Unclear psychiatric referrals
Ambiguous or poorly defined referral processes for psychiatric units, leading to delays or inappropriate patient placement.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
Sarah Shepherd
The Trust's Psychiatric Intensive Care Services policy lacked a clear inpatient referral process and required no written response in patient notes. Resuscitation training for nursing staff was unclear and misinterpreted guidelines, compounded by misleading aide-mémoires on equipment.
Matched on
terms: psychiatric, referral, unclear
PFD report
69match
Clarice Hilton
The coroner identified a lack of policy or guidance for psychiatric unit staff on actions to take when a patient refuses physical health observations, leading to uncertainty regarding MEWS calculation and when to seek medical assessment.
Matched on
terms: psychiatric
PFD report
65match
Man Ng
The coroner raised concerns about the complex processes and lack of streamlining in the treatment of subarachnoid haemorrhages, particularly regarding the unclear overall responsibility between neurosurgical teams and interventional radiologists, which may place patients at risk.
Matched on
terms: unclear
PFD report
61match
Dean Saunders
The coroner identified lacunas in the admissions protocol for transferring mentally disordered individuals from police custody and a lack of clarity in hospital transfer processes. Concerns were also raised regarding ACCT process training, family involvement, and the resilience of psychiatric cover at Chelmsford prison.
Matched on
terms: psychiatric
PFD report
61match
Roy Draper
The coroner noted a lack of a clear system and protocol for initiating the unblinding process in clinical trials, particularly when a patient is treated in another hospital. There is also no formal referral system for reporting adverse events, which impacts transparency between hospitals.
Matched on
terms: referral
PFD report
61match
Donna Donnellan
The coroner identified a lack of understanding between Acute and Mental Health Trust clinicians regarding the specific role of the Mental Health Liaison Team for eating disorder patients. There was also a lack of clarity on referral pathways to specialist eating disorder services.
Matched on
terms: referral
HSSIB recommendation
61match
Mental health: attempted suicide while under the care of community services
Early exploration of adjustments that individual service users might need to engage in the triage and referral processes.
Matched on
terms: referral
PFD report
57match
Andrew Horgan
The coroner identified knowledge gaps among doctors and medical staff regarding referral procedures for mental health assessments and engaging Mental Health Partnership personnel, noting a need for improved training on effective communication pathways.
Matched on
terms: referral
PFD report
53match
Caroline Staite
Concerns were raised regarding the robustness of procedures for clients being considered by Mind, and the lack of transparent processes for patients returning from Mind to the Neighbourhood Mental Health Team.
Matched on
classifier match
PFD report
49match
Kirabo Kiwanuka
The coroner noted a lack of agreement among senior professionals on diagnosing and managing NMS, and uncertainty about the optimal care model for acutely manic patients with physical illness. There were also concerns about limited family involvement in best interest decisions for sectioned patients.
Matched on
classifier match
PFD report
49match
Richard Jones
The coroner raises concerns about the inconsistent recording of information from patients presenting with mental health issues, specifically regarding the perceived level of risk and urgency for assessment. There were also conflicting accounts about the division of responsibilities and the urgency of care between different mental health services.
Matched on
classifier match
PFD report
49match
Christopher Higgins
The coroner noted gaps in staff observation protocols, insufficient procedures for mental health patient transfers involving police, and a lack of environmental risk assessment for an outdoor area. There was also no formal agreement between services for managing detained patients in A&E.
Matched on
classifier match
PFD report
49match
Daisy French
The coroner identifies gaps in communication and transition between CAMHS and adult mental health services for 16-18 year olds. This includes issues with out-of-hours provision, placement in adult crisis houses, and returning them to unsupervised supported living.
Matched on
classifier match
PFD report
49match
Andrew Shambrook
The health board lacks a documented and robust policy for decision-making, criteria, and future treatment pathways for patients referred to the Home Treatment Team.
Matched on
classifier match
PFD report
49match
Girmaye Guyo
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.
Matched on
classifier match
PFD report
49match
Rachel Garrett
The coroner notes that Mental Health Liaison teams in acute hospital A&E departments cannot use Section 5 holding powers due to their employment by a separate Mental Health Trust, creating a risk of patients absconding before an acute hospital doctor can intervene.
Matched on
classifier match
PFD report
49match
Aaron Deeley
The coroner identified gaps in mental health care for patients held under Section 5(2) MHA on acute wards, noting no allocated Responsible Clinician and lack of mental health liaison team attendance for risk assessment. Concerns also included acute staff's lack of specialist training, confusion over 1:1 observation policy, and no joint protocol between Trusts for these vulnerable patients.
Matched on
classifier match
PFD report
49match
Warren Green
The coroner noted that patients at high risk of self-harm could leave the acute ward without proper risk assessment or staff knowledge. There was also a lack of clarity in the Mental Health Liaison Service's criteria for escalating patients to a Consultant Psychiatrist, limiting oversight.
Matched on
classifier match
PFD report
45match
Stuart Long
The coroner noted confusion among professionals regarding the appropriate management of anti-social behaviour by individuals who are intoxicated or mentally unwell, suggesting a place of safety could have prevented Mr Long's death.
Matched on
classifier match
PFD report
45match
Andrew Frost
The coroner noted a lack of shared understanding between general practitioners and the Islington Crisis Team regarding the team's capacity and whether it functions as an emergency service, recommending specific training for GPs on crisis team limitations.
Matched on
classifier match
PFD report
45match
Colette Dunn
A full Mental Health Act assessment was not performed before discharge, despite police concerns about suicidal intent. The coroner also noted a lack of clear inter-agency discharge protocols and insufficient facilities for mental health crisis management in Milton Keynes.
Matched on
classifier match
PFD report
45match
Khalid Yousef
The coroner raises concerns about the absence of commissioned psychiatrists in Liaison and Diversion (L&D) services, limiting practitioners' ability to identify serious mental illness. This is compounded by police misunderstanding L&D's role and reduced availability of Forensic Medical Examiners.
Matched on
classifier match
PFD report
45match
Hayley Beavington
The coroner identified concerns regarding a crisis house's refusal to admit Ms Beavington despite high suicide risk, and the consultant psychiatrist not providing guidance on how to challenge this decision effectively.
Matched on
classifier match
PPO recommendation
43match
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff at Pentonville understand that referrals to secure mental health units should only be made through the prison’s mental health Inreach team.
Matched on
terms: referral
Committee recommendation
41match
#28 - Prisons used as places of safety, despite Government aims to end the practice
We were shocked and appalled to hear that prisons are used as a place of safety. We acknowledge and welcome that the Government aims to end this practice in the Mental Health Bill. We request details of how this will work in practice and when this will be implemented. (Conclusion, Paragraph 110)
Matched on
classifier match
PPO recommendation
39match
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who appear acutely, psychiatrically unwell are considered for transfer to a psychiatric hospital, and these discussions are recorded in the medical record.
Matched on
terms: psychiatric
PHSO casework decision
39match
P-003967 - Surrey and Borders Partnership NHS Foundation Trust
Mrs E complained the Trust misdiagnosed her son's psychotic crisis as autistic behavior and failed to conduct a senior psychiatric consultant assessment. She stated this led to mental health deterioration.
Matched on
terms: psychiatric
PHSO casework decision
35match
P-004668 - Kingston and Richmond NHS Foundation Trust
Mr A complained the Trust dismissed his symptoms, pressured him into a psychiatric diagnosis and medication, ignored evidence, and linked his issues to past drug use unprofessionally.
Matched on
terms: psychiatric
GIRFT recommendation
32match
Children and Young People's Mental Health Services
Commissioners, including lead providers within a collaborative, must ensure that there are effective protocols in place so that when a social need, rather than medical, is present there is a clear and understood pathway to follow which operates both in and out of hours. a Commissioners and providers must develop a clear, commissioned, multiagency pathway.
Matched on
classifier match
IMB recommendation
31match
Belmarsh (2023)
Would the Minister consider the impact of prison on those with serious mental illness and review systems for assessment and more appropriate placements?
Matched on
classifier match
Article 2 learning point
31match
Mr Everest — HMP Altcourse - LP 4
A prisoner presenting with an altered mental state, particularly with possible psychotic symptoms, should be assessed at the earliest opportunity by a suitably-qualified mental health practitioner. The practitioner should take a full history, review previous entries and assess the person’s current mental state to establish the diagnosis. The prisoner should be referred to a psychiatrist as soon as...
Matched on
classifier match
PHSO casework decision
31match
P-003321 - Kent and Medway NHS and Social Care Partnership Trust
Mx E complained Kent and Medway NHS and Social Care Partnership Trust did not appropriately assess them as an autistic person, denied access to secondary mental health services, and a nurse behaved inappropriately.
Matched on
classifier match
PHSO casework decision
31match
P-004265 - Cornwall Partnership NHS Foundation Trust
Dr J complained Cornwall Partnership NHS Foundation Trust's CAMHS assessment failed to measure her son's needs, use full evidence, and inappropriately labelled him with a mild learning disability.
Matched on
classifier match
IMB recommendation
27match
Wakefield (2022)
We ask the minister to explain how the government intends to address longstanding and yet unresolved problems with the assessment and transfer of prisoners who present with serious mental health and personality disorders from HMP Wakefield to hospital (section 47, Mental Health Act 1983).
Matched on
classifier match
PHSO casework decision
27match
P-001294 - North West Boroughs Healthcare NHS Foundation Trust
Miss Y complained the Trust incorrectly referred her to outreach services instead of a psychiatrist and that the assessment staff member was unsympathetic.
Matched on
classifier match
PHSO casework decision
27match
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
classifier match
LGO / SPSO decision
23match
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.
Matched on
classifier match