Conflicting mental health care plans
Care plans for high-risk mental health patients containing contradictory instructions, incompatible with legal duties.
Source spread
Where this theme appears
This theme appears across 16 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
97 PFD reports
4 committee recs
1 HSSIB rec
3 CQC actions
1 PPO rec
1 PHSO rec
5 IMB recs
1 Article 2 learning point
14 DHR recs
45 PHSO decisions
138 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(2)
SP51 — GMMH local structured risk assessment responsibility
Recommendation: At the local level, Greater Manchester Mental Health NHS Foundation Trust should liaise with all of the relevant community healthcare organisations (including Child and Adolescent Mental Health Services and Criminal Justice Liaison Services) to ensure that there is clarity about …
Gov response: DHSC has limited powers to direct NHS Foundation Trusts to implement recommendations 51 and 53. The Secretary of State for Health and Social Care has written to Greater Manchester Mental Health NHS Foundation Trust and …
Accepted
BRIS-19 — Require effective communication among healthcare professionals to avoid conflicting patient advice
Recommendation: 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.
Unknown
Prevention of Future Deaths reports(97)— showing 50 strongest matches
David Chatburn
Concerns: 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.
Response (Department of Health): • Department of Health officials consulted NHS England regarding the coroner's report. • The Department of Health noted that from April 2014, patients with mental health conditions gained the legal … (AI summary)
Overdue
Norma Sheppard
Concerns: The coroner noted considerable confusion regarding Mrs Sheppard’s discharge terms, with the written discharge letter indicating continued subcutaneous fluids while the understanding upon discharge was that she would not receive them. This discrepancy created difficulties in finding a suitable care home.
Overdue
Stephen Goodhall
Concerns: The coroner noted the absence of a clear policy to determine candidacy for ITU and contradictory messages between nursing and medical staff regarding this.
Overdue
Samiyo Farah
Concerns: 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.
Response (Department of Health): • The Department stated that the National Institute for Health and Care Excellence (NICE) produced detailed guidance on self-harm in 2013, which covers issues related to moving between services. • … (AI summary)
Overdue
Darren Arnoup
Concerns: 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.
Response: • The medical centre conducted a detailed review of events and commissioned an external medical records review, committing to implement its recommendations. • The medical centre amended its procedures to … (AI summary)
Overdue
Samarjit Singh
Concerns: 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.
Response (Wirral Clinical Commissioning Group): • An additional perinatal mental health midwife post was approved and filled, increasing the number of such midwives to two. • The new specification for IAPT services includes a requirement … (AI summary)
Response (Department of Health): • NHS England developed a specification for specialised perinatal services, including Mother and Baby Units. • The Department of Health copied the correspondence to the Chief Nursing Officer for England … (AI summary)
Overdue
Katherine Bonaventura
Concerns: 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.
Overdue
Michael McCrory
Concerns: The coroner identified that staff practice for Level 1 observations did not specify patient whereabouts beyond 'on the ward,' despite policy requirements. The report also notes a lack of clear evidence regarding staff training and development to minimise future risks.
Overdue
Simon Tree
Concerns: Concerns are raised regarding the security of the airlock system, which has allowed patients to 'tailgate' visitors and leave the unit. The report also notes a lack of monitoring by staff in the reception area.
Response (Surrey Borders Partnership): • A Security Manager has been recruited to undertake annual site security audits at all inpatient sites. • An out-of-hours receptionist has been employed to support ward staff during visiting … (AI summary)
Responded
Tanya Page
Concerns: The coroner noted a lack of communication between hospital wards regarding a patient's disclosure of a self-harm attempt, which appeared to be influenced by a concern about perceived blame between staff.
Overdue
Mark Daniels
Concerns: The crisis team failed to adhere to Mr Daniels' visit plan or document non-compliance, and had communication issues. Concerns were also raised about delays in crisis house referrals and insufficient consideration of hospital admission despite high-risk factors.
Response (Camden and Islington NHS Trust): • The Trust stated that a comprehensive action plan had been put in place. • The Trust confirmed that measures had been implemented across all Crisis Teams and Crisis Houses. … (AI summary)
Responded
Masoud Ghaderi
Concerns: The coroner noted inconsistent record-keeping of service user engagement and a lack of a designated staff member with overall responsibility for reviewing risk assessments to identify trends. Concerns were also raised about ward rounds relying on brief summaries rather than the full care record.
Response (Avon and Wiltshire NHS Trust): • The Trust rolled out local training on its Engagement and Observation Policy and conducted targeted training in inpatient suicide prevention. • Monthly spot audits of caseload supervision records will … (AI summary)
Overdue
Lee Bates
Concerns: The coroner identified insufficient guidance and communication between sleep apnoea specialists and psychiatrists regarding CPAP use, sedative medication risks, and monitoring for Obstructive Sleep Apnoea (OSA) patients in psychiatric care.
Response (Cambian Group): • The hospital manager at Cambian Churchill Hospital met with staff at St Thomas'. • A protocol was agreed to address communication and care for patients. (AI summary)
Overdue
Charlotte Bevan and Zaani Malbrouck
Concerns: 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.
Response: • Dr Kathryn Bundle has been tasked to review perinatal pathway arrangements against NICE guidelines, with draft algorithms developed and being consulted on. • The Trust plans to prepare and … (AI summary)
Responded
David Pooley
Concerns: 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.
Response (Lancashire Care NHS Trust): • The Trust undertook a joint investigation with East Lancashire Hospitals NHS Trust and developed an action plan to improve safety. • All staff were briefed on the referral process, … (AI summary)
Overdue
Julie Rose
Concerns: The Trust's protocol for patients unable to be contacted lacks clear stipulations for when police welfare checks are mandatory. A shift co-ordinator was also not conversant with the protocol, raising questions about its reinforcement within the team.
Response (Kent and Medway NHS Trust): • The Trust reviewed and amended its 'Unable to Make Contact' Protocol, which is now in use and subject to a three-month pilot. • A new 'Acute Service Line Welfare … (AI summary)
Responded
Dorota Kijowska
Concerns: The outcome of a review meeting was not signed off in writing by those in attendance and was not clearly communicated to the individual concerned.
Overdue
Tracey Lynch
Concerns: No specific concerns are provided in the truncated text.
Overdue
Lee Grimes
Concerns: 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.
Response (Next Stage): • The communications policy was revised to detail procedures for reporting client concerns. • All staff receive training on this policy during initial induction, and it will be added to … (AI summary)
Response (Response 5 Borough Partnership NHS Trust): • A review of procedures for processing referrals to Wigan Recovery North was undertaken. • The team's correct contact details, including the telephone number, were re-circulated to partner agencies. • … (AI summary)
Responded
Leslie Morrison
Concerns: 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.
Response (MORRISON Leslie): • The Trust stated it would implement a Trustwide initiative to develop a policy or pathway for proactively gathering information for complex and vulnerable patients. • The Trust is piloting … (AI summary)
Overdue
Danny Sweet
Concerns: The coroner identified a lack of consistent assessment and discharge decisions, noting gaps in managing patients with capacity who decline care despite family concerns. The Serious Incident Report was also found to be incomplete.
Response (Cornwall NHS Trust): • The Trust stated it would launch a review into the clinical risk assessment of people presenting with suicidal thoughts or acts, to be completed by the end of February … (AI summary)
Responded
Pamela Gressman
Concerns: The coroner noted insufficient consideration of potential physical effects from reported ingestion of foreign bodies and the lack of a clear treatment and observation plan, which might contribute to similar deaths.
Response (Tees Esk amd Water Valleys NHS Trust): • The Trust has shared findings and lessons learned from the internal investigation and inquest with the ward multidisciplinary team and across the Trust. • A review of the observation … (AI summary)
Responded
Rohan Fitzsimons
Concerns: 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.
Response (Avon and Wiltshire NHS Trust): • The Section 17 procedure was amended to require a mental state examination by a registered practitioner and authorisation of leave prior to commencement, with a new recording template developed. … (AI summary)
Overdue
Anthony Preston
Concerns: The discharge procedure lacked robustness, with no documentary proof of calls to the Crisis Team or immediate written notice of discharge, leaving a high-risk patient without support.
Overdue
Oliver Ford
Concerns: The coroner raised concerns regarding the telephone triage process, noting a need to include a risk assessment within it and ensure all risk assessments are documented. There were also concerns about the weekend cover for the PCLS service to prevent delays in patient follow-up.
Response (Avon and Wiltshire NHS Trust): • The telephone triage process now incorporates an Access Trigger Tool to conduct in-depth risk assessments. • Clinicians are required to document a full rationale for decision-making on RIO following … (AI summary)
Responded
Margaret Richardson
Concerns: The coroner noted the need for a robust and comprehensive action plan with timescales, to be implemented following a Serious Incident Investigation and inquest findings.
Overdue
John Jones
Concerns: The coroner noted a delay of approximately one week in notifying Mr. Jones' GP of his discharge from the Crisis Team, which meant he lacked community support. There was also no clear provision in the Crisis Team's protocols for immediate GP notification.
Overdue
Sandra Brotherton
Concerns: 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.
Response (Pennine Care NHS Trust): • The Trust's Care Programme Approach Policy was updated in November 2016, and the Trust records audit was reviewed, amended, and went live in January 2017 to address contingency planning … (AI summary)
Responded
Jonathan Zucker
Concerns: 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.
Response (PSYCH): • The Royal College of Psychiatrists stated that its Professional Practice and Ethics Committee would consider issues related to consultant accountability, ownership during transitions, and care involving multiple teams. • … (AI summary)
Response (Department of Health): • Department of Health officials liaised with the Royal College of Psychiatrists regarding the concerns raised. • The Royal College of Psychiatrists intends to ask its Professional Practice and Ethics … (AI summary)
Responded
Janet Muller
Concerns: 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.
Overdue
Matthew Edwards
Concerns: Routine delays in dispatching discharge summaries meant GPs were not informed of patient hospital stays or discharge plans, and no system ensured follow-up appointments were booked pre-discharge. Additionally, a shortage of CT angiogram slots caused diagnostic delays.
Response (Matthew Edwards): • Extra resources were allocated to clear a backlog of discharge summaries. • The Trust introduced increased managerial focus and monitoring of discharge summaries for in-patient wards, including routine 'safety … (AI summary)
Responded
Olaseni Lewis
Concerns: 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.
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) reformatted Standard Operating Procedures into "Toolkits" and replaced the Policing Mental Health SOP with a Mental Health Toolkit. • Officer Safety Training (OST) modules … (AI summary)
Response (South London and Maudsley NHS Trust): • The Trust operates a Mandatory Training Policy (Version 1.2 – April 2015) to monitor training logs for all professional groups. • The policy specifies immediate actions, including booking training … (AI summary)
Responded
Dean Rowland
Concerns: 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.
Response (South Staffordshire and Shropshire Healthcare): • The Community Mental Health Team (CMHT) conducted an assessment of Mr. Rowland's needs within expected referral timeframes. • The CMHT determined Mr. Rowland was at low risk for self-harm … (AI summary)
Response (Peel Medical Practice): • The practice has instituted a duty doctor and telephone triage system. • Patients requiring an appointment sooner than a routine slot are offered a callback from the duty team. … (AI summary)
Responded
Jonathan Meaney
Concerns: 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.
Response: • The Trust stated it would work closely with Camden & Islington NHS Foundation Trust (CANDI) to assist with their Serious Incident investigation and the development of an action plan. … (AI summary)
Response: • A serious incident review is being undertaken to analyse the process of securing a bed and the sequence of events, with findings to be shared within the relevant clinical … (AI summary)
Responded
Andrew Codling
Concerns: A community health team's voicemail message to the deceased was too brief, stating the office was closing and advising to call back Monday, thus missing an opportunity to reinforce alternative help and crisis numbers for immediate support.
Response (East London NHS Trust): • A new protocol has been developed and implemented within the Community Mental Health Teams (CMHTs). • The protocol provides guidance to staff on the use of mobile phones in … (AI summary)
Responded
Rebecca Romero
Concerns: 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.
Overdue
John Sloan
Concerns: The coroner identified that the deceased was not asked about suicidal ideas or plans on 8/8/17. Additionally, the daughter's concerns were not recorded on 11/8/17, both preventing the implementation of supportive measures.
Overdue
Keith Heatley
Concerns: The coroner identified a lack of formal policy or procedure in Wales for reviewing and assessing voluntary patients before home leave, leading to reliance on undefined 'best practice'. There were also insufficient procedures for hospital staff to liaise with families and community psychiatric nurses regarding home leave preparedness and support.
Response (Swansea Bay Health Board): • The Health Board implemented a checklist to ensure multi-disciplinary team members and the patient's family are involved in leave decisions for informal patients. • A ward clerk was appointed … (AI summary)
Responded
Patricia Chambers
Concerns: The report identifies concerns regarding the West London Mental Health Trust's Discharge Medication Summary and 7-Day Follow-Up processes, noting they need to be redrawn. Issues were also raised about the system for collecting, recording, and disseminating information.
Overdue
Neil Black
Concerns: The coroner identified a lack of joint handovers between drug detoxification and primary care nurses, alongside unclear responsibilities for observations and animosity between these teams. Concerns were also raised about the absence of a clear protocol for examining injection sites and DVT sites.
Response (Birmingham Community Healthcare NHS Trust): • A process for verbal handovers between the B3 and IDTS nursing teams for patients requiring joint care commenced on 11 February 2019. • A new protocol clarifies physical observation … (AI summary)
Responded
Nicky Reilly
Concerns: The coroner noted the discontinuation of the Care Program Approach upon prison transfer, inadequate psychological support and record-keeping, and limited quality of documentation and attendance at multi-disciplinary care plan meetings.
Response (Greater Manchester Mental Health NHS Foundation Trust): • The Trust informed the prison psychology team about the process for accessing patients' clinical records. • Mental Health and psychology staff now participate in weekly multi-disciplinary team meetings to … (AI summary)
Response (HM Prison and Probation Service): • The Challenge Support Intervention Plan (CSIP) has been implemented, providing guidance and templates for multi-disciplinary engagement and record-keeping. • HMP Manchester holds weekly multi-disciplinary meetings to manage complex prisoners, … (AI summary)
Responded
Kieran Hubbard
Concerns: 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.
Overdue
Irene Whittingham
Concerns: The coroner noted conflicting guidance for clinicians on monitoring Vitamin D and Calcium blood levels, with no advice issued to the GP for community monitoring. There were also concerns about WellSky and EMIS software allowing prescribing of doses exceeding national guidelines due to confusing dropdown menus.
Response (Bolton NHS Foundation Trust): • The Trust had already taken a number of actions related to the dispensing error, as detailed in a Serious Incident Review Report. • A prescribing guideline for colecalciferol in … (AI summary)
Overdue
Lee Carpenter
Concerns: 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.
Overdue
Billy Jenkins
Concerns: 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.
Response (Oxleas NHS Foundation): • The Trust implemented measures to ensure robust patient assessments, including sharing an induction tool and conducting reflective practice sessions. • The Trust instigated a rolling programme of training for … (AI summary)
Overdue
Daniel Moran
Concerns: 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.
Overdue
Sam Pringle
Concerns: 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.
Response (Greater Manchester Medicines Management Group NHS Stockport Clinical Commission Groupw): • Stockport CCG communicated with General Practice colleagues to highlight shared care issues and ensure reporting for oversight. • Pennine Care senior managers and clinicians reasserted the importance of communication … (AI summary)
Responded
Sophie Boothe
Concerns: UK mental health services did not adequately review or understand overseas medical information, including the Australian equivalent of 'Sectioned' status, which contributed to a downgraded referral and poor inter-departmental communication.
Response (Berkshire NHS Foundation Trust): • The Trust implemented a policy requiring triage workers to contact referrers before downgrading referrals. • Referrals with a substantive international element are now referred for triage by a manager. … (AI summary)
Responded
Kimberley Smith
Concerns: 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.
Response (Surrey and Borders Partnership NHS Foundation Trust): • The Trust stated it would develop a standalone written policy for informal patient leave, incorporating risk assessments, monitoring, and reporting missing persons. • The Trust confirmed it had completed … (AI summary)
Responded
Katy Samuels
Concerns: The Coventry and Warwickshire Partnership NHS Trust's Section 17 Leave Policy for detained patients requires clearer guidance on escorted leave, including verification of escorts and confirmation that patients leave with them. The report also notes insufficient time allocated for staff handovers.
Response (Coventry and Warwickshire Partnership NHS Trust): • The Trust amended its Section 17 Leave Policy to include clear definitions of leave types and ensure patients are collected and returned by identified persons. • Reporting forms were … (AI summary)
Responded
Select committee recommendations(4)
#3 —
Recommendation: 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 …
Response attribution not verified
#12 —
Recommendation: 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
Response attribution not verified
#11 —
Recommendation: 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 …
Response attribution not verified
#16 — Publish clear guidance on key worker roles to ensure care coordination for service users.
Recommendation: 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 …
Response attribution not verified
CQC inspection actions(3)
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.
Should Do
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.
Should Do
Charlton House Medical Centre
Arrangements for monitoring and review of patients experiencing poor mental health (including people with dementia) continued to place patients at risk of harm.
Must Do
PPO death in custody recommendations(1)
IMB individual recommendations(5)
Swinfen Hall (2020)
Swinfen Hall received many prisoners on open challenge, support, and intervention plans (CSIPs) or uninvestigated referrals (43 last year). This places additional demands on the prison’s resources and potentially disadvantages prisoners. In any case, the outcomes of CSIPs are poor (see paragraph 4.3(c)). What is the Prison Service proposing to do to improve this situation?
HMPPS
In Progress
Lowdham Grange (2022)
There is a compelling need for all government departments to work together to ensure that appropriate facilities are available for those prisoners with severe mental health disorders; this will avoid the need for prisons to hold such prisoners in segregation for extended periods.
Ministry of Justice
In Progress
Isle of Wight (2022)
the urgent need to strengthen mental health provision and to carefully consider decisions about the relocation of individuals with complex mental health conditions from secure locations to mainstream prisons
HMPPS
Gartree (2024)
The Board remains concerned that many prisoners wait for long periods to access specialist mental health services and/or assessments. Can the Minister please explain how longstanding problems with the assessment and transfer of prisoners who present with serious mental health and personality disorders from Gartree to suitable secure hospital will be addressed (as per Section 47 of the Mental Health …
Ministry of Justice
In Progress
Altcourse (2020)
The inpatient facility has 12 beds, which are used for prisoners with physical and mental health needs. This results in an uneasy mix, as both sets of patients require different approaches and skills. This, together with the length of time taken to transfer mental health patients to secure units, creates an environment which could be detrimental to some patients’ recovery. …
Ministry of Justice
In Progress
Health investigations(31)
Independent investigation: Sidney Waller, Manchester (2008) — Rec 4
The Trust should develop a clinical guideline that would trigger a clinical case conference when the formulation of a service user’s needs are particularly complex or when there is clinical disagreement about how these needs should be met and managed. This guideline will: be developed in conjunction with Trust senior …
north_west
Independent investigation: Rina Panchal, Thurmaston, Leicester (2007) — Rec 1
LPT must review the interface between operational policies of teams operating within Adult Services. LPT must ensure that at minimum the operational policies pertaining to: inpatient services; community mental health services; Leicester City and Leicester County crisis resolution and home treatment teams; assertive outreach; and …
midlands
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 13
It needs to be made clear how differences in opinion should be resolved when patients are referred to medium secure services. (DB)
london
Independent investigation: Allah Ditta, Barking (2005) — Rec 2
Where there is uncertainty about a service user’s diagnosis the AOT, (or any mental health service) should take steps to pool their information and to agree on a diagnosis, or the steps needed to secure a definitive one, with a view to determining a coherent and consistent treatment plan that …
london
Independent investigation: Alison Stevenson, Helston (2021) — Rec 1
Care planning post prison release There was an absence of an explicit and shared understanding across the ICMHT about the working or provisional diagnosis ascribed by two separate consultant psychiatrists. This resulted in a lack of structured and proactive approaches to working with the patient with a psychotic disorder. The …
south_west
*Independent investigation into the care and treatment of Mr W: … — Rec 2
The Trust and its commissioner should ensure that the Best Practice guidance on the co-ordinated treatment of individuals with a dual diagnosis of mental health problems and substance misuse problems is implemented. The Trust should ensure that when an individual with a substance misuse problem is admitted to hospital for …
Merseycare NHS Foundation Trust
north_west
Independent investigation into the care and treatment of Mr C … — Rec Recommendation Eight
It is recommended that: - CANDI’s Medical Director informs all doctors in the Trust’s Psychiatric services that they have a duty to ensure participation in the multidisciplinary decisions made for patients for which they are responsible. The Trust’s Medical Director to inform all doctors in the Trust Psychiatric services that …
Camden and Islington NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of a … — Rec R7
Escalation route to be clarified when professional differences [are] needing a [Mental Health Act assessment].
south_west
Accepted
An independent investigation into the care and treatment of a … — Rec 2
The Trust must ensure that clarity is provided to the early intervention team about the process for seeking a second opinion and/or formal consultation with another clinician or team (in particular the forensic team) when a patient has not responded to treatment for a prolonged period of time and where …
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
An independent investigation into the care and treatment of a … — Rec 1
The Trust must ensure that clarity is provided to early intervention team staff about what approach to take when there is diagnostic uncertainty (either within a single team or between teams involved in a patient’s care and treatment).
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
Independent review of the care and treatment of Mr X — Rec 1
The Trust should ensure that for those service users with a primary diagnosis of personality disorder (and offending histories), there is clarity and agreement between teams and services within ELFT, including both formal and informal processes for resolving uncertainty and disagreement.
london
Accepted
Independent investigation into the care and treatment of Mr I — Rec 4
When multiple agencies are involved in the care and support of an individual, a shared care plan must be in place that details the individual’s history, risks, crisis interventions and escalation plans.
Mr I who committed a homicide in April 2012. At the time of the death, Mr I was in receipt of mental health service from Central and North West London NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr H — Rec 1
The Trust should ensure that where there is a probation licence condition of contact with mental health services, a joint agency care plan with clear communication lines and escalation protocols should be in place and agreed by all parties. Measures to ensure that agreed interagency care plans are adhered to …
london
Accepted
An independent investigation into the care and treatment of Ms … — Rec 4
In order to ensure that, in cases where there is a difference of opinion in relation to the decision to admit, a mechanism is developed and implemented by the Trusts involved in Ms K’s care to ensure a multi-disciplinary team discussion takes place to review the individual patient’s options for …
north_east_yorkshire
An independent external quality assurance review of the independent investigation … — Rec 3
The Trust and relevant local authorities must ensure that where systems do not already exist: • when there are doubts or differences of opinion about the use of the Mental Health Act (MHA), a formal discussion that involves an Approved Mental Health Professional (AMHP) takes place and is properly recorded; …
north_west
Independent investigation: Warren Duke, Slough (but Tees patient) (2015) — Rec Recommendation 2
TEWV must review the EIPT operational policy to set out agreed methods and expectations around multidisciplinary working, to ensure that senior medical staff are involved appropriately in discussions about patients where staff have concerns, and at least annually, where patients are receiving antipsychotic medication.
north_east_yorkshire
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 1
A joint protocol should be agreed between substance misuse services and mental health services outlining joint working procedures and lead responsibility for dual diagnosis clients. (AA)
london
Independent investigation: Eric Daggers, Croydon (2005) — Rec 13
It needs to be made clear how differences in opinion should be resolved when patients are referred to medium secure services. (DB)
london
Independent investigation: Eric Daggers, Croydon (2005) — Rec 2
Care co-ordination by the most appropriate service for dual diagnosis clients must be made clear particularly in cases involving drug addiction and severe mental illness. (DB)
london
Independent investigation: Eric Daggers, Croydon (2005) — Rec 1
A joint protocol should be agreed between substance misuse services and mental health services outlining joint working procedures and lead responsibility for dual diagnosis clients. (AA)
london
An independent inquiry into the care and treatment of Ms … — Rec 4
GPs and mental health professionals need to be explicit about roles, responsibilities and boundaries in patients with complex physical problems and serious mental illness
south_east
Independent review of the care and treatment of Mr X — Rec 2
NHS England should ensure that a pan-London ‘task and finish’ group is set up with key provider and commissioner stakeholders. The aim of this work is to focus on health service provision for individuals with a primary diagnosis of personality disorder and a history of offending behaviour that does not …
london
Accepted
Independent investigation into the care and treatment of patient H: … — Rec R4
The Trust’s care programme approach should be multi-disciplinary, include the appropriate consultant psychiatrist and also be used for reviews of clients’ community treatment orders and section 117 aftercare arrangements.
Birmingham and Solihull Mental Health NHS Foundation Trust
midlands
Accepted
An independent investigation into the care and treatment of Mr … — Rec 20
in the absence of diagnostic clarity, it would have been helpful for there to be a clearer integrated formulation2 regarding the nature of Mr L’s difficulties considered from a longer term viewpoint. This could have included the function that some of his more problematic behaviours served, the drivers to increasing …
north_east_yorkshire
Independent investigation: Amina Ali, Sheffield (2004) — Rec 1
The West Continuing Needs Service has commenced work to agree a draft protocol/pathway for managing clinical disputes but the status of this project needs to be elevated so that it is adopted as an Adult Services wide project with defined timescales and deliverables that are monitored by the Trust or …
north_east_yorkshire
Independent investigation: Sarah Smart, Oxford (2005) — Rec 15.7
The panel recognises that in working cases like Mr S, who do not necessarily meet Crisis Resolution and Home Treatment criteria but do need urgent responses, there is a need for CMHTs and other teams to work effectively in transferring patient care across team interfaces. Where there is disagreement between …
south_east
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 5
Trusts should ensure that there is clarity in the role and function of Crisis Response Teams, Home Treatment Services and Community Mental Health Teams.
northern_ireland
Independent investigation: Karen Godden, Leicester (2007) — Rec 4
The IIT is disappointed at the lack of formalised joint working arrangements between the MHSU’s CMHT and his wife’s AOT. However, it is commendable that LPT has addressed this issue in its current CPA policy document implemented in 2007 (page 14, section 3.4). Although the principles espoused at section 3.4 …
midlands
Independent investigation: Enrique Parada- Blanco, Kingsbury (2008) — Rec 6
The Trust to seek clarity on the national status of the series of Policy Implementation Guidancedocuments(PIG)inrelationtotheoptimumwayofdeliveringcareforpeoplewith anacutementalillness.
london
An independent inquiry into the care and treatment of Ms … — Rec 2
The relevant responsible community team and named care co-ordinator should be established early on in an admission (within 7 days) to allow adequate links to be established. By default inpatients are subject to CPA and rapid allocation is good practice.
south_east
*Independent investigation into the care and treatment of Mr R: … — Rec 1.5.1
Commissioners of services must ensure the early involvement of clinical teams with patients when the first steps of planning movement between services are proposed and to monitor attendance of the appropriate staff at any planning meetings. Early dissent on the appropriateness of moves should be aired and resolved. Commissioners must …
Northamptonshire Healthcare NHS Foundation Trust
midlands
Accepted
Independent reviews(2)
Wessely Review — Rec 56
Amendments to the MCA, the Codes of Practice, and relevant procedures before the Court of Protection and Tribunal should be made to clarify the position in relation to those in the community subject to both the MCA and the MHA. Dual authorisation under s.17 MHA and DoLS/LPS should not be …
Health & Social Care
Accepted
Wessely Review — Rec 57
The criteria for CTOs should be revised in line with detention criteria.
Health & Social Care
Accepted
PHSO casework decisions(45)
P-004782 — Central and North West London NHS Foundation Trust
Mr and Mrs R complained their son's psychiatrist didn't fully consider his history, incorrectly concluded he wasn't depressed, and inappropriately increased his sertraline dose.
NHS in England
Partly Upheld
Feb 2026
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.
NHS in England
Upheld
May 2021
P-001907 — Mersey Care NHS Foundation Trust
Mrs E complained her son's OCD worsened because the Trust declined a funding letter for treatment and discharged him without a plan between April and November 2021.
NHS in England
Mar 2023
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.
NHS in England
Partly Upheld
Aug 2024
P-004755 — Lancashire and South Cumbria NHS Foundation Trust
Mr H complained about an inaccurate EUPD diagnosis, lack of appropriate medication and community mental health support, leading to negative impacts on his mental and physical health.
NHS in England
Jan 2026
P-001114 — Southern Health NHS Foundation Trust
Mrs I complained the Trust changed her mental health referral from urgent to routine without notice, delayed contact, recommended unsuitable medication, and did not provide individual psychotherapy.
NHS in England
Partly Upheld
Sep 2021
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.
NHS in England
Partly Upheld
Jan 2023
P-002575 — George Eliot Hospital NHS Trust
A consultant dismissed his decade-long mental health diagnosis, supported by a specialist nurse, causing anxiety, suicidal feelings, and loss of confidence.
NHS in England
Apr 2024
P-002854 — South West Yorkshire Partnership NHS Foundation Trust
Miss P alleged the Trust wrongly diagnosed her with EUPD, ignored her private ADHD diagnosis, and stopped her ADHD medication, causing distress due to lack of support.
NHS in England
Aug 2024
P-003121 — Cheshire and Wirral Partnership NHS Foundation Trust
Mr R complained the Trust stopped his Clozapine medication without an alternative plan, ignoring concerns and causing a severe 'rebound psychosis' which nearly killed him.
NHS in England
Nov 2024
P-003363 — East London NHS Foundation Trust
Mr O complained that the Trust failed to maintain contact, manage risk, and ensure care for his brother, Mr H, whose body was undiscovered for six months. The Trust also delayed informing the family about the investigation outcome.
NHS in England
Upheld
Feb 2025
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.
NHS in England
Apr 2025
P-003778 — An independent provider in the York area
Mr E complained his ADHD assessments were unduly strict, a recommended antidepressant was unavailable on the NHS, and he was unfairly referred to the same psychiatrist for review.
NHS in England
Aug 2025
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.
NHS in England
Upheld
Sep 2025
P-004369 — Norfolk and Suffolk NHS Foundation Trust
Mrs I complained the Trust failed to reassess her son for ADHD, denied a second opinion, and refused specialist referrals. This meant her son lacked support, leading to self-harm.
NHS in England
Partly Upheld
Nov 2025
P-004668 — Kingston and Richmond NHS Foundation Trust
Mr A complained the Trust dismissed his symptoms, pressured him into a psychiatric diagnosis and medication, ignored evidence, and linked his issues to past drug use unprofessionally.
NHS in England
Jan 2026
P-004570 — Sussex Partnership NHS Foundation Trust
The Trust failed to provide support/treatment since March 2024, incorrectly discharged her in October 2024, and communicated poorly.
NHS in England
Jan 2026
P-002273 — Sussex Partnership NHS Foundation Trust
Mr G complained the Trust provided inadequate care for his daughter, Miss J, by delaying urgent appointments, using non-medical staff, and ignoring an overseas diagnosis. He also alleged staff slandered him in her records.
NHS in England
Oct 2023
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.
NHS in England
Jan 2024
P-002405 — Sussex Partnership NHS Foundation Trust
Mrs E complained Sussex Partnership NHS Foundation Trust failed to check her past medical history when prescribing ADHD medication, causing distress and feeling doubted.
NHS in England
Jan 2024
P-002552 — King's College Hospital NHS Foundation Trust
The Trust prematurely discharged his mother, failed to test for COVID-19, poorly managed oxygen, and provided conflicting information, potentially contributing to her death.
NHS in England
Apr 2024
P-002532 — Sussex Partnership NHS Foundation Trust
Mr R complained the Trust failed to recognize his deteriorating mental health, delaying referrals and support for various conditions, and not informing his school about suicidal ideation. He sought acknowledgement and payment.
NHS in England
Apr 2024
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.
NHS in England
Jul 2024
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.
NHS in England
Jul 2024
P-003053 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mrs T complained the Trusts provided inadequate care to her husband, including delayed detention, insufficient nutrition, and unconsented ECT. She also alleged poor nursing care and delayed medical review, leading to Wernicke's Encephalopathy.
NHS in England
Oct 2024
P-003544 — University Hospitals of Derby and Burton NHS Foundation …
Mrs O complained the Trust failed to follow safeguarding policy, delayed a cardiology referral, provided conflicting information, and gave incorrect discharge papers for her son.
NHS in England
May 2025
P-003616 — A practice in the Canterbury area
Miss G complained her GP referred her to mental health services and prescribed medication without consent, causing distress, PTSD symptoms, and significant life disruption.
NHS in England
Jun 2025
P-003734 — Cambridgeshire and Peterborough NHS Foundation Trust
Mrs U complained the Trust failed to involve her in her husband's care planning or inform her about his Care Programme Approach and a Deprivation of Liberty Safeguards application.
NHS in England
Jun 2025
P-003803 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs T complained the Trust denied her husband needed support for PTSD and unfairly restricted her hospital access in April 2021. She alleged this caused him distressing flashbacks and affected her mental health.
NHS in England
Aug 2025
P-003967 — Surrey and Borders Partnership NHS Foundation Trust
Mrs E complained the Trust misdiagnosed her son's psychotic crisis as autistic behavior and failed to conduct a senior psychiatric consultant assessment. She stated this led to mental health deterioration.
NHS in England
Sep 2025
P-004218 — A practice in the Sheffield area
The Practice refused blood tests for poisoning, and the Trust later refused to remove a "delusional disorder" diagnosis, which Mr O claims impacted his insurance and health.
NHS in England
Sep 2025
P-004388 — Gloucestershire Health and Care NHS Foundation Trust
Mr K and Miss C complained the Trust's CAMHS delayed prescribing medication and declined an eating disorder referral, causing Mr K's symptoms to worsen.
NHS in England
Dec 2025
P-004662 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs B complained the Trust's Eating Disorders Service wrongly advised another hospital to keep her daughter in a wheelchair longer than necessary, despite stabilising health.
NHS in England
Jan 2026
P-002028 — Southern Health NHS Foundation Trust
Her sister was inappropriately discharged, given unsuitable medication, and missed opportunities for readmission, which she believes led to her death.
NHS in England
Jun 2023
P-002303 — South West Yorkshire Partnership NHS Foundation Trust
Miss H complained the Trust's consultant psychiatrist changed her medication and refused to revert it, which she believes led to her mental health deteriorating and being sectioned.
NHS in England
Upheld
Nov 2023
P-002469 — Tees, Esk and Wear Valleys NHS Foundation Trust
Mrs A complained about negligent mental health care for her son, citing failure to diagnose conditions, delayed medication reduction, and prolonged drug prescription.
NHS in England
Feb 2024
P-002465 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mrs H complained clinicians imposed inconsistent restrictions on her visiting her husband, denied her visits, questioned his capacity, and refused a chaplain visit.
NHS in England
Feb 2024
P-002626 — A practice in the North Yorkshire area
Mrs N complained a GP practice shared inaccurate information with a mental health tribunal in 2019, causing an incorrect decision and significant distress.
NHS in England
May 2024
P-002721 — Kent and Medway NHS and Social Care Partnership …
Mrs U complained the Trust prescribed olanzapine in 2017 without proper medication reviews, causing significant changes to her personality, mood, and physical health.
NHS in England
Jun 2024
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.
NHS in England
Upheld
Jun 2025
P-003805 — Berkshire Healthcare NHS Foundation Trust
Mr R complained the Trust inappropriately requested a Deprivation of Liberty Safeguards (DoLS) instead of a Section 3 for his mother and failed to communicate effectively with family.
NHS in England
Aug 2025
P-004126 — Lincolnshire Partnership NHS Foundation Trust
Mrs I complained about the care and treatment provided to her son by multiple NHS Trusts from 2011 to 2023, leading up to his death.
NHS in England
Oct 2025
P-004151 — Norfolk and Suffolk NHS Foundation Trust
The Trust allegedly failed to communicate with Ms B's family, ignored distress, poorly managed records and suicide risk, misdiagnosed EUPD, and changed medication without consulting prior plans.
NHS in England
Partly Upheld
Oct 2025
P-004484 — Lincolnshire Partnership NHS Foundation Trust
Mr A and Mrs B complained about Mr A's inpatient care, including missed medication, forced medication, lack of family involvement, and rude staff communication, impacting his mental health.
NHS in England
Not Upheld
Dec 2025
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.
NHS in England
Sep 2023
LGO / SPSO decisions(138)
24-007-618b — North London NHS Foundation Trust (24 007 618b)
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Health
Upheld
Feb 2026
24-007-618a — NHS North Central London ICB (24 007 618a)
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Health
Upheld
Feb 2026
21-014-685a — Oxford Health NHS Foundation Trust (21 014 685a)
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.
LGO (Local Government & …
Health
Mar 2022
21-007-637a — NHS East Sussex Clinical Commissioning Group (21 007 …
Summary: Mrs B complained about the care provided to her late husband, Mr B, by a care provider commissioned by the Council and the CCG to meet his aftercare needs. We found the care provider failed to properly record Mrs B’s late husband’s needs around eating and food consistency. As …
LGO (Local Government & …
Health
Upheld
Mar 2022
21-003-925a — Cambridgeshire and Peterborough NHS Foundation Trust (21 003 …
Summary: We found fault with the Trust; it did not allocate Mr Q a new care coordinator, did not conduct a S117 review or formally discharge him, and it was not clear with Mr P during the complaints process. We also found the Council did not understand the care package …
LGO (Local Government & …
Health
Upheld
May 2022
18-006-752b — South West Yorkshire Partnership NHS Foundation Trust (18 …
Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they …
LGO (Local Government & …
Health
Upheld
Jul 2022
18-006-752a — South West Yorkshire Partnership NHS Foundation Trust (18 …
Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they …
LGO (Local Government & …
Health
Upheld
Jul 2022
21-012-907 — Southampton City Council
Summary: Mr B complained on behalf of Miss X and Mr Y that the Council failed to notify them of their right to appeal a housing allocation decision and failed to deal with reports of mould. Mr B said this impacted on the physical and mental health of Miss X, …
LGO (Local Government & …
Housing
Upheld
Sep 2022
21-018-569b — NHS Norfolk and Waveney ICB (21 018 569b)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or …
LGO (Local Government & …
Health
Upheld
Oct 2022
22-010-012a — Leeds & York Partnership NHS Foundation Trust (22 …
Summary: The Ombudsmen will not investigate this complaint about a decision to detain someone under the Mental Health Act. We are unlikely to find fault in the actions of the Trust’s mental health team before the assessment. Investigation into the actions of the Approved Mental Health Professional is unlikely to …
LGO (Local Government & …
Health
Dec 2022
22-002-090c — Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust …
Summary: We found fault in the way a Council, Mental Health Trust and GP Practice supported a vulnerable man in the community for over two years. Each of the organisations has accepted its failings and the impact of them and has taken steps to prevent recurrences, so we have not …
LGO (Local Government & …
Health
Not Upheld
Dec 2022
23-015-462 — London Borough of Enfield
Summary: Mrs Y complained about the way the Council decided she was not entitled to an extra bedroom. Mrs Y says sharing a bedroom will have a negative impact on her health. The Council was at fault for not assessing Mrs Y’s care needs after being asked to. It was …
LGO (Local Government & …
Housing
Upheld
Apr 2024
23-009-939a — East London NHS Foundation Trust (23 009 939a)
Summary: We will not investigate this complaint about the decision to detain a patient under the Mental Health Act, because of concerns they were refusing treatment for their physical health. This is because there was a right to appeal the assessment outcome through a tribunal and it would have been …
LGO (Local Government & …
Health
Apr 2024
22-009-742b — NHS Northamptonshire ICB (22 009 742b)
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 …
LGO (Local Government & …
Health
Upheld
Apr 2024
22-009-742a — NHS Northamptonshire ICB (22 009 742a)
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 …
LGO (Local Government & …
Health
Upheld
Apr 2024
22-009-742 — West Northamptonshire Council
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 …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
22-009-742d — Northamptonshire Health Care NHS Foundation Trust (22 009 …
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 …
LGO (Local Government & …
Health
Upheld
Apr 2024
22-009-742c — Northamptonshire Health Care NHS Foundation Trust (22 009 …
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 …
LGO (Local Government & …
Health
Upheld
Apr 2024
23-017-445a — South West London & St. Georges Mental Health …
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.
LGO (Local Government & …
Health
May 2024
23-017-881b — NHS Gloucestershire ICB (23 017 881b)
Summary: Mrs A complains about the section 117 aftercare being provided to her sister, Ms B. We should not investigate this complaint because the Trust has already admitted fault and taken steps to remedy the injustice to Ms B. Further investigation would not achieve anything more.
LGO (Local Government & …
Health
May 2024
23-017-881a — Gloucester Health & Care NHS Foundation Trust (23 …
Summary: Mrs A complains about the section 117 aftercare being provided to her sister, Ms B. We should not investigate this complaint because the Trust has already admitted fault and taken steps to remedy the injustice to Ms B. Further investigation would not achieve anything more.
LGO (Local Government & …
Health
May 2024
23-005-445a — Norfolk & Suffolk NHS Foundation Trust (23 005 …
Summary: We investigated a complaint about the care and support provided to Mr O’s late brother Mr K by a Council and NHS Trust. We found fault by both organisations. The Council took too long to allocate Mr K a social worker and too long to respond to Mr O’s …
LGO (Local Government & …
Health
Upheld
Jul 2024
24-001-919a — Devon Partnership NHS Trust (24 001 919a)
Summary: Mr X complains about the way Devon County Council and Devon Partnership NHS Trust acted in relation to a hospital detention. We will not investigate this complaint. This is because an investigation is unlikely to find fault in the organisations’ actions.
LGO (Local Government & …
Health
Jul 2024
24-003-061b — NHS South West London ICB (24 003 061b)
Summary: Ms M complains about the way her son’s care was managed by the Trust after he left hospital in June 2021. We will not investigate this complaint because the organisation has already admitted fault in several areas of Mr N’s care. It has investigated several times, provided five written …
LGO (Local Government & …
Health
Sep 2024
24-003-061a — South London and Maudsley NHS Foundation Trust (24 …
Summary: Ms M complains about the way her son’s care was managed by the Trust after he left hospital in June 2021. We will not investigate this complaint because the organisation has already admitted fault in several areas of Mr N’s care. It has investigated several times, provided five written …
LGO (Local Government & …
Health
Sep 2024
24-004-207b — East London NHS Foundation Trust (24 004 207b)
Summary: Ms A complains about the care provided to her sister at Bridgeside Lodge Care Home (the Care Home). We will not investigate this complaint because the Care Home is willing to reinvestigate. There is nothing more we can achieve by looking at the complaint before the Care Home completes …
LGO (Local Government & …
Health
Sep 2024
24-004-207a — NHS North Central London ICB (24 004 207a)
Summary: Ms A complains about the care provided to her sister at Bridgeside Lodge Care Home (the Care Home). We will not investigate this complaint because the Care Home is willing to reinvestigate. There is nothing more we can achieve by looking at the complaint before the Care Home completes …
LGO (Local Government & …
Health
Sep 2024
24-021-993 — Staffordshire County Council
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. …
LGO (Local Government & …
Adult Care Services
Apr 2025
24-001-411a — NHS Humber and North Yorkshire Integrated Care Board …
Summary: We do not uphold G’s complaint about City of York Council and NHS Humber and North Yorkshire Integrated Care Board’s decision to reduce their section 117 aftercare in December 2023. However, the Council and ICB should have reviewed G’s aftercare need before they left hospital in March 2024. That …
LGO (Local Government & …
Health
Upheld
Jun 2025
24-005-064b — NHS South East London ICB (24 005 064b)
Summary: Mrs H complained about the care provided to her son, Mr G, by London Borough of Bromley, NHS South East London Integrated Care Board and Oxleas NHS Foundation Trust. We found fault by these organisations for their handling of Mr G’s discharge from hospital. This caused Mr G and …
LGO (Local Government & …
Health
Upheld
Aug 2025
24-005-064a — Oxleas NHS Foundation Trust (24 005 064a)
Summary: Mrs H complained about the care provided to her son, Mr G, by London Borough of Bromley, NHS South East London Integrated Care Board and Oxleas NHS Foundation Trust. We found fault by these organisations for their handling of Mr G’s discharge from hospital. This caused Mr G and …
LGO (Local Government & …
Health
Upheld
Aug 2025
23-012-177a — Avon & Wiltshire Mental Health Partnership NHS Trust …
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 …
LGO (Local Government & …
Health
Upheld
Oct 2024
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 …
LGO (Local Government & …
Health
Nov 2024
23-010-463b — Cheshire & Wirral Partnership NHS Foundation Trust (23 …
Summary: We uphold Mr X’s complaint about his brother, Mr Y’s, care and treatment. There was a short break in Mr Y’s medication management. We also found Mr X was not informed about one of Mr Y’s Mental Health Act assessments. However, we have not found a significant injustice arising …
LGO (Local Government & …
Health
Upheld
Dec 2024
23-010-463a — Cheshire & Wirral Partnership NHS Foundation Trust (23 …
Summary: We uphold Mr X’s complaint about his brother, Mr Y’s, care and treatment. There was a short break in Mr Y’s medication management. We also found Mr X was not informed about one of Mr Y’s Mental Health Act assessments. However, we have not found a significant injustice arising …
LGO (Local Government & …
Health
Upheld
Dec 2024
24-003-060b — NHS Buckinghamshire, Oxfordshire and Berkshire West ICB - …
Summary: Mrs X complained about top-up fees for accommodation without being offered of a suitable and affordable alternative. We did not find fault with the accommodation the Council offered. We found fault with some communication and recommended the Council and the NHS Trust apologise for any distress this caused to …
LGO (Local Government & …
Health
Not Upheld
Dec 2024
24-003-060a — Oxford Health NHS (24 003 060a)
Summary: Mrs X complained about top-up fees for accommodation without being offered of a suitable and affordable alternative. We did not find fault with the accommodation the Council offered. We found fault with some communication and recommended the Council and the NHS Trust apologise for any distress this caused to …
LGO (Local Government & …
Health
Upheld
Dec 2024
25-005-077b — NHS North West London ICB (25 005 077b)
We find fault by West London NHS Trust and London Borough of Hammersmith and Fulham in terms of their delivery of aftercare services to which Mr X was entitled under section 117 of the Mental Health Act 1983. This fault caused Mr X uncertainty and distress. The Trust and Council …
LGO (Local Government & …
Health
Not Upheld
Feb 2026
25-005-077a — West London NHS Trust Headquarters (25 005 077a)
We find fault by West London NHS Trust and London Borough of Hammersmith and Fulham in terms of their delivery of aftercare services to which Mr X was entitled under section 117 of the Mental Health Act 1983. This fault caused Mr X uncertainty and distress. The Trust and Council …
LGO (Local Government & …
Health
Upheld
Feb 2026
NIPSO-202001941 — Southern Health and Social Care Trust
A complainant raised concerns about how the Southern Trust cared for her vulnerable sister. Our investigation found a number of failings by the Trust.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2024
PSOW-202000537 — Hywel Dda University Health Board
Ms D complained that the Hywel Dda University Health Board (“the Health Board”) failed to provide her partner, Mr B, with appropriate care and treatment. In particular, Ms D complained that the Health Board failed to provide Mr B with appropriate mental health support and treatment and that Mr B …
PSOW (Public Services Om…
Health
Upheld
May 2021
PSOW-202208324 — Cardiff and Vale University Health Board
Miss X complained about the alleged change to her son’s placement who is currently a patient at an assessment and treatment unit for learning disabilities under section 3. Miss X alleges that the change in placement may not meet his care and treatment needs. The Ombudsman decided that due to …
PSOW (Public Services Om…
Health
Apr 2023
PSOW-202304142 — Betsi Cadwaladr University Health Board
Mr C complained about the standard of mental health care provided to his nephew, Mr B, by Betsi Cadwaladr University Health Board (“the Health Board”). Mr B, a 50 year old man, had schizophrenia and lived with and cared for his elderly mother, who had dementia. She entered full time …
PSOW (Public Services Om…
Health
Upheld
Dec 2024
PSOW-202406503 — Cwm Taf Morgannwg University Health Board
Mrs B complained about the care and treatment provided by the Health Board for her mental health and neurological condition. In addition, Mrs B raised concerns about not receiving responses from the relevant team involved in her care. The Ombudsman found that although the Health Board had provided a response …
PSOW (Public Services Om…
Health
Jan 2025
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 …
PSOW (Public Services Om…
Health
Not Upheld
Feb 2025
PSOW-202500676 — Aneurin Bevan University Health Board
Mrs A complained because she was unhappy with Aneurin Bevan University Health Board’s care and treatment of her late son. Mrs A’s son sadly died in September 2023. The Ombudsman noted that the Health Board had completed a Serious Incident Report which identified points of learning. The Ombudsman decided that …
PSOW (Public Services Om…
Health
Jul 2025
21-002-440a — Hertfordshire Partnership University NHS Foundation Trust (21 002 …
Summary: Mr E has complained about the mental health and social care of his sister, Mrs F, by the Council and Trust. We find fault with the mental health and social care of Mrs F but not with her mental health assessment or the Trust’s complaint handling. The Trust and …
LGO (Local Government & …
Health
Upheld
Jan 2022
19-018-519a — Sussex Partnership NHS Foundation Trust (19 018 519a)
Summary: The complainant, Ms B, said she learnt in 2020 the Council, the Trust and two Clinical Commissioning Groups did not properly consider her daughter’s, Miss G’s, entitlement to free aftercare following her detainment under the Mental Health Act 1983. She also complained about the care and support provided to …
LGO (Local Government & …
Health
Upheld
Mar 2022
21-013-253b — North East London Clinical Commission Group (21 013 …
Summary: Ms B complains on behalf of her mother, Ms A, about her care and treatment. We will not investigate the complaint as we are not satisfied Ms A has fully consented to Ms B complaining to us on her behalf. We do not therefore consider Ms B suitable to …
LGO (Local Government & …
Health
Mar 2022
21-013-253a — NHS East London NHS Foundation Trust (21 013 …
Summary: Ms B complains on behalf of her mother, Ms A, about her care and treatment. We will not investigate the complaint as we are not satisfied Ms A has fully consented to Ms B complaining to us on her behalf. We do not therefore consider Ms B suitable to …
LGO (Local Government & …
Health
Mar 2022
Domestic Homicide Reviews(14)
Manchester — recommendation GMP 4
GMP has policy and procedures in place when attending domestic incidents and incidents when persons present with mental health related concerns. This dictates how information is recorded so risk can be managed, and the appropriate safeguarding put in place. GMP policy states, at present, that a Domestic Abuse Plan (referred …
Greater Manchester Police
Greater Manchester Police
Gloucester — recommendation 2
NHS England to ensure that, at regional and national level, patients with severe mental health issues (such as schizophrenia) requiring regular antipsychotic medication have clear and specific care plans that identify their regular medication needs. This information must be contemporaneous and should be visible across all healthcare systems, including prison, …
NHS England
NHS England
St Helens — recommendation 8
Lack of Clarity around the formal CPA process as opposed to the New Ways of Working ‘Care Coordinator Assessment and Review Process’ (Nurse lead MDT Reviews)
North West Boroughs Healthcare
North West Boroughs Healthcare …
Nottingham — recommendation NHFT 1
The Local Mental Health Team (LMHT) and Crisis Resolution Home Treatment (CRHT) to have regular joint multi-disciplinary team discussion on complex cases and consideration to be taken to invite other agencies if relevant.
Nottinghamshire Healthcare NHS Foundation Trust
Nottinghamshire Healthcare NHS Foundation …
Lambeth — recommendation 6.5
The London Probation Trust and SLaM work together to develop a working protocol for putting in place and managing Community Order “Mental Health Requirements”
London Probation Trust | South London …
South London and Maudsley …
Lewisham — recommendation 9)
That LPT and Slam agree a process to ensure all relevant staff within both organisations are provided with guidance on how a community order with a mental health treatment requirement is assessed and administered and any case where clients are being cared for by both organisations.
London Probation Trust | South London …
South London and Maudsley …
Sheffield — recommendation 9
Providers should make the Dual Diagnosis protocols clear and accessible to staff. Individuals confirmed as reaching the threshold for “dual diagnosis” must have their care co-ordinated by the Mental Health Trust.
NHS providers
Leicester — recommendation S_R9
Supervisor’s will audit all cases where there is mental health involvement to ensure joint working procedures are being adhered to
Swanswell
Derby — recommendation 7
A coordinated and collaborative approach should be the aspiration of mental health services including crisis, community and hospital teams, across areas and trusts, with other relevant organisations to enable seamless continuity of care focused on the needs of individuals, with specific consideration of history and current circumstances particularly when transfer …
Mental health services
Lambeth — recommendation 6.2
It is recommended that London Probation and Community Mental Health in Lambeth explore how they might work more closely together to promote the effective management and treatment of offenders with offending related mental health issues. the perpetrator would be an interesting case example for joint study.
London Probation Trust | Community Mental …
Probation Service
Lambeth — recommendation 1.7
The Trust works with the London Probation Trust to develop a working protocol for putting in place and managing Community Order “Mental Health Requirements”.
South London & Maudesley NHS Foundation …
South London and Maudsley …
Ealing — recommendation 7.5.2(c)
Workshops on this and other cases where mental health is a feature to build team understanding about thresholds and consistent practice
Ealing Children’s Social Care
Ealing Council
Tendring — recommendation 10
The Mental Health Trust should review the Care Programme Approach to ensure that it is effectively coordinating the needs of its service users and the agencies supporting them by: (a) That robust auditing of CPA is implemented where Consultants act as the care coordinator. (b) Ensure that relevant agencies such …
North Essex Partnership NHS Foundation Trust
North Essex Partnership University …
Ealing — recommendation 1
(a) WLMHT to implement a homogenous approach across the Mental Health Integrated Network Teams (known as MINT) to manage emergent tasks via local duty with a clear, standardised system to avoid potential confusion (b) WLMHT is currently developing new policy and guidance as part of the transformation to Mental Health …
West London NHS Trust
West London NHS Trust