Unclear psychiatric referrals
22 items
1 source
Ambiguous or poorly defined referral processes for psychiatric units, leading to delays or inappropriate patient placement.
Cross-Source Insight
Unclear psychiatric referrals has been flagged across 1 independent accountability source:
22 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (22)
Warren Green
Concerns: High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service lacks clear escalation criteria to consultants, leading to insufficient oversight for vulnerable patients.
Response: Mid and South Essex NHS Foundation Trust has reviewed and updated relevant policies and flowcharts to guide staff in managing high-risk self-harm patients and preventing them from leaving wards unsupervised. …
Response: EPUT defers concerns about patients leaving acute wards to MSE. For the Mental Health Liaison Service, EPUT has introduced a Consultant Psychiatrist review for all patients assessed by the MHLT …
Responded
Hayley Beavington
Concerns: A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed to guide the junior doctor on challenging this decision, leading to premature discharge and the patient's death.
Responded
Caroline Staite
Concerns: Procedures for referring clients between the Neighbourhood Mental Health Team and Mind, and for patients returning to NHS care from Mind, lack robustness and transparency.
Responded
Aaron Deeley
Concerns: Patients held under Section 5(2) MHA in acute wards lack a Responsible Clinician or Mental Health Liaison assessment. Acute staff lack specialist mental health training, and policy for 1:1 observation is confusing, leaving a critical protocol gap.
Responded
Donna Donnellan
Concerns: A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role and appropriate referral pathways to specialist eating disorder services.
Responded
Rachel Garrett
Concerns: A technical issue regarding the employment status of Mental Health Liaison staff prevents them from detaining patients under the Mental Health Act in acute hospitals, creating a serious risk of vulnerable patients absconding.
Responded
Girmaye Guyo
Concerns: There's a risk of patients being discharged under the Nearest Relative Power despite still meeting detention criteria, due to a lack of clear procedures and legal tests for clinicians to apply.
Overdue
Andrew Shambrook
Concerns: The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.
Responded
Roy Draper
Concerns: There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other hospitals. The absence of a formal referral system also hinders transparent communication about adverse events and unblinding.
Responded
Colette Dunn
Concerns: A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge protocols between agencies and inadequate facilities for mental health crisis intervention were identified.
Overdue
Daisy French
Concerns: Critical failures include poor communication and transition between CAMHS and Adult Services for 16-18 year olds, leading to inappropriate out-of-hours treatment as adults. This includes placement in adult crisis units and unsupervised supported living post-assessment.
Responded
Dean Saunders
Concerns: Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.
Overdue
Clarice Hilton
Concerns: Psychiatric units lack a policy or guidance for staff on how to manage patients who refuse physical health observations, leading to critical delays in medical assessment.
Responded
Christopher Higgins
Concerns: Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, and poor inter-agency agreements for A&E assessment of detained patients led to unsafe conditions.
Responded
Richard Jones
Concerns: Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence and confusion regarding responsibilities and communication between mental health services.
Responded
Andrew Frost
Concerns: A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, highlighting a need for specific training on crisis team service limitations.
Responded
Stuart Long
Concerns: Confusion regarding appropriate responses to anti-social behavior in intoxicated, mentally unwell individuals led to a failure to take Mr. Long to a place of safety, exposing him to significant danger.
Overdue
Andrew Horgan
Concerns: Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.
Responded
Kirabo Kiwanuka
Concerns: Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.
Overdue
Sarah Shepherd
Concerns: The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training and misleading aide-memoires, risking inappropriate patient care.
Overdue
Man Ng
Concerns: Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical responsibility and risk patient safety.
Overdue
Khalid Yousef
Concerns: Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This is compounded by misunderstanding of L&D's role and a reduction in qualified Forensic Medical Examiners.
Responded