Poor mental health triage record-keeping
15 items
1 source
Lack of comprehensive written records for triage decisions in mental health services, leading to gaps in accountability.
Cross-Source Insight
Poor mental health triage record-keeping has been flagged across 1 independent accountability source:
15 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (15)
Edward Hands
Concerns: Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and delayed medical assessment.
Pending
Paul Dunne
Concerns: Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, and incompatible electronic record systems prevented crucial information sharing between departments.
Overdue
Jan Raciborski
Concerns: The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and risks obscuring future threats to life.
Responded
Leslie Swindells
Concerns: Critical failures included mental health assistant practitioners having limited training and supervision, inadequate call screening by agency staff, and reliance on telephone assessments, compromising patient risk assessment.
Responded
Jack Farrington
Concerns: Fragmented electronic medical record systems prevent timely access to patient history across NHS trusts, impacting clinical decision-making. Handover records are not consistently integrated into electronic systems, and some records remain paper-based.
Overdue
Demet Akcicek
Concerns: A mental health duty worker failed to escalate a patient's severe distress, omitted their case from multi-disciplinary team discussion, and made inadequate notes, with no clear trust-level actions to prevent future recurrences.
Responded
Darrell Sharples
Concerns: A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.
Responded
Gregory Rewkowski
Concerns: Systemic failures included ward staff difficulties escalating welfare concerns and making 111 calls, inadequate NWAS investigation and triage by untrained staff, and police confusion over Section 136 powers at private homes.
Responded
Natalie Hunter
Concerns: The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient care, especially for mental health needs. Additionally, underfunding has led to inadequate out-of-hours mental health staffing.
Overdue
Greg Hutchins
Concerns: Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in record-keeping and inter-area communication.
Overdue
Richard Walsh
Concerns: Systemic failures and inadequate communication processes between police, courts, healthcare, and prison services led to crucial mental health assessment information not being effectively shared or accessed.
Responded
Oliver Ford
Concerns: The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for patients triaged on Fridays.
Responded
Adam Withers
Concerns: Psychiatric nursing staff failed to sufficiently record patient observations and interactions, lacking understanding of their importance, and made unlabelled retrospective entries after death, compromising patient assessment and care.
Responded
Sean Seabourne
Concerns: Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans not being acted upon, preventing a crucial face-to-face assessment.
Overdue
Keith Nottle
Concerns: Mental health crisis triage bypasses specialist assessment, relying on telephone workers' limited judgment. There was a lack of care coordination for complex patients and unclear multi-disciplinary team decision-making.
Responded