Conflicting mental health care plans
Care plans for high-risk mental health patients containing contradictory instructions, incompatible with legal duties.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PHSO casework decision
94match
P-002857 - Herefordshire and Worcestershire Health and Care NHS Trust
A patient complained of misdiagnosis with a personality disorder instead of Bipolar, lack of psychological help, and staff not taking his mental health issues or suicidal thoughts seriously.
Matched on
terms: care, health, mental
GIRFT recommendation
90match
Children and Young People's Mental Health Services
The crisis and urgent care pathways, including inpatient admissions, must be seamless with consistent treatment plans, objectives, and care coordination. In most circumstances, this will require the community care coordinator remaining as the main point of contact and driver of care regardless of the crisis, urgent care or inpatient setting the patient is within. There must be a...
Matched on
terms: care, health, mental, plan
PFD report
85match
Janet Muller
The coroner noted incomplete nursing records, handovers, and care plans, with audits failing to identify these deficiencies. Concerns were also raised about patients detained under the Mental Health Act being able to abscond due to insufficient security and inadequate staffing levels.
Matched on
terms: care, health, mental, plan
PFD report
85match
Kimberley Smith
The coroner identified no clear written policy for informal patients requesting leave from an Acute Care Unit, specifically regarding risk assessments and risk management. Concerns also included outstanding aspects of a protocol for managing alcohol detoxification on mental health wards.
Matched on
terms: care, health, mental
Inquiry recommendation
85match
BRIS-19 - Require effective communication among healthcare professionals to avoid conflicting patient advice
Healthcare professionals responsible for the care of any particular patient must communicate effectively with each other. The aim must be to avoid giving the patient conflicting advice and information.
Matched on
terms: care, conflicting, health
PHSO recommendation
85match
Discharge from mental health care: making it safe and patient-centred
We note the Department of Health and Social Care's (DHSC) national statutory guidance on discharge from mental health settings. As it is implemented, DHSC and NHS England must engage with people and services to assess the impact the guidance has on them. In particular, they must make sure that Integrated Care Systems account for the different professionals that...
Matched on
terms: care, health, mental
Committee recommendation
83match
#12 - 3rd Report - Legislative Scrutiny: Mental Health Bill
The Government should, however, carry out an urgent review of the interface between the MHA and MCA and take prompt action to provide the clarity that is currently lacking. (Recommendation, Paragraph 78) Children
Matched on
terms: health, mental
Committee recommendation
83match
#11 - 3rd Report - Legislative Scrutiny: Mental Health Bill
It is disappointing that the Mental Health Bill has not taken the opportunity to provide greater clarity to the interface between the Mental Health Act and the Mental Capacity Act and to make clear when detention and treatment under one or the other should be authorised. In a legislative scrutiny inquiry like this one, we are not in...
Matched on
terms: health, mental
PFD report
81match
Samiyo Farah
Concerns included the absence of national observation protocols for young people in mental health units and a lack of formal information transfer protocols between healthcare sectors. The coroner also noted inconsistent psychiatric referral decisions in A&E.
Matched on
terms: care, health, mental
PFD report
81match
Charlotte Bevan and Zaani Malbrouck
The coroner noted a lack of evidence that multi-disciplinary team meetings are consistently held or that comprehensive, widely-circulated care plans are consistently developed for pregnant individuals with known mental health conditions.
Matched on
terms: care, health, mental, plan
PFD report
81match
Jonathan Zucker
The coroner identified the absence of a requirement or system for a lead clinician to oversee and coordinate Mr. Zucker's care, which was provided by both private and NHS mental health services.
Matched on
terms: care, health, mental
PFD report
81match
Dean Rowland
The coroner noted delays in the deceased's ability to discuss antidepressant medication with a GP and concerns about his discharge from the community mental health team after a single consultation without a follow-up plan, despite prior suicide attempts.
Matched on
terms: health, mental, plan
PFD report
81match
Billy Jenkins
The coroner identified that the Community Mental Health Nurse's assessment gathered insufficient information, leading to an inadequate multidisciplinary team review and a failure to properly assess the individual's mental health. The plan moving forward also lacked robustness.
Matched on
terms: health, mental, plan
PHSO casework decision
81match
P-001064 - Pennine Care NHS Foundation Trust
Ms O complained about receiving an inappropriate letter 18 months after discharge from a mental health service and conflicting information about her discharge status, leading her to pay for private therapy.
Matched on
terms: care, conflicting, health, mental
PPO recommendation
81match
The Head of Healthcare at Lewes
The Head of Healthcare at Lewes should ensure that a formal clinical handover is arranged for all complex mental health prisoners before transfer to a new prison.
Matched on
terms: care, health, mental
PHSO casework decision
81match
P-002748 - Surrey and Sussex Healthcare NHS Trust
Mrs L complained the Trust incorrectly stopped her mental health medication during admission, delaying its restart and negatively impacting her mobility and mental health, prolonging her hospital stay.
Matched on
terms: care, health, mental
LGO / SPSO decision
81match
22-009-742d - Northamptonshire Health Care NHS Foundation Trust (22 009 742d)
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did not make reasonable adjustments when communicating with Mr...
Matched on
terms: care, health, mental
LGO / SPSO decision
81match
22-009-742c - Northamptonshire Health Care NHS Foundation Trust (22 009 742c)
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did not make reasonable adjustments when communicating with Mr...
Matched on
terms: care, health, mental
LGO / SPSO decision
81match
23-017-445a - South West London & St. Georges Mental Health NHS Trust (23 017 445a)
Summary: We will not investigate Mr X’s complaint about the decision to detain him under Section 2 of the Mental Health Act 1983. This is because Mr X appealed this decision to the First Tier Tribunal (Mental Health). This means we are prevented from investigating this complaint.
Matched on
terms: care, health, mental
LGO / SPSO decision
81match
23-012-177a - Avon & Wiltshire Mental Health Partnership NHS Trust (23 012 177a)
Summary: Avon & Wiltshire Mental Health Partnership NHS Trust did not appropriately record Miss X’s reasonable adjustments during a meeting. That did not cause her an injustice but the Trust should still take action to stop similar fault happening to others. Also, an Approved Mental Health Professional for North Somerset Council did not inform Mr X of his...
Matched on
terms: care, health, mental
LGO / SPSO decision
81match
24-009-187a - Derbyshire Healthcare NHS Foundation Trust (24 009 187a)
Summary: Ms X complains about Derbyshire County Council and Derbyshire Healthcare NHS Foundation Trust. She says the organisations acted with fault when she was detained in hospital under the Mental Health Act in 2022. Ms X’s complaint is late and there are not enough good reasons for the Ombudsmen to investigate it now.
Matched on
terms: care, health, mental
HSSIB recommendation
81match
Patients at risk of self-harm: continuous observation
Is there a shared understanding of the different roles and responsibilities of mental and physical healthcare staff in caring for a patient, including checking their personal belongings for items that could be used to self-harm. Are the different roles and responsibilities documented in care plans and shared at shift handover?
Matched on
terms: care, health, mental, plan
PHSO casework decision
78match
P-001717 - Avon and Wiltshire Mental Health Partnership NHS Trust
Mr A complained about poor communication, lack of debriefs, early discharge, and insufficient consideration of his fiancée's autism during her inpatient anorexia treatment.
Matched on
terms: health, mental
PFD report
77match
David Pooley
The coroner noted that a named nurse was not allocated until the day before the patient's death, contrary to trust policy. This resulted in essential duties like risk assessments, care plans, and family contact not being carried out.
Matched on
terms: care, plan
PHSO casework decision
77match
P-003585 - Nottinghamshire Healthcare NHS Foundation Trust
Mrs R complained Nottinghamshire Healthcare NHS Foundation Trust failed to provide effective mental health support to her father, Mr Y, leading to his accidental death, by discharging him while suicidal and mismanaging appointments.
Matched on
terms: care, health, mental
Committee recommendation
74match
#3 - 2nd Report - The impact of environmental regulations on development
It does not help the Government achieve its policy commitments if local planning authorities operate without clear, consistent, achievable, and co-ordinated national policies. National political leadership needs to be shown in setting out which priorities should prevail when individually important policies conflict with each other.
Matched on
terms: mental, plan
Committee recommendation
74match
#16 - Publish clear guidance on key worker roles to ensure care coordination for service users.
In some areas, the emphasis on care coordination may have been lost through the rollout of the CMHF. We recommend that NHS England publish clear guidance on the role of key workers to ensure all service users have access to a named individual responsible for coordinating their care. (Recommendation, Paragraph 110)
Matched on
terms: care, health
PHSO casework decision
74match
P-003508 - Black Country Healthcare NHS Foundation Trust
Miss U complained Black Country Trust reduced her father's medication and ignored requests for antipsychotics, causing a relapse. She also alleged Wolverhampton Trust inappropriately prescribed medication and placed him on a COVID-19 ward, contributing to his death.
Matched on
terms: care, health
PHSO casework decision
74match
P-003994 - Kent and Medway Mental Health NHS Trust
Ms N complained the Trust failed to review her son's medication, provide support, assess risk, or properly discharge him, leading to his arrest and conviction, and her distress.
Matched on
terms: health, mental
PFD report
73match
David Chatburn
The coroner identified issues with the GP's clinical management of the patient's mental health, including the absence of specialist referral and lack of recognised assessment tools. Concerns were also raised about bureaucratic barriers preventing GPs from easily accessing mental health services.
Matched on
terms: health, mental
PFD report
73match
Samarjit Singh
There was no Specialist Community Perinatal Mental Health Service in Wirral, resulting in sub-optimal treatment. Additionally, the Liverpool City Region lacked a Mother and Baby in-patient Unit, leading to many distant referrals being declined.
Matched on
terms: health, mental
PFD report
73match
Katherine Bonaventura
The coroner noted insufficient consultation with family/carers when detained patients return from leave, often limited to a few words in the patient's presence. There is also no system for a thorough mental state assessment of the patient upon their return to the unit.
Matched on
terms: care, mental
PFD report
73match
Leslie Morrison
The coroner raised concerns about the lack of formal mental capacity assessment and DoLS consideration both in the community and upon hospital admission. There was also insufficient communication between care providers, resulting in crucial patient information not being shared with the hospital.
Matched on
terms: care, mental
PFD report
73match
Rohan Fitzsimons
The coroner identified insufficient availability of in-patient mental health beds, leading to delays in Mental Health Act Assessments. These delays could result in individuals taking their own lives before assessment and bed provision.
Matched on
terms: health, mental
PFD report
73match
Jonathan Meaney
The coroner identified a lack of urgency in securing a mental health bed for a seriously ill patient and noted inadequate assessment by the mental health nurse before discharge. Concerns included insufficient team consultation and unclear follow-through on post-discharge referrals.
Matched on
terms: health, mental
PFD report
73match
Rebecca Romero
The coroner noted a lack of clear processes for in-patient transfers, time-specific care plans, and consistent risk assessment terminology. Insufficient guidance for staff communicating with young persons and managing out-of-area psychiatric care for children was also identified.
Matched on
terms: care, plan
PFD report
73match
Kieran Hubbard
The coroner noted failures by GMMH to expedite the search for and secure an inpatient mental health bed, citing insufficient communication and information exchange with PCFT, and decisions to abandon the search without clinical input.
Matched on
terms: health, mental
PFD report
73match
Lee Carpenter
The coroner noted concerns regarding the absence of a documented rationale for downgrading an urgent GP mental health referral without consulting the patient or GP. Additionally, the staff member making the triage decision was not identified, and no system for accountability in such decisions was in place at the time of the inquest.
Matched on
terms: health, mental
PFD report
73match
Daniel Moran
The coroner identified gaps in staff understanding of when to breach patient confidentiality for safety, clarification needed regarding roles in risk management and authorising leave, and better understanding of criteria for Mental Health Act detention.
Matched on
terms: health, mental
PFD report
73match
Sam Pringle
The coroner noted that some psychiatrists ask GPs to instigate Lithium prescriptions, contravening the shared care protocol. This practice leads to delays or non-provision of essential medication for mentally ill patients.
Matched on
terms: care, mental
CQC action
72match
Northwick Park Hospital
The trust should work with system partners to ensure there is a seamless service and clarity about clinical decision making in the provision of care at the trust and other NHS providers of mental healthcare.
Matched on
terms: care, health, mental
CQC action
72match
Ealing Hospital
The trust should work with system partners to ensure there is a seamless service and clarity about clinical decision making in the provision of care at the trust and other NHS providers of mental healthcare.
Matched on
terms: care, health, mental
PHSO casework decision
72match
P-002418 - Mersey Care NHS Foundation Trust
Ms E complained about inconsistent psychological and psychiatric care, cancelled appointments, incorrect referrals, lack of insomnia diagnosis, and inadequate bereavement support, impacting her mental health.
Matched on
terms: care, health, mental
PHSO casework decision
72match
P-002767 - Hampshire and Isle of Wight Integrated Care Board
Mrs A complained the ICB failed to implement agreed SEND tribunal recommendations and delayed addressing her sons' mental health needs, causing significant family impact.
Matched on
terms: care, health, mental
PHSO casework decision
72match
P-002332 - Nottinghamshire Healthcare NHS Foundation Trust
The Trust failed to plan for his brother's care, ensure medication, and contact him before his death, leading to fatal clozapine poisoning.
Matched on
terms: care, health, plan
LGO / SPSO decision
72match
PSOW-202305228 - Cardiff and Vale University Health Board
Ms A’s complaint centred on whether the care and treatment provided to her by the Health Board, and specifically its assessment and management of her risk of suicide and self-harm, on specified dates was appropriate. The Ombudsman’s investigation found that broadly the assessment and management of Ms A’s risk of suicide was reasonable. It is recognised that in...
Matched on
terms: care, health, mental
PFD report
69match
Darren Arnoup
The coroner raised concerns regarding the process for managing an individual's mental health risks, including suicidal ideation, after specific details had been communicated to their GP practice.
Matched on
terms: health, mental
PFD report
69match
Lee Grimes
The coroner identified a lack of action by Next Stage staff following overdose disclosures, insufficient follow-up with mental health services, and inadequate staff training. Concerns also relate to the mental health trust's unclear guidance for managing such disclosures.
Matched on
terms: health, mental
PFD report
69match
Sandra Brotherton
The coroner identified a lack of contingency planning for sole carers and inadequate documentation for sharing care plans with personal assistants. Concerns included difficulties securing urgent psychiatric appointments and no follow-up after a carer reported an unusual incident.
Matched on
terms: care, plan
PFD report
69match
Olaseni Lewis
Police training was insufficient on restraint techniques, the understanding of Acute Behavioural Disturbance (ABD), and the meaning of 'prolonged restraint'. The report also notes a lack of clarity on police and healthcare roles and issues with hospital staffing policy adherence.
Matched on
terms: care, health