Poor mental health triage record-keeping
Lack of comprehensive written records for triage decisions in mental health services, leading to gaps in accountability.
37 items
8 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
Keith Nottle
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.
Matched on
terms: health, mental, triage
PFD report
85match
Greg Hutchins
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.
Matched on
terms: health, keeping, mental, record
PFD report
85match
Paul Dunne
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.
Matched on
terms: health, mental, record
PFD report
81match
Darrell Sharples
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.
Matched on
terms: health, mental, triage
PPO recommendation
81match
The Head of Healthcare
The Head of Healthcare should: • review the mental health referral and triage process to ensure that assessments are based on all available information; and • ensure that prison staff are involved in case discussions when they report concerns about prisoners’ deteriorating mental health.
Matched on
terms: health, mental, triage
PFD report
77match
Richard Walsh
There were failures in communication between custodial and health professionals regarding the deceased's risks and needs, with crucial information being lost as he moved through different services; there was a lack of a national process for sharing mental health assessment information.
Matched on
terms: health, mental
IOPC learning recommendation
76match
Recommendations - Northumbria Police, July 2024
The IOPC recommends that Northumbria Police provides guidance to the Street Triage Team (STT) around the importance of considering the particular circumstances faced by frontline officers when attending an incident, when making a decision about how best to resolve a mental health related matter, to avoid placing too much weight on the patient’s past presentation during other historical...
Matched on
terms: health, mental, triage
PFD report
69match
Sean Seabourne
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.
Matched on
terms: health, mental
PFD report
69match
Natalie Hunter
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.
Matched on
terms: health, mental
PFD report
69match
Demet Akcicek
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.
Matched on
terms: health, mental
PFD report
69match
Leslie Swindells
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.
Matched on
terms: health, mental
PPO recommendation
69match
The Head of Healthcare at The Mount
The Head of Healthcare at The Mount should ensure that the reasons for mental health referrals are clearly documented so that staff can assess any potential risks.
Matched on
terms: health, mental
CQC action
69match
Verve Health
The service must ensure that observation records indicate the level of observation and reasoning for levels of observation.
Matched on
terms: health, record
Committee recommendation
67match
#73 - First Report - Universities and Scotland
Students in Scotland, as with so many groups, faced unprecedented challenges over the course of the pandemic. Whilst we welcome the investments the Scottish Government has made in student wellbeing and mental health during this period, we have heard evidence of structural underfunding that predated the pandemic, long waiting lists and poor triaging of mental health inquiries. This...
Matched on
terms: health, mental, poor
PHSO casework decision
67match
P-004151 - Norfolk and Suffolk NHS Foundation Trust
Mrs Y complains about the mental health care provided to her late daughter Ms B, by the Norfolk and Suffolk NHS Foundation Trust. Specifically, she complains about a lack of communication, poor risk management and record keeping, poor care plan management, an incorrect diagnosis, and unwarranted medication changes.
Matched on
terms: health, keeping, mental, poor
PFD report
61match
Adam Withers
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.
Matched on
terms: record
PFD report
61match
Oliver Ford
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.
Matched on
terms: triage
PFD report
61match
Jack Farrington
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.
Matched on
terms: record
PHSO casework decision
60match
P-004260 - Oxford Health NHS Foundation Trust
Dr J complains that a mental health nurse from the Trust gave incorrect advice to the police, who had attended her home following a 999 call.
Matched on
terms: health, mental
LGO / SPSO decision
59match
PSOW-201903330 - Cwm Taf Morgannwg University Health Board
Ms C complained about her daughter, H’s, management and care by Cwm Taf Morgannwg University Health Board’s “(the First Health Board’s”) Child and Adolescent Mental Health Services (“CAMHS”), including what Ms C felt was an unreasonable delay in diagnosing her daughter’s Borderline Personality Disorder (“BPD”). Ms C also complained about a lack of support provided to her prior...
Matched on
terms: health, mental
PFD report
57match
Jan Raciborski
The consistent failure to document risk assessments in contact records hinders information sharing, impedes investigations into deaths, and risks obscuring future threats to life.
Matched on
terms: record
PFD report
57match
Edward Hands
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.
Matched on
terms: health
LGO / SPSO decision
55match
24-018-535b - Hampshire and Isle of Wight Healthcare NHS Foundation Trust (24 018 535b)
Summary: We will not investigate this complaint about the decision to apply for a warrant to gain entry to Miss D’s home and take her to a place of safety to assess her mental health. It is unlikely we would find fault and Miss D had a right of appeal about the decision to detain her and this...
Matched on
terms: health, mental
IMB recommendation
51match
Elmley (2020)
The Board would ask the minister to review the effectiveness of the Criminal Justice Liaison and Diversion Service (CJLADS), given the number of prisoners that arrive at the establishment with a mental health diagnosis. Is the scheme working as it was designed to do, and is it properly resourced?
Matched on
terms: health, mental
IMB recommendation
47match
Exeter (2020)
Will the Secretary of State exert influence with colleagues to improve the transfer arrangements for those with severe mental health issues, to an environment more suitable to meet their mental health needs? The Board remains concerned about the difficulties encountered in transferring prisoners with severe mental health issues, often held in the segregation unit, to an environment where...
Matched on
terms: health, mental
LGO / SPSO decision
46match
24-018-535a - Island City Practice (24 018 535a)
Summary: We will not investigate this complaint about the decision to apply for a warrant to gain entry to Miss D’s home and take her to a place of safety to assess her mental health. It is unlikely we would find fault and Miss D had a right of appeal about the decision to detain her and this...
Matched on
terms: health, mental
PFD report
45match
Gregory Rewkowski
The coroner notes practical difficulties for nurses raising welfare concerns on an acute ward, unclear reasons for the clinical lead's inaction, failure to escalate to a senior manager, restrictions on ward telephones, limited NWAS investigation, and concerns about police handling of Section 136 cases.
Matched on
classifier match
LGO / SPSO decision
42match
25-000-113b - NHS Cheshire and Merseyside ICB (25 000 113b)
Summary: Ms X complains the Council, Trust and ICB are not providing her with section 117 aftercare support which she is entitled to after being detained under Section 3 of the Mental Health Act 1983. We will not investigate this complaint because we have seen evidence all the organisations have offered support, Ms X does not agree this...
Matched on
terms: health, mental
LGO / SPSO decision
42match
25-000-113a - Mersey Care NHS Foundation Trust (FT) (25 000 113a)
Summary: Ms X complains the Council, Trust and ICB are not providing her with section 117 aftercare support which she is entitled to after being detained under Section 3 of the Mental Health Act 1983. We will not investigate this complaint because we have seen evidence all the organisations have offered support, Ms X does not agree this...
Matched on
terms: health, mental
LGO / SPSO decision
42match
24-021-993a - North Staffordshire Combined Health Care NHS Trust (24 021 993a)
Summary: We will not investigate Ms X’s complaint about Staffordshire County Council, North Staffordshire Combined Healthcare NHS Trust and NHS Staffordshire and Stoke-on-Trent Integrated Care Board. She says they ignored her views when it moved her brother, Mr Y, to a care home, which cannot meet his mental health needs. The matter has and still is being considered...
Matched on
terms: health, mental
CQC action
36match
Sunnyside
Further improvement was required in the level of detail, particularly around what action staff had taken to de-escalate people's behaviour prior to the use of medication. Furthermore, no analysis of incidents had occurred in order to identify any potential trends which may have contributed to the event.
Matched on
classifier match
IOPC learning recommendation
36match
Recommendation - Sussex Police, January 2025
The IOPC recommends that Sussex Police update its call-handling training and guidance to include clear direction on when Contact Officers should seek specialist medical advice or support, particularly in cases where a sudden death is suspected. This follows an IOPC independent investigation where a member of the public reported a child hanging from a tree. Initially, the Contact...
Matched on
classifier match
LGO / SPSO decision
33match
24-021-993b - NHS Staffordshire and Stoke-On-Trent ICB (24 021 993b)
Summary: We will not investigate Ms X’s complaint about Staffordshire County Council, North Staffordshire Combined Healthcare NHS Trust and NHS Staffordshire and Stoke-on-Trent Integrated Care Board. She says they ignored her views when it moved her brother, Mr Y, to a care home, which cannot meet his mental health needs. The matter has and still is being considered...
Matched on
terms: health, mental
LGO / SPSO decision
30match
21-009-384d - Rotherham, Doncaster & South Humber NHS Foundation Trust (21 009 384d)
Summary: Ms A complained about several organisations involved in her father, Mr D’s care, when his physical health and behaviour deteriorated towards the end of his life. Mr D had dementia. Ms A said failings in Mr D’s care meant his family were distressed by his deterioration. We found fault with a Council. and it agreed to take...
Matched on
terms: health