Poor mental health step-down planning
Absence of detailed risk assessment and management plans during mental health care step-downs or medication weaning.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
GIRFT recommendation
100match
Mental Health Rehabilitation
3. All trusts, health commissioners and LAs should develop robust systems to bring patients treated out of area back to their local area. a A senior named placements co-ordinator, as part of the CRT, to review and plan the person's move back to local care, and in the community wherever possible. Need to have or be directly linked...
Matched on
terms: health, mental, planning
HSSIB recommendation
100match
Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of...
Organisations can improve patient safety by ensuring that a person centred approach to biopsychosocial assessment should be offered for all patients who have contact with mental health services, when a patient has an episode of self-harm or suicidal thinking, every time they make a transition between mental health services, and at key important times in the person’s life....
Matched on
terms: health, mental, planning
Committee recommendation
89match
#22 - Rural communities receive minimal NHS mental health support during and after crisis events.
Crisis events can have short- and long-term effects on people’s mental health, but civil society groups told us NHS support is minimal or short-term, despite greater support being likely to help people deal more successfully with trauma. Rural health providers suggested only limited local planning takes place with no extra resources being available, while NHS England suggested more...
Matched on
terms: health, mental, planning
PFD report
87match
Debrata Sircar
The coroner noted delays in securing a bed and conducting a Mental Health Act assessment for a patient needing hospitalization, due to unavailability of a local authority practitioner. There was an absence of an interim care plan and a lack of clarity regarding psychiatric monitoring during this period.
Matched on
terms: health, mental
HSSIB recommendation
86match
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services...
Inpatient children and young people’s mental health services can improve patient safety by ensuring that young people, families, and carers are involved, informed and prepared as possible for the young person’s next place of care. This may require increased levels of engagement with partner inpatient adult mental health services to support a full understanding of the differences that...
Matched on
terms: health, mental
GIRFT recommendation
86match
Children and Young People's Mental Health Services
There must be a clear strategy and plan on reducing the proportion of young people remaining on the inpatient unit for more than 60 days. The plan must include: • promotion and development of effective alternatives to an inpatient admission, including provision through social care and education; • rapid and appropriate access to therapeutic support on the inpatient...
Matched on
terms: health, mental
PFD report
85match
Peter Stanley
The coroner identified gaps in mental health assessments and 'step-down' support for young people in custody or transitioning from adult mental health services. Concerns also included insufficient information sharing between agencies and the incorrect classification of homeless young persons, affecting proper support.
Matched on
terms: down, health, mental, step
PFD report
85match
Georgia Nelson
The coroner notes a lack of suitable long-term housing and rehabilitation placements for young mental health patients in RBKC, and highlights the need for improved discharge planning and consideration of rehabilitation before discharge.
Matched on
terms: health, mental, planning
Committee recommendation
82match
#29 - 3rd Report - Legislative Scrutiny: Mental Health Bill
The Bill should be amended to ensure that conditions depriving a restricted patient of their liberty are reviewed by the Mental Health Tribunal promptly and regularly In particular, the Secretary of State should refer the restricted patient’s case to the tribunal after 6 months (unless the case has already been considered) and every restricted patient subject to deprivation...
Matched on
terms: health, mental
Committee recommendation
78match
#28 - 3rd Report - Legislative Scrutiny: Mental Health Bill
We can see that in narrow circumstances, where the need to ensure the safety of the public makes deprivation of liberty in the community the least restrictive option available, being able to impose conditions on the discharge of a restricted patient that amount to a deprivation of liberty may be beneficial and compatible with Article 5 ECHR. However,...
Matched on
terms: health, mental
NCEPOD recommendation
78match
Mental Healthcare in Young People and Young Adults
Matched on
terms: health, mental
PFD report
77match
Alice Mead
The coroner raised concerns about the patient being left without a Care Co-ordinator and not being informed of discussions about her medication review request. Additionally, the Mental Health Team's response to urgent concerns from a Health Visitor was noted as delayed.
Matched on
terms: health, mental
PFD report
77match
Laura McRory
The coroner identified a need for a clear process when NELFT staff require mental health care but are hesitant to share information internally, including prompt referral to a different Trust and adequate safety plans on discharge.
Matched on
terms: health, mental
PFD report
77match
Christopher Jones
Delays in completing Care Treatment Plans post-discharge meant patients might not see a consultant psychiatrist for up to sixteen months. Concerns were also raised about insufficient staff cover due to increasing demand on mental health services.
Matched on
terms: health, mental
PFD report
77match
David Phillips
The coroner noted insufficient expertise of the mental health professional conducting the assessment of an older person who self-harmed, and inadequate access for the healthcare professional to the detainee's full medical records.
Matched on
terms: health, mental
PFD report
77match
David Knight
The coroner identified a limited risk assessment before S17 leave and a lack of communication with local mental health teams, which meant no mitigation plan was in place. Out-of-county placement also made family involvement difficult.
Matched on
terms: health, mental
PFD report
77match
Sian Witheridge
The coroner noted deficiencies in the availability and review of mental health records, inadequate detail in risk assessments, and staff misunderstanding of suicide risk indicators. There were also concerns regarding disjointed care coordination between providers.
Matched on
terms: health, mental
PFD report
77match
Terence Tuttle
The coroner identified a lack of early dietician and mental health assessments, inaction despite documented weight loss, and an inability to adequately care for a mentally unwell patient refusing food. Concerns were also raised about excluding family from care and failing to recognise serious harm.
Matched on
terms: health, mental
PFD report
77match
Leroy Hamilton
Insufficient inpatient mental health beds and safe spaces meant patients awaited specialist care in emergency departments. The coroner also noted West Midlands Police's understanding of missing person classification and risk assessment.
Matched on
terms: health, mental
PPO recommendation
77match
The Head of Healthcare
The Head of Healthcare should ensure that mental health services meet the needs of prisoners by: implementing a referral system that results in a timely, face-to-face assessment using all relevant information for appropriate continuity of care and follow-up; ensuring that care plans are adhered to and adequate resources are available so that prisoners can have regular face-to-face contact...
Matched on
terms: health, mental
IMB recommendation
76match
Downview (2023)
There seems to be some limitations in communication between HMP Bronzefield and the prison (for example, with regards to transferred prisoners with significant mental health conditions and with missing property and medication issues). Is this because HMP Bronzefield is a private prison, and systems and processes may not be compatible?
Matched on
terms: down, health, mental
Committee recommendation
76match
#11 - Require Government to set out plans for reducing autistic detentions and improving community alternatives.
In response to this report, the Government should set out: • The reasons why the number of autistic people detained in mental health hospitals has increased; and how it plans to reduce that number, and by when. • The steps it will take to improve access to and availability of community-based alternatives to inpatient settings, including the additional...
Matched on
terms: down, health, mental, step
IMB annual report
76match
Lowdham Grange (2021)
HMP Lowdham Grange operated a restricted regime throughout the year due to COVID-19, which impacted various aspects of prison life and the Board's monitoring capabilities. Despite these challenges, the prison was generally well-managed, maintaining safety with reduced violence, effective healthcare provision, and positive staff-prisoner relationships, though staff morale declined. Key concerns remain around mental health transfers, property management,...
Matched on
terms: down, health, mental
HSSIB recommendation
74match
Investigation report: Mental health inpatient settings - out of area placements
NHS organisations can improve patient safety by maintaining clinical and welfare oversight and responsibility for patients being treated in an out of area placement. This can ensure harm is minimised and that patients are returned to their sending hospital as soon as possible.
Matched on
terms: health, mental
PFD report
73match
Rebecca Overy
The immediate transfer of a patient upon turning 18 was detrimental to her mental health, driven by statutory obligations rather than her best interests. The coroner also identified a lack of secure mental health care provisions for young adults aged 18-24 with similar complex clinical needs.
Matched on
terms: health, mental
PFD report
73match
Louise Turner
The coroner noted inadequate post-discharge mental health care and ineffective duty/buddying systems. Concerns were also raised about the expectation for severely ill patients to initiate contact and the lack of female intensive psychiatric beds in Devon.
Matched on
terms: health, mental
PFD report
73match
Lester Stacey
The coroner noted the deceased was discharged from mental health services without pre-arranged follow-up appointments and no attempt was made to visit him to re-engage with services. Concerns were also raised about the lack of monitoring for his changed medication after discharge.
Matched on
terms: health, mental
PFD report
73match
Terence Pimm
The coroner raised concerns regarding police call handling and record-keeping, and the sufficiency of guidance for call handlers on immediate risk assessment and for mental health assessors on family input. The report also notes insufficient information sharing between agencies and a lack of understanding among mental health clinicians regarding the effect of warrants on their ability to assess...
Matched on
terms: health, mental
PFD report
73match
Daniel Collins
The mental health crisis team transferred patient care to another service, placing contact responsibility on the patient shortly after an attempt, without alerting the receiving service or having a system for follow-up, risking patients being lost to services.
Matched on
terms: health, mental
PFD report
73match
Joshua Rennard
The report highlights a delay in actioning recommendations for Mental Health Act S2 assessments, specifically an 8-day gap in Joshua's case, due to Approved Mental Health Professional allocation. Such delays are reportedly not unusual and may place individuals at risk.
Matched on
terms: health, mental
Committee recommendation
73match
#27 - Eighth Report - Children and young people’s mental health
We therefore recommend that the Department accelerates the shift towards increased community-based provision and a reduced inpatient bed base as a national priority to ensure that children and young people with the most complex needs receive good quality care in a setting that is right for them. A national strategy should be set out to establish jointly commissioned...
Matched on
terms: health, mental
Committee recommendation
73match
#26 - Eighth Report - Children and young people’s mental health
Inpatient units have a role to play in treating some of the most severe and complex mental health conditions, especially those that are resistant to community treatment. However, in most cases the most compassionate and effective care for children and young people is provided in the community–and increasing its provision must be the overall aim of the Department...
Matched on
terms: health, mental
IMB annual report
73match
Downview (2022)
HMP/YOI Downview experienced another year significantly impacted by the Covid-19 pandemic, leading to a restricted regime and challenges across various departments. While the Board found the prison safe and prisoners treated fairly, it raised significant concerns regarding the management and provision of healthcare, staffing pressures, and the lack of digital access for education. These issues highlight the ongoing...
Matched on
terms: down, health
PHSO casework decision
73match
P-002645 - North Staffordshire Combined Healthcare NHS Trust
Ms H complained the Trust discharged her from mental health support without investigating root causes or arranging a care plan. She also alleged a data breach involving a lost sensitive statement.
Matched on
terms: health, mental
PHSO casework decision
72match
P-004418 - Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Miss A complained about her daughter's premature discharge, inadequate medication, lack of updated risk assessment, and insufficient aftercare, causing mental health deterioration.
Matched on
terms: health, mental
PFD report
69match
John Delahaye
The coroner identified confusion over a risk assessment question for in-possession medication, potentially leading to incorrect authorisations. Further concerns included unreliable 'read coding' in prison healthcare records and insufficient healthcare attendance at ACCT reviews.
Matched on
terms: health
PFD report
69match
Michael Cox
The coroner identified a potential shortage of suitable placements for individuals with mental health history, leading to persistent difficulties for social workers and occupational therapists in finding appropriate facilities.
Matched on
terms: health, mental
PFD report
69match
Lewis Francis
The coroner noted a lack of a mechanism for transferring individuals in police custody with serious charges to medium secure mental health facilities, and insufficient understanding of the needs of prisoners on the autistic spectrum.
Matched on
terms: health, mental
PFD report
69match
Kieran Crimmins
The coroner identified issues with the Crisis Recovery and Home Treatment Team's manual action tracking, where incomplete tasks were marked as done. Concerns included the lack of a clear re-entry pathway and communication gaps for vulnerable patients discharged from mental health services.
Matched on
terms: health, mental
PFD report
69match
Roger Stevenson
The coroner's concerns included a vulnerable adult being "lost in the system" with inadequate follow-up and inappropriate housing. There was also a lack of long-term support for cyclical mental ill health, delays in accessing services, insufficient family engagement, and ongoing staffing shortages.
Matched on
terms: health, mental
Scottish FAI
69match
Jordan Barron
Given that HMYOI, Polmont has a high intake of disturbed young men from socially and economically deprived backgrounds, perhaps further thought should be given by NHS and SPS to their future aims towards mental health and behavioural issues of such inmates whilst within the prison setting and to supported care from other agencies on their release.
Matched on
terms: health, mental
PHSO casework decision
69match
P-002499 - Avon and Wiltshire Mental Health Partnership NHS Trust
Ms E complained the crisis team did not listen or offer support options, and as an inpatient, she was denied free movement, proper toilet facilities, correct diet, and a discharge plan.
Matched on
terms: health, mental
IMB annual report
68match
Leicester (2021)
HMP Leicester is a well-run local male adult prison that maintained strong leadership and an engaged staff during a challenging year of COVID-19 restrictions. Despite prisoners being largely confined to cells for 23 hours daily, the prison saw significant reductions in violence, self-harm, and drug use, partly due to the restricted regime and enhanced security. The Board commended...
Matched on
terms: health, mental
LGO / SPSO decision
68match
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 ongoing concerns, there was a need for the...
Matched on
terms: health, step
IMB annual report
68match
Ranby (2021)
For the reporting period ending March 2021, HMP Ranby operated under severe Covid-19 restrictions, including a 22-hour lockdown. Despite this, the prison commendably controlled Covid-19 outbreaks and saw significant reductions in self-harm and violence. However, the Board highlighted recurring concerns regarding mental health provision, cell sharing, resettlement issues, and deficiencies in prisoner complaint handling and transfer processes.
Matched on
terms: down, health, mental
LGO / SPSO decision
68match
PSOW-202106332 - Cwm Taf Morgannwg University Health Board
Mr D complained that Cwm Taf Morgannwg University Health Board (“the First Health Board”) failed to provide care and support to his late daughter, Miss E, when her mental health deteriorated during 2020. Mr D said the First Health Board failed to transfer her section 117 aftercare (free help and support following a hospital stay under the Mental...
Matched on
terms: health, mental
IMB recommendation
67match
Heathrow immigration removal centre (2023)
The Board consider Rules 40 and 42 are being misused. There were several instances in 2023 where Rule 40 and 42 have been used for prolonged situations. It is imperative that Rules 40 and 42 are used for the shortest possible time and as a means of last resort. It should not be used to hold mentally ill...
Matched on
terms: health, mental, poor
LGO / SPSO decision
67match
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 experienced delays and difficulties in obtaining a dual...
Matched on
terms: health, mental
PHSO casework decision
67match
P-001933 - South Tyneside and Sunderland NHS Foundation Trust
Miss D complained about delayed medication, poor pressure care, insufficient mental health support, and basic nursing failings for her father, which she believed contributed to his avoidable death.
Matched on
terms: health, mental, poor
PFD report
65match
Katherine Bonaventura
The coroner noted insufficient consultation with family/carers when detained patients return from leave, often limited to a few words in the patient's presence. There is also no system for a thorough mental state assessment of the patient upon their return to the unit.
Matched on
terms: mental