Poor mental health step-down planning
63 items
1 source
Absence of detailed risk assessment and management plans during mental health care step-downs or medication weaning.
Cross-Source Insight
Poor mental health step-down planning has been flagged across 1 independent accountability source:
63 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (63)
Darren Dickson
Concerns: Inadequate policies allowed supervision records to be overwritten and subsequently destroyed, preventing accurate ascertainment of information and raising concerns about proper record retention.
Pending
Charlotte Jones
Concerns: Information sharing procedures between different health services are inadequate, failing to ensure the proper exchange of service user information regardless of treatment pathway, which risks patient safety.
Pending
Paul Thompson
Concerns: HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing with Probation Services.
Pending
Roger Leadbeater
Concerns: Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and risking public safety.
Overdue
Timothy Reading
Concerns: The lack of formal, agreed S.117 plans for mental health discharge creates disjointed patient support. There is also no national guidance clarifying the required components for S.117 plans.
Pending
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
Cain Donald
Concerns: Deficiencies in discharge planning from a psychiatric unit, including inadequate engagement with family and probation, and a failure to supervise post-discharge medication compliance, contributed to mental health deterioration.
Responded
David Bendell
Concerns: A lack of step-down community rehabilitation facilities for patients not eligible for inpatient care but too frail for home-only support risks unsafe hospital discharges.
Responded
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
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
Stephen Dulling
Concerns: The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple lapses, including inadequate nutritional assessments and delayed responses to critical incidents.
Responded
Emilia Allsopp
Concerns: A critical lack of adequate community-based support for dementia patients and their families forced a move to an unfamiliar care home, instead of allowing safe care at home.
Responded
Emily Collishaw
Concerns: Insufficient, uncoordinated support and excessively long waiting times (up to seven months) for residential rehabilitation placements put vulnerable patients at significant risk, including sudden death.
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
Luke Whitelaw
Concerns: Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and inadequate risk assessment formulation in patient care.
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
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
Carol Robinson
Concerns: The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, or communication with external agencies and family.
Responded
Leroy Hamilton
Concerns: Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police also failed to correctly classify and risk-assess mentally unwell individuals as high-risk missing persons.
Responded
Daniel Nelson
Concerns: The Trust lacked essential protocols, policies, or adequate standard operating procedures for governing Section 117 discharges, indicating a significant systemic gap in patient management.
Responded
Kieran Crimmins
Concerns: Crisis team actions were poorly monitored and falsely marked as complete, and significant procedures were communicated inappropriately. A lack of clear re-entry routes for vulnerable discharged patients revealed poor inter-service information sharing.
Overdue
Claire Copeland
Concerns: The prescription delivery system is unsafe, relying on physical documents without witnessed delivery or confirmation. It lacks effective mechanisms to detect or remedy failed deliveries, risking discontinuity of vital medical treatment.
Responded
Joshua Rennard
Concerns: Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.
Overdue
Darrell Devlin
Concerns: Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client assessment, risking harm from excessive dosage or polydrug exposure.
Responded
Terence Tuttle
Concerns: Failures included inadequate dietician and mental health assessments, inaction on weight loss, poor mental capacity assessment, and insufficient care for mentally unwell patients refusing food, excluding family expertise.
Overdue
Sean Owen
Concerns: Medication compliance was not monitored after discharge, care coordinator contact was insufficient, and there were significant delays in arranging a psychiatrist appointment despite the patient's deteriorating mental state.
Responded
Lewis Francis
Concerns: A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient understanding of autistic prisoners' needs pose significant risks.
Responded
Samantha Savage-Greene
Concerns: A patient at high risk was repeatedly denied monitoring by the Home Based Treatment Team due to rigid protocol adherence, creating a significant gap in supervision for vulnerable individuals falling between service remits.
Overdue
Sam Spooner
Concerns: A severe lack of multi-agency information sharing, communication, and co-operation led to fragmented care for a suicidal patient, with an over-reliance on the family and inadequate intervention by healthcare providers.
Responded
Charlotte Grace
Concerns: Patients are discharged from mental health care without routine involvement from receiving care agencies or supportive family/friends, a systemic failure repeatedly identified as a risk.
Responded
Kim Morris
Concerns: A persistent lack of continuity in crisis mental health care, caused by under-resourcing and high demand, meant the patient repeatedly had to recount their story, causing distress and inadequate support prior to discharge.
Responded
Michael Cox
Concerns: There is a critical shortage of suitable long-term placements for individuals with complex mental health histories, causing persistent difficulties for social workers in finding appropriate facilities.
Responded
Georgia Nelson
Concerns: Critical failures in discharge planning, including inadequate housing review and lack of transfer to the home treatment team, contributed to a patient's death by suicide following a mental health relapse.
Responded
John Delahaye
Concerns: National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.
Overdue
Agnes Lambert
Concerns: Senior staff failed to ensure a nurse's ward transfer despite patient fixation concerns, leading to an incident. The trust also caused distress by taking an unacceptably long four months for a disciplinary investigation.
Responded
Daniel Collins
Concerns: A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.
Overdue
Scott Carton
Concerns: Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.
Overdue
Nigel Malloy
Concerns: There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for a patient with severe alcohol dependence and repeated admissions.
Responded
Miriam Roach
Concerns: Inadequate aftercare and transition arrangements exist for high-risk self-harm and suicide patients discharged from hospital, specifically concerning establishing essential contact.
Overdue
Martin Tilley
Concerns: A psychiatric patient with severe suicidal ideation and hallucinations was not followed up by the Homeless Healthcare Team after missing an appointment, and no emergency assessment referral was made.
Overdue
Angela Byrne
Concerns: W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor communications between inpatient and community services with inconsistent records.
Overdue
Michael Vukovic
Concerns: The patient was discharged from psychiatric admission without follow-up, as the Home Treatment Team never saw him and a referral to a drug and alcohol service was not followed up by the hospital.
Responded
Sian Witheridge
Concerns: Mental health records were unavailable or unread, risk assessments were inadequate and unenforceable, and there was a misunderstanding of suicide risk coupled with disjointed care between services.
Overdue
Terence Pimm
Concerns: Deficiencies in police call handling, record-keeping, and inter-agency information sharing hampered risk assessment for individuals with mental health issues. Insufficient training also affected police in identifying immediate risk and mental health assessors.
Responded
Lester Stacey
Concerns: A patient with complex physical and mental health issues disengaged from community mental health services post-discharge following medication changes, contributing to low moods and his subsequent death.
Overdue
David Knight
Concerns: National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.
Responded
Victoria Halliday
Concerns: A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for complex patients left individuals unsupported. Care Programme Approach and NICE guidelines were not followed.
Responded
Debrata Sircar
Concerns: A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence of an interim care plan, compromised care for a patient at high risk of falls.
Overdue
David Phillips
Concerns: An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional lacked critical access to the detainee's medical records.
Overdue
Christopher Jones
Concerns: Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created staff cover deficiencies.
Responded
Louise Turner
Concerns: Inadequate post-discharge mental health care, ineffective support systems, and inappropriate expectations for patients to initiate contact were identified. Devon also lacks female intensive psychiatric care beds.
Responded
John Jones
Concerns: A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear communication protocols for such handovers.
Overdue
Laura McRory
Concerns: The Trust lacked a clear process for employees seeking mental health care, especially regarding confidentiality and external referrals. There was also an inadequate safety plan on discharge and deficiencies in the internal investigation.
Responded
Alice Mead
Concerns: Significant failings in mental health care involved the absence of a care coordinator, ignored patient requests for medication review, and an unacceptably delayed, "hands off" response to urgent concerns for a vulnerable patient.
Responded
Robert Yarnell
Concerns: Critical failures in continuity of care post-discharge from a mental health unit occurred, with inadequate community team follow-up, failed inter-team referral, and a prolonged lack of patient contact.
Overdue
Tanya Page
Concerns: Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.
Overdue
Michael McCrory
Concerns: The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear training on minimising recurrence risks.
Overdue
Simon Tree
Concerns: The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.
Responded
Katherine Bonaventura
Concerns: The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.
Overdue
Rebecca Overy
Concerns: An immediate transfer, mandated by law, was detrimental to a young adult's mental health. This highlighted a critical service gap for secure mental health care for 18-24 year olds with complex needs.
Overdue
Janette Insley
Concerns: Inpatients lacked access to psychological treatment due to unavailable psychologists and resources, with an overemphasis on community services, leaving vulnerable patients without support post-discharge.
Responded
John Andrews
Concerns: Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, heating, or groceries.
Overdue
Peter Stanley
Concerns: A lack of formal 'step-down' policy exists for young people discharged from or failing to engage with Adult Mental Health Services. Additionally, there is insufficient encouragement for insurers to deny cover to establishments selling 'legal highs' linked to mental health issues.
Overdue