Poor mental health step-down planning
Absence of detailed risk assessment and management plans during mental health care step-downs or medication weaning.
288 items
9 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
Christopher Jones
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.
Matched on
terms: health, mental, planning
PFD report
89match
Terence Tuttle
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.
Matched on
terms: health, mental, poor
Committee recommendation
89match
#22 - Rural communities receive minimal NHS mental health support during and after crisis events.
Crisis events can have short- and long-term effects on people’s mental health, but civil society groups told us NHS support is minimal or short-term, despite greater support being likely to help people deal more successfully with trauma. Rural health providers suggested only limited local planning takes place with no extra resources being available, while NHS England suggested more...
Matched on
terms: health, mental, planning
PFD report
85match
David Knight
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.
Matched on
terms: health, mental, poor
PFD report
85match
Debrata Sircar
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.
Matched on
terms: health, mental
PFD report
85match
Roger Stevenson
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.
Matched on
terms: health, mental, poor
PFD report
81match
Peter Stanley
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.
Matched on
terms: down, health, mental, step
PFD report
81match
Alice Mead
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.
Matched on
terms: health, mental
PFD report
77match
Laura McRory
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.
Matched on
terms: health, mental
PFD report
77match
David Phillips
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.
Matched on
terms: health, mental
PFD report
77match
Sian Witheridge
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.
Matched on
terms: health, mental
PFD report
77match
Daniel Collins
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.
Matched on
terms: health, mental
PPO recommendation
77match
The Head of Healthcare
The Head of Healthcare should ensure that mental health services meet the needs of prisoners by: implementing a referral system that results in a timely, face-to-face assessment using all relevant information for appropriate continuity of care and follow-up; ensuring that care plans are adhered to and adequate resources are available so that prisoners can have regular face-to-face contact...
Matched on
terms: health, mental
IMB recommendation
76match
Downview (2023)
There seems to be some limitations in communication between HMP Bronzefield and the prison (for example, with regards to transferred prisoners with significant mental health conditions and with missing property and medication issues). Is this because HMP Bronzefield is a private prison, and systems and processes may not be compatible?
Matched on
terms: down, health, mental
Committee recommendation
76match
#11 - Require Government to set out plans for reducing autistic detentions and improving community alternatives.
In response to this report, the Government should set out: • The reasons why the number of autistic people detained in mental health hospitals has increased; and how it plans to reduce that number, and by when. • The steps it will take to improve access to and availability of community-based alternatives to inpatient settings, including the additional...
Matched on
terms: down, health, mental, step
IMB annual report
76match
Lowdham Grange (2021)
HMP Lowdham Grange operated a restricted regime throughout the year due to COVID-19, which impacted various aspects of prison life and the Board's monitoring capabilities. Despite these challenges, the prison was generally well-managed, maintaining safety with reduced violence, effective healthcare provision, and positive staff-prisoner relationships, though staff morale declined. Key concerns remain around mental health transfers, property management,...
Matched on
terms: down, health, mental
PFD report
73match
Rebecca Overy
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.
Matched on
terms: health, mental
PFD report
73match
Robert Yarnell
After the patient's discharge from a mental health unit, the Burnley and Pendle Complex Care and Treatment Team did not make sufficient attempts to contact him or his family, and care was not effectively transferred to the Trafford Crisis Resolution Home Treatment Team.
Matched on
terms: health, mental
PFD report
73match
Louise Turner
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.
Matched on
terms: health, mental
PFD report
73match
Lester Stacey
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.
Matched on
terms: health, mental
PFD report
73match
Terence Pimm
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.
Matched on
terms: health, mental
PFD report
73match
Georgia Nelson
There is a lack of suitable housing specifically for young patients with severe and enduring mental health issues.
Matched on
terms: health, mental
PFD report
73match
Kim Morris
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.
Matched on
terms: health, mental
PFD report
73match
Joshua Rennard
Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.
Matched on
terms: health, mental
PFD report
73match
Leroy Hamilton
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.
Matched on
terms: health, mental
Committee recommendation
73match
#27 - Eighth Report - Children and young people’s mental health
We therefore recommend that the Department accelerates the shift towards increased community-based provision and a reduced inpatient bed base as a national priority to ensure that children and young people with the most complex needs receive good quality care in a setting that is right for them. A national strategy should be set out to establish jointly commissioned...
Matched on
terms: health, mental
Committee recommendation
73match
#26 - Eighth Report - Children and young people’s mental health
Inpatient units have a role to play in treating some of the most severe and complex mental health conditions, especially those that are resistant to community treatment. However, in most cases the most compassionate and effective care for children and young people is provided in the community–and increasing its provision must be the overall aim of the Department...
Matched on
terms: health, mental
IMB annual report
73match
Downview (2022)
HMP/YOI Downview experienced another year significantly impacted by the Covid-19 pandemic, leading to a restricted regime and challenges across various departments. While the Board found the prison safe and prisoners treated fairly, it raised significant concerns regarding the management and provision of healthcare, staffing pressures, and the lack of digital access for education. These issues highlight the ongoing...
Matched on
terms: down, health
PHSO casework decision
73match
P-002645 - North Staffordshire Combined Healthcare NHS Trust
Ms H complains the Trust discharged her from its mental health support service without looking into the root causes of her problems and without arranging a care plan for her. She also complains the Trust broke data protection by losing a statement she had written that included sensitive information about historic traumatic experiences.
Matched on
terms: health, mental
PFD report
69match
Scott Carton
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.
Matched on
terms: health, mental
PFD report
69match
John Delahaye
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.
Matched on
terms: health
PFD report
69match
Michael Cox
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.
Matched on
terms: health, mental
PFD report
69match
Lewis Francis
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.
Matched on
terms: health, mental
IMB annual report
68match
Leicester (2021)
HMP Leicester is a well-run local male adult prison that maintained strong leadership and an engaged staff during a challenging year of COVID-19 restrictions. Despite prisoners being largely confined to cells for 23 hours daily, the prison saw significant reductions in violence, self-harm, and drug use, partly due to the restricted regime and enhanced security. The Board commended...
Matched on
terms: health, mental
LGO / SPSO decision
68match
PSOW-202208324 - Cardiff and Vale University Health Board
Miss X complained about the alleged change to her son’s placement who is currently a patient at an assessment and treatment unit for learning disabilities under section 3. Miss X alleges that the change in placement may not meet his care and treatment needs. The Ombudsman decided that due to ongoing concerns, there was a need for the...
Matched on
terms: health, step
IMB annual report
68match
Ranby (2021)
For the reporting period ending March 2021, HMP Ranby operated under severe Covid-19 restrictions, including a 22-hour lockdown. Despite this, the prison commendably controlled Covid-19 outbreaks and saw significant reductions in self-harm and violence. However, the Board highlighted recurring concerns regarding mental health provision, cell sharing, resettlement issues, and deficiencies in prisoner complaint handling and transfer processes.
Matched on
terms: down, health, mental
LGO / SPSO decision
68match
PSOW-202106332 - Cwm Taf Morgannwg University Health Board
Mr D complained that Cwm Taf Morgannwg University Health Board (“the First Health Board”) failed to provide care and support to his late daughter, Miss E, when her mental health deteriorated during 2020. Mr D said the First Health Board failed to transfer her section 117 aftercare (free help and support following a hospital stay under the Mental...
Matched on
terms: health, mental
IMB recommendation
67match
Heathrow immigration removal centre (2023)
The Board consider Rules 40 and 42 are being misused. There were several instances in 2023 where Rule 40 and 42 have been used for prolonged situations. It is imperative that Rules 40 and 42 are used for the shortest possible time and as a means of last resort. It should not be used to hold mentally ill...
Matched on
terms: health, mental, poor
LGO / SPSO decision
67match
PSOW-202000537 - Hywel Dda University Health Board
Ms D complained that the Hywel Dda University Health Board (“the Health Board”) failed to provide her partner, Mr B, with appropriate care and treatment. In particular, Ms D complained that the Health Board failed to provide Mr B with appropriate mental health support and treatment and that Mr B experienced delays and difficulties in obtaining a dual...
Matched on
terms: health, mental
PHSO casework decision
67match
P-001933 - South Tyneside and Sunderland NHS Foundation Trust
Miss D complains the Trust delayed giving her father medication and its nursing care was poor. She also says there was not enough mental health support.
Matched on
terms: health, mental, poor
PFD report
65match
John Andrews
Inadequate discharge planning and communication for a vulnerable patient, leading to them returning home without necessary care arrangements, heating, or groceries.
Matched on
terms: planning
PFD report
65match
Katherine Bonaventura
The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.
Matched on
terms: mental
PFD report
65match
Martin Tilley
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.
Matched on
terms: health
PFD report
65match
Sean Owen
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.
Matched on
terms: mental
PFD report
65match
Luke Whitelaw
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.
Matched on
terms: poor
IMB annual report
65match
High Down (2022)
HMP High Down transitioned to a Category C training and resettlement prison in 2022, implementing gradual regime changes that have positively impacted prisoner life, including improved time out of cell and new community units. The Board noted reductions in self-harm and assaults, and commended improvements in induction and the visits hall. However, significant concerns remain regarding the welfare...
Matched on
terms: down, mental
PHSO casework decision
65match
P-002499 - Avon and Wiltshire Mental Health Partnership NHS Trust
Ms E complains that when the Trust's Crisis Team visited her they did not listen to her concerns. She complains that staff did not give her options for engagement with mental health services or offer access to community support groups or further health support.
Matched on
terms: health, mental
PHSO casework decision
65match
P-003355 - Birmingham and Solihull Mental Health NHS Foundation Trust
Mr R complains Birmingham and Solihull Mental Health NHS Foundation Trust incorrectly rejected his referrals to its community mental health team between August 2023 and February 2024.
Matched on
terms: health, mental
PHSO casework decision
64match
P-002857 - Herefordshire and Worcestershire Health and Care NHS Trust
Mr A complains about the Adult Mental Health Team at the Trust. He specifically complains he was misdiagnosed with a mixed personality disorder in February 2019 when he had bipolar affective disorder. He also says he was not provided with psychological help for anxiety and other mental health issues including not being given a care co-ordinator for over...
Matched on
terms: health, mental
PHSO casework decision
64match
P-004418 - Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Miss A complains about the standard of care her daughter; Miss B, received from the Trust's mental health team from February to May 2023.
Matched on
terms: health, mental