Mental health ward clinical decision policy
Lack of rigorous policies for critical clinical decisions on mental health wards, such as safe return of personal items.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
GIRFT recommendation
95match
Children and Young People's Mental Health Services
Clear therapeutic models must be present on each unit, concordant with available NICE guidance, for the most common reasons for admissions. The model requires identified clinical interventions including frequency, intensity and expected outcomes. These models should be accurately staffed and link to the funding model for the unit. a Each provider to review the service offer requirements of...
Matched on
terms: clinical, health, mental
HSSIB recommendation
94match
Mental health inpatient settings
HSSIB recommends that The Shelford Group reviews and updates the Mental Health Optimal Staffing Tool on a regular basis following collection of recent data from mental health inpatient settings. This is to ensure the tool remains valid for potential changes in patients’ needs and the level of care they require, and to support providers to make decisions about...
Matched on
terms: decision, health, mental
HSSIB recommendation
94match
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to adults — HSSIB
Providers of mental health inpatient care can improve patient safety by ensuring that where professional judgement is used to help make workforce decisions, this accounts for ward physical environments, changes in patient acuity, and the individual mental and physical health care needs of patients that require support from a multidisciplinary workforce.
Matched on
terms: decision, health, mental, ward
CQC enforcement action
90match
Warning Notice: Nottinghamshire Healthcare NHS Foundation Trust
The Care Quality Commission (CQC) issued requirement notices to Nottinghamshire Healthcare NHS Foundation Trust following inspections from October to December last year. CQC found improvements were needed in the trust's acute wards for adults of working age and psychiatric intensive care units, and wards for older people with mental health problems, leading to two services being rated inadequate....
Matched on
terms: health, mental, ward
Committee recommendation
90match
#33 - Eighth Report - Children and young people’s mental health
In addition to our recommendations on the use of restraint that we set out in our report on the treatment of autistic people and people with learning disabilities, the use of prone restraint on children and young people should be banned in all inpatient settings and in transit. Further action should be taken with all inpatient and transport...
Matched on
terms: health, mental, ward
PFD report
85match
Dale Proverbs
The coroner raised concerns that Partnership In Care's current observation policy for patients in seclusion, which follows the Mental Health Act Code of Practice, is insufficient to prevent future deaths, unlike their prior higher standard policies.
Matched on
terms: health, mental, policy
PFD report
85match
Claire Lilley
The coroner noted a lack of a centralised, formulated risk document for patients detained under the Mental Health Act. Various risk assessments are conducted by different clinicians but are not consolidated, making it difficult for ward staff to review overall risk.
Matched on
terms: health, mental, ward
PFD report
85match
Emma Dorman
Non-clinical staff significantly influenced decisions regarding patient leave, leading clinical staff to feel unable to object. There was also a persistent lack of psychologist input on the ward for over three years.
Matched on
terms: clinical, decision, ward
PFD report
85match
Maziellie Mackenzie
The coroner identified a lack of written policy within the Trust for granting group leave from mental health units, including no mandatory risk assessment criteria or guidelines for staff-to-patient ratios during leave.
Matched on
terms: health, mental, policy
PFD report
85match
Yuksel Ismail
The coroner noted that the hospital's draft transfer policy did not adequately address the needs of high-risk mental health patients or ensure consultation with specialist staff during transfers. There was also insufficient staff training and understanding regarding the application of the Mental Capacity Act for patients deemed to lack capacity and posing a risk to themselves.
Matched on
terms: health, mental, policy
PFD report
85match
Aaron Deeley
The coroner identified gaps in mental health care for patients held under Section 5(2) MHA on acute wards, noting no allocated Responsible Clinician and lack of mental health liaison team attendance for risk assessment. Concerns also included acute staff's lack of specialist training, confusion over 1:1 observation policy, and no joint protocol between Trusts for these vulnerable patients.
Matched on
terms: health, mental, policy, ward
PFD report
85match
Luke Worrell
Clinical staff lacked awareness of clozapine's potential fatal side effects, and a Community Treatment Order was used inappropriately despite evidence supporting a Mental Health Act section.
Matched on
terms: clinical, health, mental
HSSIB recommendation
82match
Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for Health and Social...
National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.
Matched on
terms: health, mental
HSSIB recommendation
82match
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients...
HSSIB recommends that NHS England, working with other relevant national bodies, develops guidance on how to reduce and respond to non-anchored ligature risks. This will help staff to support people who attempt to hurt themselves with non-anchored ligatures and improve patient safety whilst maintaining a therapeutic environment.
Matched on
terms: health, mental
PPO recommendation
81match
The Head of Healthcare
The Head of Healthcare should ensure that where a patient has a confirmed history of a serious mental illness and there is evidence of risk to others, the mental health team should: • document whether they have considered detention under the appropriate section of the Mental Health Act; • if this is not felt to be appropriate, record...
Matched on
terms: clinical, decision, health, mental
Scottish FAI
80match
Kerry Ann Finnigan
Recommendation One All patients admitted to a psychiatric ward within NHS Lanarkshire should be reviewed by a senior clinician within at least 24 hours of admission, a policy, which has been seen to work successfully in other NHS areas such as NHS Grampian. Such a policy would ensure that admitted patients to hospital would have a senior review...
Matched on
terms: clinical, health, mental, policy
HSSIB recommendation
77match
Patients at risk of self-harm: continuous observation
Is there a physical healthcare hospital policy for the care of patients with mental health needs which includes continuous observation?
Matched on
terms: health, mental, policy
CQC action
77match
St Benedict's Hospice
The service should have a Mental Health Act policy to provide trust specific support to staff.
Matched on
terms: health, mental, policy
LGO / SPSO decision
77match
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: clinical, health, mental, policy
PFD report
73match
Dominic White
The coroner noted a lack of a robust protocol to ensure all relevant personnel are aware of documented mental health observation levels. Concerns were also raised about insufficient recognition of risks when allowing a patient, under Mental Health Act detention, to leave the hospital.
Matched on
terms: health, mental
PFD report
73match
Francesca Whyatt
The coroner identified a lack of risk assessment for the East Wing ward's multi-floor layout and insufficient formal guidance on observation competency for agency staff. Further concerns included a lack of clear policy for classifying and investigating ligature incidents as Serious Untoward Incidents.
Matched on
terms: policy, ward
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
Andrew Wells
The coroner noted deficiencies in the Trust's Root Cause Analysis process, particularly the lack of psychiatric expertise and scrutiny, and raised concerns about clinicians not appropriately applying the Mental Health Act regarding 'de-facto' detention.
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
Mollie Stansfield
Hull Royal Infirmary staff lacked understanding and incorrectly implemented Section 5(2) of the Mental Health Act 1983, with invalid paperwork. The coroner noted a need for wider awareness and training for doctors and nurses on MHA holding powers.
Matched on
terms: health, mental
PFD report
73match
Adrian James
The report describes a lack of consultant assessment for a complex patient, no proactive care during a mental health crisis, and insufficient consideration of impulsive suicide risk. There was also no follow-up after an interrupted session and inadequate communication between treatment teams.
Matched on
terms: health, mental
PFD report
73match
Kevin Ince
The coroner identified insufficient consideration of legal powers and persuasive steps when a patient detained under the Mental Health Act regularly refused medical treatment, along with insufficient action when the patient declined food over a prolonged period.
Matched on
terms: health, mental
CQC action
72match
Durham Diagnostics and Treatment Centre
The service should have a Mental Health Act policy to provide trust specific support to staff.
Matched on
terms: health, mental, policy
Scottish FAI
72match
Dr Sara Lilian Macrae
(i) When staff in a secure mental health ward are presented with evidence that a patient has vocalised suicidal ideation and demonstrated means to complete suicide by presentation of a ligature, urgent action to search that patient’s room and person for any other potential ligatures ought to be taken. In addition, consideration should be given to placing the...
Matched on
terms: clinical, health, mental, ward
PFD report
69match
Christopher Swain
The coroner identified inconsistent patient observation practices, with staff not always entering rooms, leading to uncertainty about when a patient was last seen. Additional concerns included deficiencies in mental health review, care planning, and record keeping, as well as insufficient staff for escorting sectioned patients.
Matched on
terms: health, mental
PFD report
69match
Thiago Araujo
The coroner noted Mr Araujo's crisis team referral was closed without addressing risks, and an unacceptable two-week delay occurred in securing a Mental Health Act assessment despite an identified acute suicide risk.
Matched on
terms: health, mental
PFD report
69match
Paz Ogbe-Millar
The coroner heard evidence regarding the appropriate level of observation by Emergency Department staff for mental health patients waiting in the Emergency Department.
Matched on
terms: health, mental
PFD report
69match
Charlotte Tetley
Patients risk being removed from inpatient bed lists prior to a mental health professional conducting an appropriate review on the same day, despite prior recommendations for admission or daily review.
Matched on
terms: health, mental
PFD report
65match
Natasha Raghoo
The coroner noted insufficient staff training in resuscitation, sporadic physical observations which ceased prematurely, and the lack of an electrocardiogram despite clinical need. Inconsistent staff handovers and unclear communication policies were also identified.
Matched on
terms: clinical
CQC action
65match
The Royal Oldham Hospital
The trust must ensure that, where the service continues to use the temporary mental health assessment room, the room is compliant with the standards set out in the Psychiatric Liaison Accreditation Network’s Quality Standards for Liaison Psychiatry Services
Matched on
terms: health, mental
PPO recommendation
65match
The Governor and Head of Healthcare
identify what training is needed so there is clear understanding of the lawful authority of prison staff, and when the Mental Capacity Act should be used instead, or in parallel.
Matched on
terms: health, mental
LGO / SPSO decision
65match
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 to Mrs B, she remained unclear as to...
Matched on
terms: health, mental
PHSO casework decision
65match
P-003375 - Greater Manchester Mental Health NHS Foundation Trust
Mrs H complained about her mental health care from 2021-2024, citing low lithium levels, inappropriate medication, missed appointments, and an incorrect talking therapy referral.
Matched on
terms: health, mental
PFD report
61match
Kirabo Kiwanuka
The coroner noted a lack of agreement among senior professionals on diagnosing and managing NMS, and uncertainty about the optimal care model for acutely manic patients with physical illness. There were also concerns about limited family involvement in best interest decisions for sectioned patients.
Matched on
terms: decision
PFD report
61match
Keiran Toman
The coroner noted psychiatric staff acquiescing to patient requests not to contact families, especially when patients lack insight and staff may lack training to assess capacity. This lack of family contact can isolate vulnerable patients, increase their risk, and decisions regarding family contact may not be reviewed often enough.
Matched on
terms: decision
PFD report
61match
Rafel Delezuch
Emergency Department staff lacked awareness and training on the Trust's restraint policy and the dangers of prone restraint. There were also gaps in the availability of rapid tranquilisation medication, awareness of alternatives, and adherence to NICE guidelines.
Matched on
terms: policy
PFD report
61match
Angela Frost
The Trust has no formal guidance for Consultant Psychiatrists, other healthcare professionals, or family members to seek second opinions on diagnosis, treatment, or detention criteria. There is also a lack of understanding among in-patient Consultants regarding confidentiality rules when communicating with family members.
Matched on
terms: health
PFD report
61match
Michelle Whitehead
The Trust's Rapid Tranquilisation policy was not sufficiently embedded or clear regarding post-sedation monitoring, especially for sleeping patients, and appeared to diverge from national NICE guidance. There was also a lack of guidance on managing Psychogenic Polydipsia.
Matched on
terms: policy
PFD report
61match
Shannon Lee Jordan
The coroner noted staff confusion regarding the precise timing of 15-minute observations, with some believing a 15-30 minute range was acceptable despite a new policy. There is no national standard for these observation checks.
Matched on
terms: policy
CQC enforcement action
61match
Warning Notice: Essex Partnership University NHS Foundation Trust
The Care Quality Commission (CQC) served Essex Partnership University NHS Foundation Trust with a warning notice following an inspection of two acute wards for adults of working age. The inspection raised serious concerns about patient safety, including staff not always following observation policies and the presence of blanket restrictions. CQC issued the warning notice after the trust's submitted...
Matched on
terms: ward
IMB recommendation
60match
Foston Hall (2021)
Are there plans to address: the inadequate provision for mental health throughout the criminal justice system, which is a serious concern? This is manifested in Foston Hall in a high level of unmet need for mental health treatment and delays in transferring prisoners to secure hospitals
Matched on
terms: health, mental
IMB recommendation
60match
Bullingdon (2021)
There are some prisoners in Bullingdon whose state of mental health is such that the prison is not equipped to cope with them; it is very likely that they need to be sent to secure psychiatric institutions. Some of these prisoners have spent far longer in the SSCU than 42 days, after which continued segregation has to be...
Matched on
terms: health, mental
IMB recommendation
60match
Oakwood (2024)
Could the Director work with the healthcare unit to try to ensure that a mental health professional is present during CSU GOoD reviews when the prisoner concerned has serious mental health concerns?
Matched on
terms: health, mental
IMB recommendation
60match
Isle of Wight (2024)
When prisoners in SARU fail the algorithm and are transferred to the IHU either for observation or anticipated transfer to a secure hospital facility what therapeutic engagement with the mental health team is provided for under the contract with Practice Plus Group?
Matched on
terms: health, mental
PHSO casework decision
60match
P-003123 - Oxleas NHS Foundation Trust
Mr A complained the Trust transferred him back to prison without properly considering his mental health, alleging misdiagnosis, lack of assessment, and inappropriate medication changes.
Matched on
terms: health, mental