Poor mental health triage record-keeping

Sean Seabourne

17 Dec 2013 · Worcestershire

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

Adam Withers

15 Feb 2016 · Surrey

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.

Response (Department of Health): The Department of Health states that original paper records should not be destroyed after a patient's death where the death may be subject to investigation. They state that the NHS …

Response (Adam WITHERS): The Trust has instigated work to improve the quality of engagement with adult inpatient services using a process of purposeful engagement and revised their Observation Policy to include clearer guidance …

Response (CQC): This is a joint strategic statement from NHS Improvement and the CQC about working together to ensure financial rigour while improving quality outcomes for patients. It describes how the two …

Responded

Oliver Ford

15 Aug 2016 · Avon

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.

Response (Avon and Wiltshire NHS Trust): The telephone triage process now includes the access trigger tool, which assesses risk. There are now two clinicians on duty at PCLS until 8pm Monday to Friday, and the clinicians …

Responded

Richard Walsh

25 Oct 2016 · London Inner (South)

Concerns: 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.

Response (Virgin Care Limited): Virgin Care has implemented a process to ensure colleagues have completed ACCT awareness training and are aware of PSI 1700 upon starting at HMP High Down, with annual refresher training. …

Response (Department of Health): The Department of Health has brought concerns regarding AMHP training to the attention of the HCPC, which sets criteria and approves training programs. Responsibility for AMHP training is due to …

Response (Health Care Professions Council): The Health Care Professions Council (HCPC) states that its existing criteria for AMHP training programs are appropriate and that individuals completing training have acquired the necessary skills in carrying out …

Response (Hampshire County Council): Hampshire County Council and Portsmouth City Council have taken several actions, including reviewing AMHP practices, providing additional training, commissioning audits, and reviewing policies. The HCPC reviewed documentation and closed the …

Responded

Greg Hutchins

12 Sep 2018 · Warwickshire

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

Gregory Rewkowski

28 Dec 2018 · Manchester (North)

Concerns: 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.

Response (Pennine Care NHS Trust): Pennine Care NHS Trust has increased staffing levels, issued a memo to staff for greater awareness of the requirement to seek support from On-Call managers, and are planning to update …

Response (Greater Manchester Police): Greater Manchester Police will participate in a task and finish group and is represented at senior level on the GM Health and Justice Operational Delivery Group and the Greater Manchester …

Response (GMCA): The partnership has developed a pan-GM protocol for response to mental health crisis, aiming for a common understanding of roles and responsibilities, a shared view of risk, and improved communication.

Responded

Natalie Hunter

18 Dec 2018 · Isle of Wight

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

Darrell Sharples

28 Oct 2020 · Cornwall and the Isles of Scilly

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.

Response (Cornwall Partnership NHS Foundation Trust): The Trust has introduced a 24-hour response telephone line and is developing an Initial Response Service (single point of access for people presenting with mental distress). All new staff members …

Response (Devon and Cornwall Police and Kernow NHS Clinical Commissioning Group): A former Police Superintendent has been recruited as Mental Health Liaison Officer. A trigger process to identify escalating risk in adults has been launched, including a more focused letter to …

Response (Further response and update from Cornwall Partnership NHS Foundation Trust): The Trust launched the Initial Response Service as a single point of access for people in mental distress. A standardised triage tool has been developed for adult mental health services …

Responded

Keith Nottle

· Nottingham City and Nottinghamshire

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.

Response (Turning Point): Turning Point has reviewed and refreshed helpline worker roles, agreed a Standard Operating Procedure (SOP) with Nottinghamshire Healthcare Trust, ensured staff familiarity with the SOP, introduced additional monitoring and audits, …

Response (NHS Nottinghamshire Healthcare): Nottinghamshire Healthcare is undertaking a comprehensive review of its Crisis Resolution and Home Treatment service, which is currently underway and will lead to an improvement plan by 30 November 2022.

Responded

Demet Akcicek

05 Sep 2022 · Inner North London

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.

Response (Camden and Islington NHS Foundation Trust): The CDAT team has updated its Operational Policy and implemented a daily duty sheet/tracker to ensure appropriate follow-up for all issues logged, which is checked daily by the senior on …

Responded

Jack Farrington

14 Sep 2023 · Hampshire, Portsmouth and Southampton

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.

Response (Solent NHS Trust): Solent NHS Trust is working to transfer the nursing handover from a Word document onto SystmOne, with staff to be trained in its use by the end of January 2024; …

Response (Portsmouth Hospitals University NHS Trust): Portsmouth Hospitals University NHS Trust has updated its Mental Health Liaison Policy and associated training to ensure a structured handover process for patients arriving at the Emergency Department under the …

Overdue

Leslie Swindells

17 Oct 2024 · Manchester South

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.

Response (GTD Healthcare): GTD Healthcare has implemented changes to the standard templates used by Assistant Practitioners and provided hard copies to clinicians for use during IT issues. They have also implemented safeguards to …

Response (Department of Health and Social Care): The DHSC acknowledges the concerns, states they fall under the provider's remit, and notes that NHS England and the CQC have been contacted to address them. It provides context on …

Responded

Jan Raciborski

10 Jan 2025 · Berkshire

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.

Response (Oxford Health NHS Foundation Trust): Oxford Health NHS Foundation Trust shared the report with senior colleagues and the Patient Safety team, and the team manager attended court to hear the evidence, with action to be …

Responded

Paul Dunne

21 Feb 2025 · South London

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.

Response (NHS England): NHS England is committed to improving Electronic Patient Records (EPRs) across all NHS Trusts and has provided funding to ensure all NHS Trusts have an EPR implemented. An updated MHLT …

Response (CQC): CQC acknowledges the concerns raised, and states how they will be reviewed via their internal Specific Incidents Guidance (SIG) and that they will continue to monitor the trusts in line …

Overdue

Edward Hands

17 Feb 2026 · Bedfordshire and Luton

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.

Response (Northamptonshire Healthcare NHS Foundation Trust): • A common, local protocol for managing those suspected to be under the influence of illicit substances (UTI) at HMP Bedford has been agreed and implemented with the Prison Governor …

Response (HM Prison Probation Service): • HMP Bedford and NHFT carried out a joint review of the UTI policies and protocols in place, resulting in the removal of any previous conflicting guidance and implementation of …

Responded