Unclear psychiatric referrals
Ambiguous or poorly defined referral processes for psychiatric units, leading to delays or inappropriate patient placement.
35 items
7 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
81match
Sarah Shepherd
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.
Matched on
terms: referral, unclear
PFD report
73match
Clarice Hilton
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.
Matched on
terms: psychiatric
PFD report
73match
Dean Saunders
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.
Matched on
terms: psychiatric, unclear
PFD report
69match
Andrew Horgan
Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.
Matched on
terms: referral
PFD report
65match
Kirabo Kiwanuka
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.
Matched on
terms: unclear
PFD report
65match
Man Ng
Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical responsibility and risk patient safety.
Matched on
terms: unclear
PFD report
61match
Roy Draper
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.
Matched on
terms: referral
PFD report
57match
Donna Donnellan
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.
Matched on
terms: referral
PFD report
53match
Hayley Beavington
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.
Matched on
classifier match
PFD report
53match
Warren Green
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.
Matched on
classifier match
PFD report
49match
Richard Jones
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.
Matched on
classifier match
PFD report
49match
Christopher Higgins
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.
Matched on
classifier match
PFD report
49match
Andrew Shambrook
The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.
Matched on
classifier match
PFD report
49match
Girmaye Guyo
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.
Matched on
classifier match
PFD report
49match
Rachel Garrett
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.
Matched on
classifier match
PFD report
49match
Aaron Deeley
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.
Matched on
classifier match
PFD report
49match
Caroline Staite
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.
Matched on
classifier match
PFD report
45match
Stuart Long
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.
Matched on
classifier match
PFD report
45match
Andrew Frost
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.
Matched on
classifier match
PFD report
45match
Daisy French
The report identifies concerns regarding communication and information sharing between CAMHS and Adult Services, the transition of care, and out-of-hours provision for 16 to 18 year olds, and the appropriateness of placing under 18s in adult crisis houses or supported living without staff.
Matched on
classifier match
PFD report
45match
Colette Dunn
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.
Matched on
classifier match
PFD report
45match
Khalid Yousef
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.
Matched on
classifier match
PPO recommendation
43match
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff at Pentonville understand that referrals to secure mental health units should only be made through the prison’s mental health Inreach team.
Matched on
terms: referral
Committee recommendation
41match
#28 - Prisons used as places of safety, despite Government aims to end the practice
We were shocked and appalled to hear that prisons are used as a place of safety. We acknowledge and welcome that the Government aims to end this practice in the Mental Health Bill. We request details of how this will work in practice and when this will be implemented. (Conclusion, Paragraph 110)
Matched on
classifier match
PPO recommendation
39match
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who appear acutely, psychiatrically unwell are considered for transfer to a psychiatric hospital, and these discussions are recorded in the medical record.
Matched on
terms: psychiatric
PHSO casework decision
39match
P-003321 - Kent and Medway NHS and Social Care Partnership Trust
Mx E complains they did not receive an appropriate mental health assessment by the Trust's psychiatric nurse in August 2023.
Matched on
terms: psychiatric
PHSO casework decision
35match
P-004668 - Kingston and Richmond NHS Foundation Trust
Mr A complains about the care and treatment he received from the Trust following three consultations from the end of 2023 to 2024. He explains he feels dismissed, ignored, and pressured into accepting a psychiatric diagnosis and treatment without adequate investigation into his symptoms.
Matched on
terms: psychiatric
IMB recommendation
31match
Belmarsh (2023)
Would the Minister consider the impact of prison on those with serious mental illness and review systems for assessment and more appropriate placements?
Matched on
classifier match
Article 2 learning point
31match
Mr Everest — HMP Altcourse - LP 4
A prisoner presenting with an altered mental state, particularly with possible psychotic symptoms, should be assessed at the earliest opportunity by a suitably-qualified mental health practitioner. The practitioner should take a full history, review previous entries and assess the person’s current mental state to establish the diagnosis. The prisoner should be referred to a psychiatrist as soon as...
Matched on
classifier match
PHSO casework decision
31match
P-004265 - Cornwall Partnership NHS Foundation Trust
Dr J complains about the care provided to her son during a mental health assessment. She says the assessment was inappropriate and labelled him as having a mild learning disability.
Matched on
classifier match
IMB recommendation
27match
Wakefield (2022)
We ask the minister to explain how the government intends to address longstanding and yet unresolved problems with the assessment and transfer of prisoners who present with serious mental health and personality disorders from HMP Wakefield to hospital (section 47, Mental Health Act 1983).
Matched on
classifier match
PHSO casework decision
27match
P-001294 - North West Boroughs Healthcare NHS Foundation Trust
Miss Y complained about aspects of the care and treatment provided by North West Boroughs Healthcare NHS Foundation Trust (the Trust). Miss Y said the staff member completing her assessment was unsympathetic, and the Trust referred her incorrectly to outreach services instead of a psychiatrist.
Matched on
classifier match
PHSO casework decision
27match
P-003967 - Surrey and Borders Partnership NHS Foundation Trust
Mrs E complains the Trust misdiagnosed her son's psychotic crisis and about the lack of assessment by a consultant.
Matched on
classifier match
PHSO casework decision
27match
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
classifier match
LGO / SPSO decision
23match
21-014-685b - Woodlands Medical Centre (21 014 685b)
Summary: We will not investigate this complaint about the circumstances surrounding Dr A’s detention under Section 2. The Trust and Council have already investigated the matter and acted to improve their services. It is unlikely an Ombudsmen’s investigation would achieve more.
Matched on
classifier match