Poor mental health triage record-keeping
Lack of comprehensive written records for triage decisions in mental health services, leading to gaps in accountability.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
81match
Richard Walsh
The coroner noted significant gaps in communication and information-sharing processes between custodial, health, police, court, and prison services. This led to crucial mental health information being lost or distorted, particularly due to a lack of automatic sharing for Mental Health Act assessments between agencies.
Matched on
terms: health, mental
PFD report
81match
Jack Farrington
The coroner raised concerns about the limited sharing of electronic mental health records between NHS trusts, hindering timely access to patient history. Within the mental health unit, issues included the recording and storage of handover information and the reliance on paper records.
Matched on
terms: health, mental, record
PFD report
81match
Leslie Swindells
Concerns were raised regarding a mental health assistant practitioner's limited training, insufficient understanding of risk, and unclear supervision. The report also noted inadequate patient triage, challenges with telephone assessments, and poor documentation.
Matched on
terms: health, mental, poor, triage
PPO recommendation
81match
The Head of Healthcare
The Head of Healthcare should: • review the mental health referral and triage process to ensure that assessments are based on all available information; and • ensure that prison staff are involved in case discussions when they report concerns about prisoners’ deteriorating mental health.
Matched on
terms: health, mental, triage
PFD report
77match
Keith Nottle
The coroner identified a practice where telephone workers bypassed specialist mental health assessments, making risk judgments on limited criteria. Issues included a lack of care co-ordination and clarity in the multi-disciplinary team's discharge decisions and approach to re-referrals.
Matched on
terms: health, mental
IOPC learning recommendation
76match
Recommendations - Northumbria Police, July 2024
The IOPC recommends that Northumbria Police provides guidance to the Street Triage Team (STT) around the importance of considering the particular circumstances faced by frontline officers when attending an incident, when making a decision about how best to resolve a mental health related matter, to avoid placing too much weight on the patient’s past presentation during other historical...
Matched on
terms: health, mental, triage
PFD report
73match
Adam Withers
The coroner identified insufficient recording of observations and interactions with psychiatric patients, noting some staff lacked understanding of record-keeping importance. Additionally, concerns were raised about non-contemporaneous notes made post-death without retrospective labelling.
Matched on
terms: keeping, record
CQC action
72match
Northern General Hospital
The trust should implement systems to ensure all patients receive an initial mental health triage on arrival to the department.
Matched on
terms: health, mental, triage
PFD report
69match
Sean Seabourne
The coroner noted insufficient formal communication and clarity of roles between mental health teams, which meant critical information about a patient's settled plans to kill himself was not adequately shared or acted upon.
Matched on
terms: health, mental
PFD report
69match
Natalie Hunter
The coroner noted delays or absence of discharge summaries from the Isle of Wight NHS Trust to GPs, affecting continuity of care for mental health patients. Concerns were also raised about insufficient out-of-hours mental health staff due to funding limitations.
Matched on
terms: health, mental
PFD report
69match
Paul Dunne
Coroner noted insufficient knowledge and judgment among mental health professionals regarding high-risk assessment and Mental Health Act. Concerns also included Mental Health Trust staff's unawareness that A&E policies for risk assessment and monitoring applied.
Matched on
terms: health, mental
PPO recommendation
69match
The Head of Healthcare at The Mount
The Head of Healthcare at The Mount should ensure that the reasons for mental health referrals are clearly documented so that staff can assess any potential risks.
Matched on
terms: health, mental
CQC action
69match
Verve Health
The service must ensure that observation records indicate the level of observation and reasoning for levels of observation.
Matched on
terms: health, record
Committee recommendation
67match
#73 - First Report - Universities and Scotland
Students in Scotland, as with so many groups, faced unprecedented challenges over the course of the pandemic. Whilst we welcome the investments the Scottish Government has made in student wellbeing and mental health during this period, we have heard evidence of structural underfunding that predated the pandemic, long waiting lists and poor triaging of mental health inquiries. This...
Matched on
terms: health, mental, poor
PFD report
61match
Oliver Ford
The coroner raised concerns regarding the telephone triage process, noting a need to include a risk assessment within it and ensure all risk assessments are documented. There were also concerns about the weekend cover for the PCLS service to prevent delays in patient follow-up.
Matched on
terms: triage
PFD report
61match
Greg Hutchins
The coroner noted a lack of clear purpose and documentation for telephone triage, including no notes, system updates, or staff recollection. There was also no national system for rapid information sharing for patients from outside the local area.
Matched on
terms: triage
PFD report
61match
Gregory Rewkowski
Concerns included Pennine Care Trust's process for raising welfare concerns and escalating issues, North West Ambulance Service's limited investigation and inadequate telephone triage, and inter-agency confusion over police roles in Section 136 incidents.
Matched on
terms: triage
PFD report
61match
Jan Raciborski
The coroner noted the absence of written records for risk assessments by the AMHT, which could lead to inadequate information sharing and hinder future investigations into deaths.
Matched on
terms: record
PFD report
61match
Edward Hands
The coroner noted conflicting policies between the prison healthcare provider and prison staff regarding prisoners suspected of being under the influence of illicit substances. This resulted in confusion, a lack of awareness, and a prisoner's clinical deterioration not being recognised or escalated due to missed observations.
Matched on
terms: health
PHSO casework decision
60match
P-004260 - Oxford Health NHS Foundation Trust
Dr J complained a mental health nurse from Oxford Health NHS Foundation Trust gave incorrect advice to police, resulting in her unnecessary removal from home under the Mental Capacity Act.
Matched on
terms: health, mental
LGO / SPSO decision
59match
PSOW-201903330 - Cwm Taf Morgannwg University Health Board
Ms C complained about her daughter, H’s, management and care by Cwm Taf Morgannwg University Health Board’s “(the First Health Board’s”) Child and Adolescent Mental Health Services (“CAMHS”), including what Ms C felt was an unreasonable delay in diagnosing her daughter’s Borderline Personality Disorder (“BPD”). Ms C also complained about a lack of support provided to her prior...
Matched on
terms: health, mental
PFD report
57match
Darrell Sharples
The coroner noted that the clinician conducting a telephone triage assessment was unfamiliar with the Trust's Operational Policy and Triage guidance, emphasizing the need for a robust system to ensure future clinicians are familiar with relevant documents.
Matched on
terms: triage
LGO / SPSO decision
55match
24-018-535b - Hampshire and Isle of Wight Healthcare NHS Foundation Trust (24 018 535b)
Summary: We will not investigate this complaint about the decision to apply for a warrant to gain entry to Miss D’s home and take her to a place of safety to assess her mental health. It is unlikely we would find fault and Miss D had a right of appeal about the decision to detain her and this...
Matched on
terms: health, mental
PHSO casework decision
51match
P-004151 - Norfolk and Suffolk NHS Foundation Trust
The Trust allegedly failed to communicate with Ms B's family, ignored distress, poorly managed records and suicide risk, misdiagnosed EUPD, and changed medication without consulting prior plans.
Matched on
terms: poor, record
IMB recommendation
51match
Elmley (2020)
The Board would ask the minister to review the effectiveness of the Criminal Justice Liaison and Diversion Service (CJLADS), given the number of prisoners that arrive at the establishment with a mental health diagnosis. Is the scheme working as it was designed to do, and is it properly resourced?
Matched on
terms: health, mental
PFD report
49match
Demet Akcicek
A patient was not placed on the multi-disciplinary team meeting board for discussion, leading to no follow-up despite reporting distress. The welfare check documentation was also found to be insufficient, and the Trust provided no evidence of preventative steps.
Matched on
classifier match
IMB recommendation
47match
Exeter (2020)
Will the Secretary of State exert influence with colleagues to improve the transfer arrangements for those with severe mental health issues, to an environment more suitable to meet their mental health needs? The Board remains concerned about the difficulties encountered in transferring prisoners with severe mental health issues, often held in the segregation unit, to an environment where...
Matched on
terms: health, mental
LGO / SPSO decision
46match
24-018-535a - Island City Practice (24 018 535a)
Summary: We will not investigate this complaint about the decision to apply for a warrant to gain entry to Miss D’s home and take her to a place of safety to assess her mental health. It is unlikely we would find fault and Miss D had a right of appeal about the decision to detain her and this...
Matched on
terms: health, mental
LGO / SPSO decision
42match
25-000-113b - NHS Cheshire and Merseyside ICB (25 000 113b)
Summary: Ms X complains the Council, Trust and ICB are not providing her with section 117 aftercare support which she is entitled to after being detained under Section 3 of the Mental Health Act 1983. We will not investigate this complaint because we have seen evidence all the organisations have offered support, Ms X does not agree this...
Matched on
terms: health, mental
LGO / SPSO decision
42match
25-000-113a - Mersey Care NHS Foundation Trust (FT) (25 000 113a)
Summary: Ms X complains the Council, Trust and ICB are not providing her with section 117 aftercare support which she is entitled to after being detained under Section 3 of the Mental Health Act 1983. We will not investigate this complaint because we have seen evidence all the organisations have offered support, Ms X does not agree this...
Matched on
terms: health, mental
LGO / SPSO decision
42match
24-021-993a - North Staffordshire Combined Health Care NHS Trust (24 021 993a)
Summary: We will not investigate Ms X’s complaint about Staffordshire County Council, North Staffordshire Combined Healthcare NHS Trust and NHS Staffordshire and Stoke-on-Trent Integrated Care Board. She says they ignored her views when it moved her brother, Mr Y, to a care home, which cannot meet his mental health needs. The matter has and still is being considered...
Matched on
terms: health, mental
CQC action
36match
Sunnyside
Further improvement was required in the level of detail, particularly around what action staff had taken to de-escalate people's behaviour prior to the use of medication. Furthermore, no analysis of incidents had occurred in order to identify any potential trends which may have contributed to the event.
Matched on
classifier match
IOPC learning recommendation
36match
Recommendation - Sussex Police, January 2025
The IOPC recommends that Sussex Police update its call-handling training and guidance to include clear direction on when Contact Officers should seek specialist medical advice or support, particularly in cases where a sudden death is suspected. This follows an IOPC independent investigation where a member of the public reported a child hanging from a tree. Initially, the Contact...
Matched on
classifier match
LGO / SPSO decision
33match
24-021-993b - NHS Staffordshire and Stoke-On-Trent ICB (24 021 993b)
Summary: We will not investigate Ms X’s complaint about Staffordshire County Council, North Staffordshire Combined Healthcare NHS Trust and NHS Staffordshire and Stoke-on-Trent Integrated Care Board. She says they ignored her views when it moved her brother, Mr Y, to a care home, which cannot meet his mental health needs. The matter has and still is being considered...
Matched on
terms: health, mental
LGO / SPSO decision
30match
21-009-384d - Rotherham, Doncaster & South Humber NHS Foundation Trust (21 009 384d)
Summary: Ms A complained about several organisations involved in her father, Mr D’s care, when his physical health and behaviour deteriorated towards the end of his life. Mr D had dementia. Ms A said failings in Mr D’s care meant his family were distressed by his deterioration. We found fault with a Council. and it agreed to take...
Matched on
terms: health