patients, and carers, with stakeholder engagement planned.
Response (Department of Health and Social Care): DHSC acknowledges concerns around clozapine side effects awareness and CTO use. The Mental Health Bill will introduce further professional oversight in decisions regarding the use and operation of CTOs.
Response (CQC): The CQC will review any new information provided in relation to this case via their Specific Incidents Guidance (SIG) and are committed to undertaking a national review of adult community …
Overdue
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.
Response (HM Prison and Probation Service): HMPPS is undertaking a cell design review to explore different materials that meet fire safety and anti-ligature requirements for bedding, expected to conclude at the end of 2026. To improve …
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.
Response (Cheshire and Wirral Partnership NHS Foundation Trust): The Trust has implemented several system changes, including documenting Clinical Prioritisation Meeting outcomes in SystmOne, establishing a Patient Flow Meeting, inviting clinicians to the Clinical Prioritisation Meeting, developing an SOP …
Responded
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 (Black Country Healthcare NHS Foundation): The Trust uses an Electronic Observation system (eObs) with colour-coded prompts to highlight overdue observations and requires staff to record the rationale for any overdue observation. They are introducing dynamic …
Overdue
Committee Recommendations (6)
#10 —
Recommendation: 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 …
Gov response: We already give out information every month about how force has been used on people with a learning disability and autistic people. We are working to reduce the amount of force that is used in …
Under Consideration
#33 —
Recommendation: 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 …
Gov response: The Government is considering this recommendation. Within specialised commissioning, there are a number of programmes of work to reduce restrictive practice. The national Quality Improvement Taskforce for Children and Young People’s Mental Health, Learning disability …
Not Addressed
#33 — Serious concerns about potential cuts to London's affordable housing target hindering delivery.
Recommendation: We are seriously concerned by media reports that London’s affordable housing target could be cut. Whilst the 1.5 million national target cannot be met without a significant increase in housing supply in London, a significant proportion of those new homes …
Gov response: 76. While viability pressures are impacting residential development in many parts of the country, we know they are particularly acute in London. Those pressures were already resulting in proportions of affordable housing being reduced on …
No Published Response
#21 — Government risks land value capture by announcing New Town sites without policy.
Recommendation: 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 …
Gov response: 19. The Government is aware of the potential for securing the land value uplift created by the New Towns Programme, and on 28 September this year, the Government published the New Towns Taskforce report as …
No Published Response
#12 — Update national policy to encourage minimum affordable housing targets in Local Plans.
Recommendation: 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 …
Gov response: 61. The Government is aware of the potential of securing the land value uplift created by schemes such as the New Towns Programme. Existing powers in legislation are clear that, should negotiations fail to purchase …
Accepted
#8 — Make regulations allowing local authorities to include plan-making costs in planning fees.
Recommendation: Once the Planning and Infrastructure Bill receives Royal Assent, the Secretary of State must make regulations to allow local planning authorities to take into account the cost of local and regional plan-making when calculating local planning fees. Local planning authorities …
Gov response: 51. In 2024, the Government consulted on setting indicative benchmark land values for land released from or developed in the Green Belt. The Government does not believe a national benchmark land value would sufficiently account …
Not Accepted
PPO Death in Custody Recommendations (2)
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 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.
IMB Recommendations (20)
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
Ministry of Justice
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 reported to …
HMPPS
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 instead. Some of these prisoners have spent far longer in the SSCU than 42 days, after which continued segregation has to be reported …
Ministry of Justice
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?
Governor / Director
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?
Governor / Director
Heathrow Immigration Removal Centre (2020)
Consideration should be given to making the Care Suite available to a greater number of detainees in distress, even if this results in a wider definition of being ‘in crisis’.
Governor / Director
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.
Ministry of Justice
Liverpool (2022)
Strengthen and enhance legislation to prevent prisoners being segregated for long periods of time, particularly those experiencing mental health difficulties.
Ministry of Justice
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.
Governor / Director
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, where assessment …
Other
Styal (2020)
Over the year, there has been a significant reduction in the time spent by more complex prisoners in long-term segregation within the prison. The repurposing of the Valentina unit has provided temporary respite in a number of cases but there is still a pressing need for more specialist facilities, nationally, that can be easily accessed
Other
Downview (2021)
Provide support to enable prompt recruitment to critical psychology intervention roles to address reduced capacity, headcount, and waiting lists, particularly during a time of increased demand.
HMPPS
Wayland (2022)
The Board recommends to the Prison Service that the new care and separation unit, built, so we are informed, at considerable cost, can at least be staffed to properly address the ‘care’ element as well as that of ‘separation’ in the management of prisoners held there when it does, finally, open.
HMPPS
Isis (2020)
commission research into the impact of the time spent in cells during the pandemic on the mental health of prisoners
HMPPS
Whitemoor (2021)
Will the prison service please review urgently the use of specialised units in order to ensure that better and speedier arrangements can be made for prisoners whose needs are difficult or impossible to meet in a prison like Whitemoor? This would avoid the sad spectacle of men languishing for months at a time in demoralising and degrading conditions.
HMPPS
Heathrow Immigration Removal Centre (2021)
The Home Office should consider ways of improving the multi-disciplinary team (MDT) reviews in the CSU in order not to ‘overcrowd’ or overwhelm detainees.
Home Office
Elmley (2021)
We hope that the minister will give careful thought to the notion of confining men for long periods in small spaces, with little in the way of facilities, in order to protect them from infection. More thought should be given to the effect on their physical and mental health.
Ministry of Justice
Long Lartin (2022)
Will the Prison Service commit permanently to limiting the roll of CSRU prisoners to 26?
HMPPS
Long Lartin (2022)
Will the Minister give a clear lead on strategies to ensure that this unit [CSRU] is only used as a short-term measure?
Other
Feltham (2025)
Reopen the enhanced support unit on Feltham A.
HMPPS
Health Investigations (3)
Independent investigation into the care and treatment of Mr L — Rec 3
The Trust must assure itself that all practices of seclusion and ‘de facto’ seclusion on the PICU, including where patients have been segregated from others after rapid tranquilisation, are fully compliant with the requirements of the Mental Health 1983 (amended 2007), the MHA Code of Practice and the MHA Reference …
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr L — Rec 3
The Trust must assure itself that all practices of seclusion and ‘de facto’ seclusion on the PICU, including where patients have been segregated from others after rapid tranquilisation, are fully compliant with the requirements of the Mental Health 1983 (amended 2007), the MHA Code of Practice and the MHA Reference …
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
Accepted
An independent review of the Independent Investigations for Mental Health … — Rec 1
It is recommended that the process for Independent Investigations in Mental Health Homicides is reviewed in line with the review of the Serious Incident Framework. This process review should consider the proposals for: I. a single approach to the quality of reports; including standardised template and agreed investigation methodology II. …
north_east_yorkshire
Scottish Fatal Accident Inquiries (2)
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 within 24 …
Jan 2026
Health
5 recs
Scotland
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 patient on …
Dec 2024
Health
4 recs
Scotland
PHSO Casework Decisions (8)
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.
NHS in England
Jul 2022
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.
NHS in England
Mar 2024
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.
NHS in England
Sep 2024
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.
NHS in England
Nov 2024
P-001771 — Priory Group Limited
Ms L complains about the care, treatment, diagnosis she received while she was admitted to the Priory Hospital.
NHS in England
Jan 2023
P-002912 — University Hospitals Birmingham NHS Foundation Trust
Mr A complains that in March 2023 the Trust detained him without following the relevant guidelines and he it did not provide him with the appropriate documentation about his detention.
NHS in England
Sep 2024
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.
NHS in England
Nov 2025
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.
NHS in England
Feb 2025
LGO / SPSO Decisions (5)
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 …
PSOW (Public Services Om…
Health
Jan 2025
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 …
PSOW (Public Services Om…
Health
Not Upheld
Feb 2025
21-014-685b — Woodlands Medical Centre (21 014 685b)
Summary: We will not investigate this complaint about the circumstances surrounding Dr A’s detention under Section 2. The Trust and Council have already investigated the matter and acted to improve their services. It is unlikely an Ombudsmen’s investigation would achieve more.
LGO (Local Government & …
Health
Mar 2022
23-011-009b — NHS Cornwall and Isles of Scilly ICB (23 …
Summary: We investigated a complaint about the section 117 aftercare provided to Ms A by the Council, the Trust and the ICB after she was detained under section 3 of the Mental Health Act 1983. We found no fault by any of the organisations.
LGO (Local Government & …
Health
Not Upheld
Jun 2024
23-011-009a — Cornwall Partnership NHS Foundation Trust (23 011 009a)
Summary: We investigated a complaint about the section 117 aftercare provided to Ms A by the Council, the Trust and the ICB after she was detained under section 3 of the Mental Health Act 1983. We found no fault by any of the organisations.
LGO (Local Government & …
Health
Not Upheld
Jun 2024