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.
Source spread
Where this theme appears
This theme appears across 15 independent accountability sources, so the source mix matters as much as the headline total.
33 PFD reports
6 committee recs
6 HSSIB recs
8 CQC actions
2 PPO recs
20 IMB recs
3 Scottish FAIs
1 detention investigation rec
17 DHR recs
8 PHSO decisions
5 LGO/SPSO decisions
4 CQC enforcement actions
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.
Prevention of Future Deaths reports(33)
Kirabo Kiwanuka
Concerns: 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.
Overdue
Natasha Raghoo
Concerns: 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.
Response (Partnership in Care): • A programme of monthly emergency incident drills was implemented, and a company-wide training programme for Immediate Life Support, including defibrillator use, was delivered to qualified nurses and doctors. • … (AI summary)
Overdue
Keiran Toman
Concerns: 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.
Overdue
Dale Proverbs
Concerns: 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.
Response (Department of Health): • The Department of Health completed a thorough review of the Mental Health Act 1983 Code of Practice. • The revised Code, effective 1 April 2015, strengthens requirements for reviewing … (AI summary)
Responded
Rafel Delezuch
Concerns: 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.
Response (University Hospitals of Leicester): • The Clinical Director and Head of Service for the Emergency Department ensured all clinical staff were aware of the Trust's Restraint Policy and the dangers of prolonged prone restraint. … (AI summary)
Responded
Kimberley Parsons
Concerns: Concerns were raised about a suggestion of 'assisted self-harming' to a high-risk patient lacking evidence from published research or proper procedures for novel treatments. The discussion was also not communicated to the consultant psychiatrist nor recorded.
Response (CQC): • CQC brought the report concerning the practice of an individual clinician to the attention of the Executive Director of Nursing at AWP. • CQC stated it would establish and … (AI summary)
Response (Avon Wiltshire NHS Trust): • The Trust's Medical Director has liaised with a national expert in harm minimisation. • The Trust indicated it would explore the possibility of research into harm minimisation strategies. • … (AI summary)
Responded
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
Leslie Matthews
Concerns: The coroner raised concerns about the availability and use of undetected, damaged, and defective oxygen flow meters, posing a patient safety risk. Further issues included staff not detecting audible damage and insufficient dissemination of incident information beyond the Trust.
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) investigated the adverse incident involving the cracked flowmeter and reviewed the manufacturer's instructions for use. • The MHRA forwarded the coroner's … (AI summary)
Response (County Durham and Darlington NHS Trust): • The Trust's Clinical Engineering Department checked all oxygen flowmeters across the organisation. • Associate Directors of Nursing discussed with clinical staff the importance of checking oxygen flowmeters, including for … (AI summary)
Responded
Dominic White
Concerns: 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.
Response (Whittington Hospital NHS2 Trust): • Whittington Health and Camden & Islington NHS Foundation Trust are updating mental health policies to clarify roles and responsibilities for patient observation levels. • Signage has been introduced in … (AI summary)
Overdue
Francesca Whyatt
Concerns: 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.
Response (Priory Hospital): • The hospital confirmed that environmental risk assessments, including ligature and safety audits, are conducted twice yearly and refreshed annually. • A new requirement has been added to Policy H43, … (AI summary)
Overdue
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
Rebecca Marshall
Concerns: The document indicates that concerns were raised regarding a risk of future deaths, noting the involvement of SLaM and another Trust, without detailing specific issues.
Response (Kent and Medway NHS Trust): • The Transfer and Discharge of Care policy has been reviewed to address all instances of care transfer, including for vulnerable populations. • A shared care protocol between the Trust … (AI summary)
Responded
Andrew Wells
Concerns: 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.
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
Christopher Swain
Concerns: 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.
Response (Sussex Partnership NHS Foundation Trust): • The Trust refreshed guidance on patient observations, introduced pocket guides and easy-read posters, and updated mandatory training for all staff. • A review of professional conduct was completed, and … (AI summary)
Responded
Claire Lilley
Concerns: 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.
Response (Oxleas NHS Foundation Trust): • The Trust will designate the RiO Risk Assessment document as the centralised record for all professionals to document risks. • A new mandatory formulation summary section will be added … (AI summary)
Responded
Emma Dorman
Concerns: 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.
Response (South West Yorkshire Partnership NHS Foundation Trust): • Staff understanding of the Patient Flow Procedure and associated roles will be monitored through Matron’s monthly checklists. • The Trust will review the skill-mix for vacant psychology posts, update … (AI summary)
Responded
Thiago Araujo
Concerns: 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.
Response (St Pancras Hospital): • The Trust implemented new recommendations for discharge processes, including multi-disciplinary discussion and senior overview for non-engagement discharges, ensuring clear communication to carers and updated crisis plans. • The Trust … (AI summary)
Response (Royal Mail): • Royal Mail stated its existing processes for the handling of restricted and prohibited items within the mail system are adequate and appropriate. • Royal Mail stated it does not … (AI summary)
Response (Metropolitan Police Service): • The Metropolitan Police Service updated its policies and procedures in May 2020 to assist staff with Mental Health Act warrants and requests from Approved Mental Health Professionals. • The … (AI summary)
Response (Dept. of Health and Social Care): • Officials brought the coroner's report to the attention of the Care Quality Commission (CQC). • The Department stated its commitment to expanding and transforming mental health services, supported by … (AI summary)
Response (Home Office): • The Home Office stated it is aiming to establish a consultation this summer on possible amendments to the Poisons Act, which will include more obligations on online marketplaces. • … (AI summary)
Overdue
Angela Frost
Concerns: 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.
Response (Pennine Care NHS Foundation Trust): • A draft process for requesting second opinions has been written and will be submitted to the Trust's Quality Group for scrutiny and sign-off. • An individual Consultant Psychiatrist is … (AI summary)
Responded
Maziellie Mackenzie
Concerns: 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.
Response (Lancashire and South Cumbria NHS Foundation Trust): • The Trust developed and approved a written procedure for granting group leave from The Cove unit, which has been shared with staff. • The new procedure mandates a pre-leave … (AI summary)
Responded
Yuksel Ismail
Concerns: 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.
Response (Bedfordshire Hospital NHS Foundation Trust): • The Trust has updated its Transfer Policy in collaboration with ELFT, adding a section on patient transfers for those identified at risk of absconding and supporting appendices. • The … (AI summary)
Responded
Mollie Stansfield
Concerns: 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.
Response (Department of Health): • The Department of Health will raise the issue of powers under the Mental Health Order for patient detention with Health and Social Care Trust Chief Executives. • The Department … (AI summary)
Response (NHS England): • NHS England confirmed that the curriculum for newly qualified doctors includes training on applying Section 5(2) of the Mental Health Act. • Health Education England (HEE) provides learning opportunities … (AI summary)
Responded
Girmaye Guyo
Concerns: The coroner identified a risk that the Nearest Relative Power could lead to patient discharge despite them meeting detention criteria, due to a lack of thorough procedure or legal test for clinicians to apply.
Response (Department of Health and Social Care): • The Government stated it would not amend the Nearest Relative powers of discharge. • It noted that section 25 of the Mental Health Act provides powers for Responsible Clinicians … (AI summary)
Overdue
Michelle Whitehead
Concerns: 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.
Response (Nottinghamshire Healthcare NHS Foundation Trust): • The Trust amended its Rapid Tranquilisation policy to clarify escalation requirements for reduced consciousness and monitoring patients who are asleep, including specific NEWS2 observation protocols. • A Quality Improvement … (AI summary)
Responded
Paz Ogbe-Millar
Concerns: The coroner heard evidence regarding the appropriate level of observation by Emergency Department staff for mental health patients waiting in the Emergency Department.
Response (West Hertfordshire Teaching Hospital): • The previously used proforma for mental health patients has been replaced by an electronic assessment tool, aligning with the current Standard Operating Procedure. • A Patient Safety Incident Response … (AI summary)
Responded
Roberto Bottello
Concerns: The coroner raised concerns about CNWL's duty of candour and staff operating outside policy, alongside insufficient training for SPA call handlers. Shortages in psychiatric care provision were also noted.
Response (NHS England): • NHS England published the NHS Long Term Workforce Plan in June 2023, which includes a focus on growing the psychiatric care workforce. • NHS England committed to increasing training … (AI summary)
Response (Central and NW London NHS): • CNWL has established a weekly meeting between acute hospital clinicians at St Mary's and CNWL, and an assessment centre for mental health patients opened at St Mary's Hospital in … (AI summary)
Response (Metropolitan Police Service): • The Metropolitan Police Service stated that all officers complete mandatory training on Airwaves Radios, which includes the use of the phonetic alphabet. • Recruit officers are provided with a … (AI summary)
Responded
Adrian James
Concerns: 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.
Response (NHS England): • The report and concerns were shared with and considered by NHS England’s national Mental Health Team. • NHS England will carefully consider the response provided by Central and North … (AI summary)
Response (Central and North West London): • The Trust is issuing additional guidance on managing suicide risk in patients with Complex Emotional Needs, reminding staff to consider consultant psychiatrist assessment. • The Trust has shared learning … (AI summary)
Responded
Aaron Deeley
Concerns: 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.
Response (NHS England): • NHS England's National Adult Mental Health Team reviewed the report and concerns. • NHS England confirmed that its Regulation 28 Working Group discusses all PFD reports to share learnings … (AI summary)
Response (Essex Partnership University NHS Foundation Trust): • The Trust updated its Mental Health Liaison Service Operational Policy to include support and advice for acute providers on risk management for patients requiring Mental Health Act assessment. • … (AI summary)
Response (Mid and South Essex NHS): • The Trust updated its policies for the admission and treatment of patients with mental health disorders in acute settings, incorporating new guidance and a flowchart for Section 5(2) pathways. … (AI summary)
Responded
Kevin Ince
Concerns: 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.
Response (Priory Group): • Priory Group introduced and revised flowcharts at Kemple View for managing declined physical health monitoring and poor diet/fluid intake, which include consideration of family involvement and powers under Section … (AI summary)
Responded
Luke Worrell
Concerns: 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.
Response (NHS England): • NHS England updated the Specialist Pharmacy Service website in October 2022 to highlight Clozapine risks. • NHS England's National Specialty Advisor for Mental Health Pharmacy wrote to all Mental … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare products Regulatory Agency (MHRA) confirmed that product information for clozapine describes potential fatal side effects, including gastrointestinal issues. • The MHRA published an article in … (AI summary)
Response (Department of Health and Social Care): • The Department noted that the Medicines and Healthcare Products Regulatory Agency (MHRA) has protocols in place and is reviewing clozapine product information to enhance awareness of side effects. • … (AI summary)
Response (CQC): • The CQC stated that its mental health inspectors, supported by specialist medicines inspectors, conduct assessments of Clozapine use and monitor related concerns, and that its medicines inspection team delivers … (AI summary)
Overdue
Azroy Dawes-Clarke
Concerns: The coroner noted that cell bedding material allowed a ligature to be made, and identified inconsistent officer training and understanding regarding ACCT procedures, first aid, basic life support, and the Mental Capacity Act.
Response (HM Prison and Probation Service): • HM Prison and Probation Service is undertaking a cell design review to explore different anti-ligature bedding materials, with the review expected to conclude at the end of 2026. • … (AI summary)
Responded
Charlotte Tetley
Concerns: 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.
Response (Cheshire and Wirral Partnership NHS Foundation Trust): • The Trust has embedded administrative support within First Response to ensure that outcomes of Clinical Prioritisation Meetings are directly documented in SystmOne. • A new Standard Operating Procedure for … (AI summary)
Responded
Shannon Lee Jordan
Concerns: 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.
Response (Black Country Healthcare NHS Foundation): • The Trust confirmed its policies, training materials, and Electronic Observation (eObs) system unambiguously specify 15-minute observation intervals with real-time alerts. • The Chief Nurse has liaised with NHS England … (AI summary)
Overdue
Select committee recommendations(6)
#10 —
Recommendation: We welcome the Government’s announcement that it will bring into force the Mental Health Units (Use of Force) Act 2018 in November 2021. This will go some way to reducing the use of restricted practices in inpatient facilities. However, we …
Gov response: We agree with this recommendation in principle. We agree that there are too many instances of restrictive practices being used for people with a learning disability and autistic people. We agree about the importance of …
Accepted
#33 —
Recommendation: 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 …
Response attribution not verified
#33 — Serious concerns about potential cuts to London's affordable housing target hindering delivery.
Recommendation: We are seriously concerned by media reports that London’s affordable housing target could be cut. Whilst the 1.5 million national target cannot be met without a significant increase in housing supply in London, a significant proportion of those new homes …
Response attribution not verified
#21 — Government risks land value capture by announcing New Town sites without policy.
Recommendation: There is significant potential to use land value capture as part of funding the proposed New Towns, especially on green field sites. However, we are concerned that the Government has announced substantial detail of the 12 potential sites without a …
Response attribution not verified
#12 — Update national policy to encourage minimum affordable housing targets in Local Plans.
Recommendation: As part of its ongoing review of the viability planning practice guidance, the Government must consider how different types of developer contribution could be re-negotiated following a viability assessment, to protect affordable housing contributions. The Government must also update national …
Response attribution not verified
#8 — Make regulations allowing local authorities to include plan-making costs in planning fees.
Recommendation: Once the Planning and Infrastructure Bill receives Royal Assent, the Secretary of State must make regulations to allow local planning authorities to take into account the cost of local and regional plan-making when calculating local planning fees. Local planning authorities …
Response attribution not verified
HSSIB safety recommendations(6)
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?
Learning Prompt
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 …
Safety Recommendation
Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for …
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 …
Safety Observation
Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for …
HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are …
Safety Recommendation
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services …
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 …
Safety Recommendation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
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 …
Safety Observation
CQC inspection actions(8)
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
Must Do
Cumberland Infirmary
The trust should continue to monitor its use of blanket restrictions on wards where patients may be inadvertently deprived of their liberty. Regulation 13(5).
Should Do
St Benedict's Hospice
The service should have a Mental Health Act policy to provide trust specific support to staff.
Should Do
Bushey Fields Hospital
The use of seclusion must be correctly recorded and practice monitored against the Code of Practice. The trust must ensure that areas used for seclusion are safe and risks removed and the appropriate safeguards put into place.
Should Do
Durham Diagnostics and Treatment Centre
The service should have a Mental Health Act policy to provide trust specific support to staff.
Should Do
Royal Hallamshire Hospital
The trust must ensure staff receive the appropriate training in relation to the use of restrictive interventions including restraint and rapid tranquilisation.
Must Do
Royal Hallamshire Hospital
The trust must ensure it implements effective systems to ensure staff adhere to trust policy in relation to the use of restrictive interventions including restraint and rapid tranquilisation.
Must Do
Cygnet Bury Hudson
The provider should ensure that doctors’ reviews always take place for patients placed in seclusion.
Should Do
PPO death in custody recommendations(2)
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 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.
IMB individual recommendations(20)
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
Ministry of Justice
In Progress
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 reported to …
HMPPS
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 instead. Some of these prisoners have spent far longer in the SSCU than 42 days, after which continued segregation has to be reported …
Ministry of Justice
In Progress
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?
Governor / Director
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?
Governor / Director
Heathrow Immigration Removal Centre (2020)
Consideration should be given to making the Care Suite available to a greater number of detainees in distress, even if this results in a wider definition of being ‘in crisis’.
Governor / Director
Downview (2021)
End the current severe lockdown regime in prisons, taking into account its significant and long-term impact on the mental health of prisoners.
Ministry of Justice
In Progress
Liverpool (2022)
Strengthen and enhance legislation to prevent prisoners being segregated for long periods of time, particularly those experiencing mental health difficulties.
Ministry of Justice
Heathrow Immigration Removal Centre (2022)
We would support broader use of the Colnbrook care suite for short term respite, particularly for detainees with deteriorating mental health conditions. We also urge the Contractor to replicate the Colnbrook care suite facility in Harmondsworth.
Governor / Director
Low Newton (2025)
For some years, the IMB at HMP/YOI Low Newton has raised the issue of women presenting with severe mental ill health and challenging behaviour. Given the disruption this creates, the resources required to manage them and the toll this takes on everyone around them, when can we expect that they will be re-directed to a more suitable environment, where assessment …
Other
In Progress
Styal (2020)
Over the year, there has been a significant reduction in the time spent by more complex prisoners in long-term segregation within the prison. The repurposing of the Valentina unit has provided temporary respite in a number of cases but there is still a pressing need for more specialist facilities, nationally, that can be easily accessed
Other
In Progress
Downview (2021)
Provide support to enable prompt recruitment to critical psychology intervention roles to address reduced capacity, headcount, and waiting lists, particularly during a time of increased demand.
HMPPS
Implemented
Wayland (2022)
The Board recommends to the Prison Service that the new care and separation unit, built, so we are informed, at considerable cost, can at least be staffed to properly address the ‘care’ element as well as that of ‘separation’ in the management of prisoners held there when it does, finally, open.
HMPPS
Isis (2020)
commission research into the impact of the time spent in cells during the pandemic on the mental health of prisoners
HMPPS
In Progress
Whitemoor (2021)
Will the prison service please review urgently the use of specialised units in order to ensure that better and speedier arrangements can be made for prisoners whose needs are difficult or impossible to meet in a prison like Whitemoor? This would avoid the sad spectacle of men languishing for months at a time in demoralising and degrading conditions.
HMPPS
Noted
Heathrow Immigration Removal Centre (2021)
The Home Office should consider ways of improving the multi-disciplinary team (MDT) reviews in the CSU in order not to ‘overcrowd’ or overwhelm detainees.
Home Office
Elmley (2021)
We hope that the minister will give careful thought to the notion of confining men for long periods in small spaces, with little in the way of facilities, in order to protect them from infection. More thought should be given to the effect on their physical and mental health.
Ministry of Justice
In Progress
Long Lartin (2022)
Will the Prison Service commit permanently to limiting the roll of CSRU prisoners to 26?
HMPPS
Long Lartin (2022)
Will the Minister give a clear lead on strategies to ensure that this unit [CSRU] is only used as a short-term measure?
Other
Feltham (2025)
Reopen the enhanced support unit on Feltham A.
HMPPS
Health investigations(102)
An independent investigation into the care and treatment of a … — Rec Recommendation 1
NHS England (South) should ensure that all mental health provider organisations in its geographical area have a policy in place for managing service users who are difficult to engage or who disengage from services. This policy should include clear guidance on the frequency of face-to-face contact for service users who …
south_east
An independent investigation into the care and treatment of a … — Rec R3
The Early Intervention in Psychosis Operational Policy needs to contain clear guidance for managing difficult to engage/non-engaging service users, including clarity regarding clients that are being managed at arm’s length, including frequency of face-to-face contact.
south_east
Independent investigation: Lynda Lovatt, South Shields (2004) — Rec 2
Evidence based practice Primary care services for mental health patients are relatively new. The inquiry considers that it is vitally important that the patient receives the most appropriate treatment available. This should be evidence based. In Craig Sexton’s case, when in 2001 he presented with anxiety and panic attacks he …
north_east_yorkshire
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 10
The panel recommends that the Trust gives guidance on the phrase ‘clinically significant’, as used in the CPA policy, so that all staff understand its meaning and subsequent requirements for specific actions within three months. (Paragraph 6.7)
east_of_england
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 7
The panel recommends that the Trust audit the incidence of unplanned leave and absconsions and that the Trust takes action within three months to reduce the prevalence of this practice. The Trust should require that all patients who are absent without leave should be assertively followed up. The Trust should …
east_of_england
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 6
The panel recommends to the Trust that a policy on screening for the use of illicit substances by patients is developed as a matter of urgency within three months. (Paragraph 5.12)
east_of_england
Independent investigation: Joseph Day, Folkestone (2001) — Rec 23
The East Kent Community NHS Trust should ensure that there is a clear and consistent approach to managing patients who bring illicit drugs or alcohol onto inpatient wards. This should include clear policies on discharge, the use of compulsory powers, and the involvement of drug and alcohol services.
south_east
Independent investigation: Amina Ali, Sheffield (2004) — Rec 3
SCT must establish the baseline information essential to the effective assessment of Service Users detained under the Mental Health Act. In identifying this SCT must ensure that its practice is commensurate with any relevant National Guidance and good practice standards. It is the opinion of this Investigation Team that had …
north_east_yorkshire
Independent investigation: Mary Skerrit (81)Keith Fernandez, Stoke NewingtonPalmers Green — Rec R4
Mental health NHS trusts should remind clinicians of the need to examine both the nature and the degree of mental disorder in considering the possible use of the Mental Health Act 1983 to detain a patient in hospital.
london
Independent investigation: Jordan Cooper, Washington (2011) — Rec 7
The authors of SI reports should always refer to the relevant NICE guidelines, both those that were in place at the time of the incident and any subsequent revisions, when reviewing a patient’s treatment plans.
north_east_yorkshire
Independent investigation: John Williams, Camberley (2011) — Rec Recommendation 12
Guidance should be provided to clinical staff as a part of the Clinical Risk and CPA policy documentation which sets out requirements for service user engagement in therapeutic work and long-term care planning. Guidance should be provided in the following areas: when taking positive risks; when balancing aspects of a …
south_east
Independent investigation: John Williams, Camberley (2011) — Rec Recommendation 1
The Trust must ensure that the diagnostic practice within the Early Intervention Service conforms to national best practice policy guidance. This to include: all patients will be held on CPA for at least the first six months to ensure multi-disciplinary input into formulation of diagnosis; consideration of diagnosis will be …
south_east
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R9
Clinical decisions should not be made in the Monday management round.
london
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R8
The role and purpose of the Monday management round and Friday “putting to bed” round should be evaluated and clarified by the trust.
london
Report of a review in respect of: The provision of … — Rec 13
The health board should ensure that where Consultant Psychiatrists or other clinicians seek to apply a diagnosis of malingering, that it is supported by a clear and substantial evidence base relating to an individual patient.
wales
Independent investigation: Doreen Griggs, Wisbech, Cambs (2004) — Rec 2
The West Norfolk Primary Care Trust1 and the Cambridgeshire and Peterborough Foundation Trust should have formal policies with regard to the referral of a patient to a Psychiatric Intensive Care Unit.
east_of_england
Independent investigation: Florise Corette, Lewisham (2015) — Rec 1
Psychosis Clinical Advisory Group (CAG) senior management to develop a process to review the length of stay when diagnosis is unclear to the local bed management system.
london
Multi-agency systems review to identify the learning following five homicides … — Rec 12
Revised Peninsula Wide Section 136 policy in place and operational. Set a timescale for the agreement and implementation of the Peninsula Wide Section 136 policy. This should include clarity on the process for using Section 136 if the person is already in custody.
south_west
Accepted
*Mental health homicide investigation legacy report into the care and … — Rec Recommendation Two
The Trust will examine all extant clinical policies and procedures to ensure that NICE guidance is embedded within them. The Trust training and development needs analyses will be constructed to ensure that an explicit link is made to the requirements of the NICE guidance with particular reference to substance misuse …
Mr X This is the report of the independent investigation into the care and treatment of Mr X . Mr X was a former patient at Sussex Partnership NHS Foundation Trust
south_east
*Mental health homicide investigation legacy report into the care and … — Rec Recommendation One
The Trust will ensure that all clinical policies and procedures are amended to instruct clinicians of the importance of providing a differential diagnosis where indicated as clinically appropriate. These amendments will also include instructions as to the importance of providing a clear formulation and the guidance for doing so.
Mr X This is the report of the independent investigation into the care and treatment of Mr X . Mr X was a former patient at Sussex Partnership NHS Foundation Trust
south_east
Independent Investigation into the care and treatment of X: October … — Rec 6
The Trust should be satisfied that there is clear practice guidance for the management of risk items on admission to Jade Ward, and that any guidance on restrictions is reasonable, proportionate and necessary.
South Essex University Partnership NHS Foundation Trust
east_of_england
Independent investigation into the care and treatment of Mr MC … — Rec 9
The Trust should develop good practice guidance on leave of absence under section 17 of the Mental Health Act, which should, amongst other elements, require responsible clinicians to set out clear criteria and conditions for such leave.
south_west
Independent care and treatment review into the care and treatment … — Rec 3
Somerset Partnership NHS Foundation Trust and Devon Partnership NHS Trust should review and ratify a Taser policy for their Trust that covers: Immediate aftercare Patient monitoring (physical and psychological) Escalation criteria (e.g. further medical review) Recognition of the impact and possible effects (including psychological effects)
midlands
An independent investigation into the care and treatment of Mr … — Rec 12
The Trust must ensure that the benefits of informal admission are properly considered and documented. If a client is not compliant with their treatment plan consideration is given and documented for assessment under the Mental Health Act.
south_east
An independent investigation into the care and treatment of MN: … — Rec Recommendation 4
Where a patient has an active psychosis and fails to engage in treatment, the Trust should ensure that he or she should be considered for assessment under the MHA, and that this discussion is documented in the notes.
MN. MN was convicted of manslaughter in August 2017. At the time of the homicide MN was receiving care and treatment from Cheshire and Wirral Partnership NHS Foundation Trust
north_west
An independent investigation into the care and treatment of mental … — Rec R1
The trust should review its risk policy to ensure that static risks are identified, and realistically assessed, and unnecessary weight is not given to dynamic factors.
Greater Manchester Mental Health NHS Foundation Trust
north_west
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 inquiry into the care and treatment of Ms … — Rec 3
We recommend that OHFT put in place a process that ensures a consistent pattern of practice that enables appropriate and adequate assessment of patients’ mental health whether or not they are detained under the Mental Health Act. This should include a clear process for determining the responsible clinician and for …
south_east
An independent external quality assurance review (published November 2019) can … — Rec 2.
The Trust should review management of aggression guidance and the clinical link pathway for Behaviours that Challenge in Mental Health Services for Older People wards to ensure that explicit guidance in how to manage an incident is an outcome of the assessment process and is included in intervention plans.
north_east_yorkshire
An independent external quality assurance review (published November 2019) can … — Rec 2.
The Trust should review management of aggression guidance and the clinical link pathway for Behaviours that Challenge in Mental Health Services for Older People wards to ensure that explicit guidance in how to manage an incident is an outcome of the assessment process and is included in intervention plans.
north_east_yorkshire
A post-publication assurance review in relation to the implementation of … — Rec A8
Senior Trust officers should discuss and agree future Trust Policy in relation to involvement / information sharing with the family of a victim, when the victim is not known to mental health services in these circumstances. In relation to this case, legal advice should be sought regarding the level of …
north_east_yorkshire
Joint Safeguarding Adult Review and Independent Mental Health Homicide Investigation, … — Rec 3
The Trust should update its Zoning Policy to reflect the immediate interventions staff should take in response to a service user changing zones. This should include the timeliness of key interventions, which staff should be involved in, and details of ongoing monitoring including frequency and leads for escalations or reporting …
london
Accepted
Independent investigation report into the care and treatment of Mr … — Rec 9
DHCFT should align the definition of long term segregation in their policy with that of the MHA code of practice, develop a system to identify any cases of long term segregation, and any instances of long term segregation should be reported and monitored formally through quality structures.
midlands
Partially Accepted
Independent investigation report into the care and treatment of Mr … — Rec 8
DHCFT should ensure that seclusion practice is monitored to provide assurance that policy requirements for reviews are met and adhered to.
midlands
Accepted
Independent investigation into the care and treatment of Ms A — Rec 13
The Trust should ensure that robust processes are in place to support a clinical decision to allow patients who are on a conditional discharge to visit other countries.
Ms A who committed a homicide in October 2011. Ms A was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Ms A — Rec 10
The Trust should satisfy itself that the practice and approach sometimes taken by an RC in applying to the MoJ, rather than the patient seeking this through the MHA Tribunal, is acceptable.
Ms A who committed a homicide in October 2011. Ms A was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of Emily … — Rec 3
TEWV must ensure that the management of restrictive interventions (including contraband items) is part of an agreed philosophy and approach, with clear protocols embedded to guide practice.
An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation: Alan Riddock, Bristol (2008) — Rec 4
The Avon and Wiltshire Mental Health Partnership NHS Trust, together with the local PCTs and Local Authorities and any other relevant partner organisation should ensure that: • there is a protocol in place to ensure that the Code of Practice accompanying the Mental Health Act is followed where there is …
south_west
Independent investigation: Alison McKenzie, Middlesbrough (2019) — Rec 4
The Trust must revise internal policies and procedures relating to the functioning of ‘clozapine clinics’ in order to be satisfied that any function relating to formal assessment of attendees’ mental health status is clearly described and supported.
north_east_yorkshire
An independent investigation into the care and treatment of a … — Rec R4
The Early Intervention in Psychosis team to monitor the risk status and management plans of those individuals whose mental state appears to be deteriorating via a Red Board meeting three times per week. Clarity needed regarding the RAG [red/amber/green] ratings, criteria for each category and what to do and when …
south_east
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1.b
Dispute resolution The possibility of dispute between professionals about applying eligibility criteria for CPA and other CPA-related areas, for example the contents of care plans, should be explicitly recognised and the policy should contain procedures to resolve disputes.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1.a
Change of eligibility criteria The characteristics of people on CPA may change – for example a person on standard CPA may become eligible for enhanced CPA. The policy should explicitly deal with this and should contain guidance about reviewing each patient’s status.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1
Current CPA policy and procedures should be amended to take into account the following:
london
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 14
The panel recommends to the Trust that the minutes of the CMHT meetings record clearly all decisions of the meetings and actions to be taken regarding patients. The minutes should identify the member who should take action and set an agreed time by which that member should report back to …
east_of_england
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 8
The panel recommends that the Trust reviews within three months the current practice of the discharge policy and ensure that the discharge of patients should only take place according to the DoH circular HSG(94)27. (Paragraph 5.14)
east_of_england
Independent investigation: Joseph Day, Folkestone (2001) — Rec 7
The East Kent Community NHS Trust and Kent County Council should ensure that there is clear guidance and training for all staff on the use of compulsory powers under the Mental Health Act 1983, particularly in situations where there is a risk of harm to others. Staff should be supported …
south_east
Independent investigation: Paul BrownDorothy Brown, Liverpool (2014) — Rec 10
The Trust should audit compliance with NICE guidelines CG178: Psychosis and schizophrenia in adults: prevention and management, within the Secure Division and implement findings
north_west
Independent investigation: Joyce Lovell, Donhead St Mary, Wilts (2008) — Rec 1
The Trust action plan should include a specific action on Mental Health Act (2007) management. This to ensure staff knowledge, practice and application is clinically appropriate.
south_west
Independent investigation: Jonathan Palgrave, Preston (2018) — Rec 2
The Trust must provide clear guidance to staff on the identification and management of patients who are not engaging with mental health services, this must include how engagement will be monitored and reviewed.
north_west
Independent investigation: John Williams, Camberley (2011) — Rec Recommendation 7
The Trust must develop a Clinical Risk Assessment and Management Policy that will apply to all mental health service users across the Trust as a matter of priority. This is in keeping with the practice of most, if not all, other mental health Trusts nationally. This policy should include: clear …
south_east
Scottish Fatal Accident Inquiries(3)
Harris James McDonell
In terms of Section 26(1)(b) of the Act the court has one recommendation to make, namely that entry and exit to Huntlyburn Ward should be controlled.
Jun 2025
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 within 24 …
Oct 2025
Health
5 recs
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 patient on …
Dec 2024
Health
4 recs
Independent reviews(21)
Wessely Review — Rec 79
The power of associate hospital managers to order discharge following a hearing should be removed.
Health & Social Care
Accepted
Wessely Review — Rec 65
The recall criteria should be updated and the process should be reformed to make it simpler.
Health & Social Care
Accepted
Wessely Review — Rec 63
As well as considering discharge, the Tribunal should, when refusing to discharge from the CTO, be able to order changes to the conditions of a CTO.
Health & Social Care
Accepted
Wessely Review — Rec 58
The onus should be on the RC to demonstrate that a CTO is a reasonable and necessary requirement to maintain engagement with services and protect the safety of the patient and others. The evidence threshold should be raised for demonstrating that contact with services has previously declined, and that this …
Health & Social Care
Accepted
Wessely Review — Rec 57
The criteria for CTOs should be revised in line with detention criteria.
Health & Social Care
Accepted
Wessely Review — Rec 86
Risk assessments of issues such as infection control should be designed specifically for mental health inpatient care, and not lifted from other health settings. The unintended psychosocial effects must also be considered.
Health & Social Care
Accepted
Wessely Review — Rec 81
The managers of the hospital (those who actually manage the hospital) should continue to have the power to discharge a patient where fundamental errors have been made in either the admission or renewal paperwork.
Health & Social Care
Accepted
Wessely Review — Rec 78
The managers of the hospital should continue to have the duty to scrutinise applications for detention, and should have a duty to scrutinise renewal documents.
Health & Social Care
Accepted
Wessely Review — Rec 75
There should be a clear statement in the new Code of Practice of the purpose and content of the SCP and section 117 aftercare.
Health & Social Care
Accepted
Wessely Review — Rec 68
If put in place, the effect of our recommendations on CTOs should be reviewed in no more than five years time, with a view to abolish CTOs if outcomes are not improved.
Health & Social Care
Accepted
Wessely Review — Rec 66
Recall to alternative locations should be considered.
Health & Social Care
Accepted
Wessely Review — Rec 64
If no appeal is made to the Tribunal in each time period there will be an automatic referral.
Health & Social Care
Accepted
Wessely Review — Rec 62
CTOs should end after 24 months, though the RC should be able to make a new application.
Health & Social Care
Accepted
Wessely Review — Rec 61
CTOs should have an initial period of 6 months, renewed at 6 months and then 12 months. Each renewal must involve two approved clinicians and an AMHP, unless the tribunal has recently reviewed the order.
Health & Social Care
Accepted
Wessely Review — Rec 60
The Nominated Person/Interim Nominated Person will have the power to object to both applications and renewals of CTOs.
Health & Social Care
Accepted
Wessely Review — Rec 59
Applications for a CTO should be made by the inpatient responsible clinician, with the community supervising clinician who will be responsible following discharge, and an AMHP.
Health & Social Care
Accepted
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 55
A patient could be held in hospital for a statutory period of up to 72 hours under MCA LPS amendments whilst it is determined whether the person is objecting.
Health & Social Care
Accepted
Wessely Review — Rec 9
Patients should be able to appeal treatment decisions at the Mental Health Tribunal following a SOAD review.
Health & Social Care
Accepted
Wessely Review — Rec 8
Patients should be able to request a SOAD review from once their care and treatment plan has been finalised or 14 days after their admission, whichever is the sooner; and again, following any significant changes to treatment.
Health & Social Care
Accepted
Wessely Review — Rec 6
Statutory advance choice documents (ACDs) should be created that enable people to make a range of choices and statements about their inpatient care and treatment. These should be piloted to identify the detail needed to inform/impact practice.
Health & Social Care
Accepted
PHSO casework decisions(8)
P-001556 — Wrightington, Wigan and Leigh NHS Foundation Trust
Mr A complained the Trust provided improper mental health treatment, discharged him while psychotic, and failed to send him copies of his medical records.
NHS in England
Jul 2022
P-002520 — South London and Maudsley NHS Foundation Trust
Ms H complained about the Trust's deliberate lack of care, forced medication, and negligence from 2008-2014, including wrongful detention and racial discrimination in housing, causing reputational damage.
NHS in England
Mar 2024
P-002945 — Manchester University NHS Foundation Trust
Miss U complained about inappropriate restraint, an unwarned injection, excessive force by security, an invalid sectioning, an inaccurate diagnosis, and not being informed of a needlestick injury or sectioning.
NHS in England
Sep 2024
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.
NHS in England
Nov 2024
P-001771 — Priory Group Limited
Ms L complained about incorrect diagnoses, medication mismanagement, unjustified detention, racism, physical assault, administrative errors, and theft during her hospital stay.
NHS in England
Jan 2023
P-002912 — University Hospitals Birmingham NHS Foundation Trust
Mr A complained the Trust unlawfully detained him without reason or proper guidelines, and failed to provide him with DoLS documents during detention or discharge.
NHS in England
Sep 2024
P-004433 — Barts Health NHS Trust
Dr G complained Barts Health did not respect her opinions, lied in medical records, treated her son disrespectfully during transfer, and failed to provide food/medication, leading to fear of hospitals and increased seizures.
NHS in England
Nov 2025
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.
NHS in England
Feb 2025
LGO / SPSO decisions(5)
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
21-014-685b — Woodlands Medical Centre (21 014 685b)
Summary: We will not investigate this complaint about the circumstances surrounding Dr A’s detention under Section 2. The Trust and Council have already investigated the matter and acted to improve their services. It is unlikely an Ombudsmen’s investigation would achieve more.
LGO (Local Government & …
Health
Mar 2022
23-011-009b — NHS Cornwall and Isles of Scilly ICB (23 …
Summary: We investigated a complaint about the section 117 aftercare provided to Ms A by the Council, the Trust and the ICB after she was detained under section 3 of the Mental Health Act 1983. We found no fault by any of the organisations.
LGO (Local Government & …
Health
Not Upheld
Jun 2024
23-011-009a — Cornwall Partnership NHS Foundation Trust (23 011 009a)
Summary: We investigated a complaint about the section 117 aftercare provided to Ms A by the Council, the Trust and the ICB after she was detained under section 3 of the Mental Health Act 1983. We found no fault by any of the organisations.
LGO (Local Government & …
Health
Not Upheld
Jun 2024
Domestic Homicide Reviews(17)
Haringey — recommendation R15
The revised policy contains a requirement that patients cared for under CPA or subject to the Mental Health Act and care coordinated by the supervisee should be discussed in supervision at least once per year.
Camden & Islington NHS Foundation Trust
North London NHS Foundation …
Middlesbrough — recommendation 4
Assurance should be provided to Middlesbrough DHR scrutiny panel that a previous recommendation that ‘The Trust must revise internal policies and procedures relating to the functioning of ‘Clozapine clinics’ in order to be satisfied that any function relating to formal assessment of attendees’ mental health status is clearly described and …
Tees Esk and Wear Valleys NHS …
Tees, Esk and Wear …
Oxford — recommendation 3
We recommend that OHFT put in place a process that ensures a consistent pattern of practice that enables appropriate and adequate assessment of patients’ mental health whether or not they are detained under the Mental Health Act. This should include a clear process for determining the responsible clinician and for …
Oxford Health NHS Foundation Trust
Oxford Health NHS Foundation …
East Sussex — recommendation SPFT4
Where engagement is an issue, consideration of use of mental health act should be discussed and documented with a rationale for decision making.
Sussex Partnership NHS Foundation Trust
Sussex Partnership NHS Trust
East Sussex — recommendation SPFT1
Lack of known and understood legal restrictions gave the perpetrator the choice to disengage with services and decline depot medication. His Care Plan and engagement was reliant on the perpetrator making contact and attending appointments when he was clear that he did not believe that this was necessary, there was …
Sussex Partnership NHS Foundation Trust
Sussex Partnership NHS Trust
Haringey — recommendation R9
Care planning for this group of patients is managed using the CPA process.
Camden & Islington NHS Foundation Trust
North London NHS Foundation …
Cornwall — recommendation 2
It is recommended that D140 (Mental Health Issues Policy) be reviewed with a view to drawing together risk areas, including domestic abuse, mental health, missing persons and child abuse investigation. Guidance and procedures should be reviewed with consideration to incorporating a ‘think family’ approach under mental health protocols and practices.
Devon and Cornwall Police
Devon and Cornwall Police
Kent — recommendation 1
KMPT should review existing policies relating to inpatient discharge in order to ensure that in every case, whether by self-discharge or not, the responsibility for further care is decided within 24 hours of the unexpected absence of a patient from a ward. This should apply whether a patient is unexpectedly …
KMPT
Kent and Medway NHS …
Tower Hamlets — recommendation 5
No patient should be considered for discharge from THCfMH within 24 hours of admission without the agreement of a senior member of staff. Senior members of staff include the following: the borough lead nurse and deputy borough lead nurse, the responsible clinician or duty consultant and the modern matron or …
East London Foundation Trust
East London NHS Foundation …
East Sussex — recommendation SPFT6
Protocol to be put in place to ensure that all eligible patients receive a Section 117 discharge meeting.
Sussex Partnership NHS Foundation Trust
Sussex Partnership NHS Trust
East Sussex — recommendation SPFT5
HCR20 risk assessment to be completed for all forensic inpatients
Sussex Partnership NHS Foundation Trust
Sussex Partnership NHS Trust
East Sussex
SPFT to address how practitioners respond to threats of risk of harm to family members made by an inpatient of mental health service and consider whether a policy needs producing or whether an existing policy needs amending.
Sussex Partnership NHS Foundation Trust
Sussex Partnership NHS Trust
Enfield — recommendation 7
BEH Mental Health Trust should review practice to ensure that: a) Where a decision is made to change a treatment plan for a patient, there should be evidence of discussion/second opinions and documentation of the reasons for change and the alternative arrangements, including contingency plans. b) Care to be taken …
Barnet, Enfield & Haringey Mental Health …
North London NHS Foundation …
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
Uttlesford — recommendation 10
That NHS England share nationally the learning from this Review, as addressed by recommendation 13, and encourage all mental health Trusts to ensure their Discharge Policies adequately address cases where patients transfer into or between prisons.
NHS England
NHS England
Uttlesford — recommendation 9
The mental health NHS Trusts named in this Report to amend their Discharge Policies to ensure that they set out clearly the procedure for when a patient under their care is transferred into prison (or into a different prison), and that these procedures take into account the learning from this …
North Essex Partnership University NHS Foundation …
North Essex Partnership University …
Chorley and South Ribble — recommendation 3
The Chorley and South Ribble CSP should work with the local safeguarding partnership to ensure that developing awareness of childhood trauma and its impact in adult life is understood and that models of good practice are adopted in local services.
Chorley and South Ribble Community Safety …
CQC enforcement actions(4)
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 …
Mar 2024
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 …
acute wards for adults of working age
Apr 2023
Warning Notice: Cheshire and Wirral Partnership NHS Foundation Trust
The Care Quality Commission (CQC) served Cheshire and Wirral Partnership NHS Foundation Trust with a warning notice following an inspection in November. The inspection found acute wards for adults of working age and psychiatric intensive care units to be inadequate. …
Mulberry ward in Macclesfield and Brooklands and …
Feb 2023
Warning Notice: Nottinghamshire Healthcare NHS Foundation Trust
Section 29A warning notice for failing to meet regulations on the governance of long-term segregation environments at Rampton Hospital and Arnold Lodge.
Nov 2025