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Showing results for tags 'Self harm/ suicide'.
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Content ArticleThis guideline from the National Institute for Health and Care Excellence (NICE) covers assessment, management and preventing recurrence for children, young people and adults who have self-harmed. It includes those with a mental health problem, neurodevelopmental disorder or learning disability and applies to all sectors that work with people who have self-harmed.
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News Article
Almost 38,000 mental health appointments miss vital 72-hour window
Patient Safety Learning posted a news article in News
Nearly 38,000 vital follow-up appointments with mental health patients were missed at the time when they were most at risk of suicide, the Royal College of Psychiatrists has said. The medical body has called for “urgent action” to ensure more people are seen for follow-ups within 72 hours of their discharge from inpatient care, to prevent them from falling “through the cracks when they are so vulnerable”. The risk of suicide is highest on the second and third days after leaving a mental health ward, but 37,999 follow-up appointments with patients were not made within this timeframe in England between April 2020 and May 2022. According to NHS data, of the 160,430 instances when patients were eligible for follow-up care within 72 hours after discharge from acute adult mental health care, only three-quarters (76%) took place within that period. The Royal College of Psychiatrists is calling for more trained specialists to check on those perceived to be at risk, which they say requires more staffing and funding. The president of the Royal College of Psychiatrists, Dr Adrian James, said: “We simply can’t afford to let people fall through the cracks at a time when they are so vulnerable. It’s vital that our mental health services are properly staffed and funded to offer proper follow-up care and help prevent suicides. “Staff are working as hard as they can to provide high-quality care, but it’s clear that current resources are not enough to meet these targets. We need urgent action to tackle the workforce crisis and achieve the suicide prevention goals set out in the NHS long-term plan.” Read full story Source: The Guardian, 22 August 2022 -
News Article
Child deaths expose mental health unit pressures
Patient Safety Learning posted a news article in News
Deaths, staff shortages and a culture of life-threatening self-harm are exposing deep fears about the quality of mental health care in hospitals for children and young people. Since 2019, at least 20 patients aged 18 or under have died in NHS or privately-run units, the BBC has found. A further 26 have died within a year of leaving units, amid claims of a lack of ongoing community support. The NHS said it had "invested record amounts... to meet record demand". Child and Adolescent Mental Health Services (CAMHS) units look after about 4,000 patients with many different diagnoses each year. The aim is to help them recover over a period of weeks or months through specialist care. Some patients are in and out of the units for years. The BBC has also heard serious claims regarding the unsafe discharge of patients sent home from CAMHS hospitals. Several former patients told the BBC they had serious self-harm incidents or tried to take their own life within days of returning home. Parents have described being on "suicide watch" 24 hours a day, to ensure their child's safety. Read full story Source: BBC News, 9 August 2022 -
News Article
Ysbyty Glan Clwyd: Stroke patients would rather go to England
Patient Safety Learning posted a news article in News
People would rather go to England if they had a stroke than use the A&E at a north Wales hospital, a health watchdog has said. Inspectors said there was a "clear and significant risk to patient safety" after inspections at the department in Ysbyty Glan Clwyd, Denbighshire. North Wales Community Health Council's Geoff Ryall-Harvey said it was the "worst situation" they had seen. The report said inspectors found staff who were "working above and beyond in challenging conditions" during a period of "unrelenting demand". Many staff told them they were unhappy and struggling to cope. They said they did not feel supported by senior managers. However inspectors said that the health board was not fully compliant with many of the health and care standards, and highlighted significant areas of concern, which could present an immediate risk to the safety of patients, including: Doctors were left to "come across" high-risk patients instead of being alerted to them. Patients were not monitored enough - including a suspected stroke patient and one considered a suicide risk. Children were at serious risk of harm as the public could enter the paediatric area unchallenged. Inspectors found evidence of children leaving unseen or being discharged against medical advice. Betsi Cadwaladr health board said it was committed to improvements. Read full story Source: BBC News, 8 August 2022 -
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Are you currently working on an inpatient mental health ward in the UK?
AmaniKrayem posted a topic in Calls for research/funding opportunities
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Are you currently working on an inpatient mental health ward in the UK? We would like to learn about how you feel towards restrictive practices on mental health wards. Go to https://tinyurl.com/restrictivepractices to find out more.
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News ArticleHundreds of children suffering from mental health issues are attending A&E each day, with some waiting up to five days in emergency departments, The Independent can reveal. Internal NHS data leaked to The Independent, shows the number of young patients waiting more than 12 hours from arrival has also more than doubled in the last year. A national survey of senior A&E doctors by the Royal College of Emergency Medicine (RCEM) found in some areas children’s mental health services have worsened in the last three years, while the majority of respondents warned there were no children’s crisis services open after 5pm. One NHS trust chief executive has warned his hospital’s A&Es have seen a “real surge” in both attendances of people with severe mental health issues and a sharp increase in long waits in recent months. One parent, Lee Pickwell, told The Independent his daughter was admitted to paediatric wards several times and stayed days in an emergency “section 136” unit while she waited more than two months for a mental health bed. Dr Mark Buchanan, RCEM’s lead for children’s mental health, told The Independent that despite improvements, children’s mental health services still fall short of what is needed. Dr Buchanan said: “I’ve seen children who have been not seen by Child and Adolescent Mental Health Services (CAMHS), who been refused the referrals, despite the fact that the mum and dad were taking it in turns to sleep outside their bedroom door because they were scared that they’d run away and do some harm.” Read full story Source: The Independent, 13 July 2022
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News Article
Woman suffering mental health crisis left waiting eight days in A&E
Patient Safety Learning posted a news article in News
An 18-year-old woman suffering a mental health crisis was forced to wait eight-and-a-half days in A&E before getting a bed in a psychiatric hospital – believed to be the longest such wait seen in the NHS. Louise (not her real name) had to be looked after by the police and security guards and sleep in a chair and on a mattress of the floor in the A&E at St Helier hospital in Sutton, south London, because no bed was available in a mental health facility. She became increasingly “dejected, despairing and desperate” as her ordeal continued and, her mental health worsening while she waited, self-harmed by banging her head off a wall. She absconded twice because she did not know when she would finally start inpatient treatment. Louise arrived at St Helier on the evening of Thursday 16 June and did not get a bed in an NHS psychiatric unit until the early hours of Saturday 25 June, more than eight days later. She was diagnosed last year with emotionally unstable personality disorder and ADHD. The mental health charity Mind said it believed it to be the longest wait in A&E ever endured by someone experiencing a mental health crisis, and described it as “unacceptable, disgraceful and dangerous”. It called for urgent action to tackle the inadequacy of NHS mental health provision and bed numbers. “An eight-and-a-half day wait in A&E for a mental health bed is both unacceptable and disgraceful. Mind has never heard of a patient in crisis waiting this long to receive the care they need, and serious questions need to be raised as to how anyone – let alone an 18-year-old – was left to suffer for so long without the care she needs,” said Rheian Davies, the head of Mind’s legal unit. “This is dangerous for staff, who are not trained to give the acute care the patient needs, and dangerous for the patient, who needs that care immediately – not over a week later." Read full story Source: The Guardian, 4 July 2022 -
News Article
CQC prosecutes troubled provider over death of teenage girl
Patient Safety Learning posted a news article in News
A struggling mental health trust is being prosecuted over accusations it failed to protect a teenager at a children’s inpatient unit. Tees, Esk and Wear Valleys Foundation Trust ran the former West Lane Hospital in Middlesbrough until the Care Quality Commission (CQC) closed it in 2019. The CQC is now prosecuting the trust, alleging it breached the Health and Social Care Act 2008 in relation to the death of Christie Harnett, who took her own life at the facility in June 2019. In a statement, the regulator claimed TEWV “failed to provide safe care and treatment” by exposing the patient to a “significant risk of avoidable harm”. A CQC spokeswoman added: “Our main priority is always the safety of people using health and social care services, and if we have concerns we will not hesitate to take action in line with our regulatory powers. We will report further as soon as we are able to do so.” Read full story (paywalled) Source: HSJ, 30 June 2022 -
News Article
Coroner issues warning on NHS mental health services after girl’s suicide
Patient Safety Learning posted a news article in News
A coroner has said Britain is failing young people and more will die because of under-resourced mental health services, as she ruled that neglect led to the death of a 14-year-old girl. Penelope Schofield, the senior coroner for West Sussex, said she would write to the health secretary, Sajid Javid, to raise concerns after the case of Robyn Skilton, who killed herself after being let down by “gross failures” in NHS mental health services. Robyn, from Horsham in West Sussex, disappeared from her family home and took her own life in a park on 7 May last year, her inquest in Chichester heard. Despite serious concerns about her mental health, Robyn did not get face-to-face consultations, was not seen by a child psychiatrist or assessed for mental health issues, and was discharged from an NHS service a month before her suicide though she was on its high-risk “red list”. Her father, Alan Skilton, told the inquest he pleaded for help, and he described the lack of care his daughter received as “astonishing”. He said he believed that if Robyn had been seen earlier, her mental health would have improved and she would not have killed herself. The coroner said: “As a society we are failing young people.” She said she was shocked to hear that the number of young people seeking mental health help had increased by 95%. “Trying to manage it without more resources means we are not providing the help that young people need. Robyn’s case is a testament to that. It’s a clear risk that more lives will be lost if we don’t address it.” Read full story Source: The Guardian, 29 June 2022 -
News Article
Birmingham hospital faces criminal probe after death of vulnerable man
Patient Safety Learning posted a news article in News
A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence. An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train. The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC". Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead the following day after being hit by a train near Birmingham's University station. The inquest in April heard other patients had previously climbed the fence and, despite concerns by members of staff, no action was taken to improve security in and around the courtyard until another patient absconded two months after Mr Caseby's death. Following the inquest, coroner Louise Hunt said she was concerned the fence and courtyard area may still not be safe and urged health chiefs to consider imposing minimum standards for perimeter fences at mental health units. She also criticised record-keeping and how risk assessments were carried out. Read full story Source: BBC News, 23 June 2022 -
News Article
Why so many Long Covid patients are reporting suicidal thoughts
Patient Safety Learning posted a news article in News
Last year, Diana Berrent—the founder of Survivor Corps, a US Long COVID support group—asked the group’s members if they’d ever had thoughts of suicide since developing Long Covid. About 18% of people who responded said they had, a number much higher than the 4% of the general US adult population that has experienced recent suicidal thoughts. A few weeks ago, Berrent posed the same question to current members of her group. This time, of the nearly 200 people who responded, 45% said they’d contemplated suicide. While her poll was small and informal, the results point to a serious problem. “People are suffering in a way that I don’t think the general public understands,” Berrent says. “Not only are people mourning the life that they thought they were going to have, they are in excruciating pain with no answers.” Long Covid, a chronic condition that affects millions of Americans who’ve had COVID-19, often looks nothing like acute COVID-19. Sufferers report more than 200 symptoms affecting nearly every part of the body, including the neurologic, cardiovascular, respiratory, and gastrointestinal systems. The condition ranges in severity, but many so-called “long-haulers” are unable to work, go to school, or leave their homes with any sort of consistency. Long COVID can also be incredibly painful, and research has linked chronic physical pain to an increased risk of suicide. Nick Güthe has been trying to spread that message since his wife, Heidi Ferrer, died by suicide in 2021 after living with Long Covid symptoms for about a year. Among her most disruptive symptoms, Güthe says, were foot pain that prevented her from walking comfortably, tremors, and vibrating sensations in her chest that kept her from sleeping. “My wife didn’t kill herself because she was depressed,” Güthe says. “She killed herself because she was in excruciating physical pain.” Read full story Source: Time. 13 June 2022 -
News Article
Record 420,000 children a month in England treated for mental health problems
Patient Safety Learning posted a news article in News
More than 400,000 children and young people a month are being treated for mental health problems – the highest number on record – prompting warnings of an unprecedented crisis in the wellbeing of under-18s. Experts say Covid-19 has seriously exacerbated problems such as anxiety, depression and self-harm among school-age children and that the “relentless and unsustainable” ongoing rise in their need for help could overwhelm already stretched NHS services. The latest NHS figures show “open referrals” – troubled children and young people in England undergoing treatment or waiting to start care – reached 420,314 in February, the highest number since records began in 2016. The total has risen by 147,853 since February 2020, a 54% increase, and by 80,096 over the last year alone, a jump of 24%. January’s tally of 411,132 cases was the first time the figure had topped 400,000. Mental health charities welcomed the fact that an all-time high number of young people are receiving psychological support. But they fear the figures are the tip of the iceberg of the true number of people who need care, and that many more under-18s in distress are being denied help by arbitrary eligibility criteria. Read full story Source: The Guardian, 22 May 2022 -
Content ArticleBoth the US Senate and the House of Representatives passed a bill to “improve the mental and behavioral health among health care providers” that President Biden signed on Friday. The Dr Lorna Breen Health Care Provider Protection Act is named after Lorna Breen, a New York City emergency medicine physician who died by suicide in April 2020, as Covid-19 raged across the city and the country. By all accounts a tireless worker, she was ultimately overwhelmed by what she experienced during those dark early days of the pandemic. Even before the coronavirus pandemic, health care institutions were struggling with maintaining the wellness of their workforces. Rates of burnout, depersonalisation, and emotional exhaustion were all significantly higher among healthcare workers than in the general population. Even more alarming, physicians and nurses complete acts of suicide at rates significantly higher than workers in other professions. The pandemic added fuel to this fire, as healthcare workers fought to provide care to legions of sick patients amid staffing and equipment shortages. Before the pandemic, approximately 40% of health care workers reported feeling burnt out. Now, between 60% and 75% of US healthcare workers report feeling emotionally drained and depressed. Clearly, something has to change. With the Breen bill, Congress hopes to halt this tragic wave of depression and burnout among health care workers by providing grants to hospitals and other health care organisations to “promote mental health and resiliency among health care providers.” Yet the solution the Breen bill proposes will not lead to meaningful change. Giving hospitals money to “promote wellness” will not magically heal healthcare workers. During the pandemic, hospitals across the country put up signs lauding their workers as heroes. Though hospital administrators may have given themselves pats on the back for such efforts, the signs meant little to those working without adequate personal protective equipment, or telling family members they could not visit dying loved ones, or wondering if they'd bring Covid home to their families and friends. The signs haven’t stopped scores of workers from leaving the healthcare field.
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News Article
Standup comedy course for men at risk of suicide wins NHS funding
Patient Safety Learning posted a news article in News
A course helping some of the most vulnerable people in the country by teaching them to be comedians is proving so successful that it is being socially prescribed by NHS trusts and private practices across the country. “I’ve taught comedy for 10 years, and students often told me how much stronger, more resilient and happier they were after exploring their personal histories through standup comedy,” said Angie Belcher, founder of Comedy on Referral and comedian-in-residence at Bristol University. “That inspired me to prove that the models, exercises and games used in a standup comedy course can help people to recover from emotional problems such as mental illness, postnatal depression, PTSD and anxiety disorders,” she said. After completing a highly successful six-week NHS course for trauma survivors in Bristol, Comedy on Referral has now won NHS funding to help men at risk of suicide in London. Belcher is also in discussions with a private practice to extend the course to young people with autism and ADHD. “My course for trauma victims encourages them to process their trauma in a different way, so they can change who the victim is and choose the narrative. They can actually go right down into ‘This is what I was thinking and then this thing happened to me’,” said Belcher. “This enables survivors to consciously use comedy to change their perspective of their experiences, but it also puts them in a physically powerful position because being on stage is very powerful,” she said. “You can speak directly to an audience about important things, which means you have the opportunity to change their lives..." Read full story Source: The Guardian, 9 May 2022 -
News Article
‘I thought she’d be safe’: a life lost to suicide in a place meant for recovery
Patient Safety Learning posted a news article in News
"I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental health hospital in Milton Keynes. Eight weeks later, Brooke took her own life. The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to her death. Elysium accepted that had she been placed on 24-hour observations, Brooke would not have died. In 2018, Brooke, who was autistic, was repeatedly sectioned under the Mental Health Act because of her escalating self-harm and suicide attempts. After a spell in an NHS facility in Surrey she moved to Chadwick Lodge, which specialises in treating personality disorders. After a few weeks there, Brooke was doing well and staff were pleased with her progress. She was due to move to Hope House, a separate unit at the hospital, to start more specialist therapy for emotionally unstable personality disorder, and was keen to make the switch. But then the teenager’s mental health deteriorated again. On 5 June 2019 she tried to kill herself. Five days later she was seen twice that evening secretly handling potential ligatures, but no appropriate action was taken. A few minutes later she was found unresponsive in her room. She received CPR but died the next day in Milton Keynes university hospital. After hearing the evidence about the care Brooke received in her final days, Tom Osborne, the coroner at the inquest, took the unusual step of issuing a prevention of future deaths notice. He sent it to Sajid Javid, the health secretary, and to Elysium Healthcare, as the owner of Chadwick Lodge. It set out the detailed criticisms that the jury had made of Elysium’s interaction with Brooke after her attempt to take her own life on 5 June. They cited the hospital’s failures to communicate information regarding Brooke’s suicide attempt, to search her room after she was found handling potential ligatures on the night she died, and to place Brooke on constant observations afterwards. Read full story Source: The Guardian, 24 April 2022 -
Content ArticleThese online resources are designed to help healthcare professionals improve conversations with their patients about suicidal ideation, self-harm and other common mental health problems. The resources are based on a field of research known as Conversation Analysis, which micro-analyses verbal and non-verbal communication to study the consequences of different ways of communicating. Resources include research findings and real examples from video-recorded psychosocial assessments with mental health nurses, social workers and other healthcare professionals. To access the resources, you need to be a healthcare professional and will need to create an account.
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Content ArticleNew data from the Office for National Statistics demonstrates that people with severe and potentially terminal health conditions are more than twice as likely to take their own lives than the general population. This press release by the Campaign for Dignity in Dying highlights the patient safety issues caused by current laws around assisted dying in the UK, including patients dying alone by suicide, without loved ones to support them.
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News Article
Father calls for overhaul of 'flawed' suicide assessments
Patient Safety Learning posted a news article in News
A father whose son took his own life in July 2020 is calling for an "urgent overhaul" of the way some counsellors and therapists assess suicide risk. His son Tom had died a day after being judged "low risk", in a final counselling session, Philip Pirie said. A group of charities has written to the health secretary, saying the use of a checklist-type questionnaire to predict suicide risk is "fundamentally flawed". The government says it is now drawing up a new suicide-prevention strategy. According to the latest official data, 6,211 people in the UK killed themselves in 2020. It is the most common cause of death in 20-34-year-olds. And of the 17 people each day, on average, who kill themselves, five are in touch with mental health services and four of those five are assessed as "low" or "no risk", campaigners say. Tom Pirie, a young teacher from Fulham, west London, had been receiving help for mental-health issues. He had repeatedly told counsellors about his suicidal thoughts - but the day before he had killed himself, a psychotherapist had judged him low risk, his father said. Tom's assessment had been based on "inadequate" questionnaires widely used despite guidelines saying they should not be to predict suicidal behaviour, Philip said. The checklists, which differ depending on the clinicians and NHS trusts involved, typically ask patients questions about their mental health, such as "Do you have suicidal thoughts?" or "Do you have suicidal intentions?" At the end of the session, a score can be generated - placing the individual at low, medium or high risk of suicide, or rating the danger on a scale between 1 and 10. Read full story Source: BBC News, 20 April 2022 -
Content ArticleThis article examines the lasting impact of the tragic case of Daksha Emson, a 34-year old psychiatrist who took her own life and that of her baby daughter in an episode of postpartum psychosis. Daksha had a history of bipolar disorder and had attempted suicide before, and the inquiry into her death found that she received “significantly poorer standard of care than that which her own patients might have expected.” The authors highlight the impact of her story on the development in the UK of both specialist perinatal mental health services and specialised confidential services for health professionals, which remove some of the stigma attached to help-seeking.
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News Article
Swamped NHS mental health services turning away children, say GPs
Patient Safety Learning posted a news article in News
Children and young people who are anxious, depressed or are self-harming are being denied help from swamped NHS child and adolescent mental health services, GPs have revealed. Even under-18s with an eating disorder or psychosis are being refused care by overstretched CAMHS services, which insist that they are not sick enough to warrant treatment. In one case, a crisis CAMHS team in Wales would not immediately assess the mental health of an actively suicidal child who had been stopped from jumping off a building earlier the same day unless the GP made a written referral. In another, a CAMHS service in eastern England declined to take on a 12-year-old boy found with a ligature in his room because the lack of any marks on his neck meant its referral criteria had not been met. The shocking state of CAMHS care is laid bare in a survey for the youth mental health charity stem4 of 1,001 GPs across the UK who have sought urgent help for under-18s who are struggling mentally. CAMHS teams, already unable to cope with the rising need for treatment before Covid struck, have become even more overloaded because of the pandemic’s impact on youth mental health. Mental health experts say young people’s widespread inability to access CAMHS care is leading to their already fragile mental health deteriorating even further and then self-harming, dropping out of school, feeling uncared for and having to seek help at A&E. “As a clinician it is particularly worrying that children and young people with psychosis, eating disorders and even those who have just tried to take their own life are condemned to such long waits”, said Dr Nihara Krause, a consultant clinical psychologist who specialises in treating children and young people and who is the founder of stem4. “It is truly shocking to learn from this survey of GPs’ experiences of dealing with CAMHS services that so many vulnerable young people in desperate need of urgent help with their mental health are being forced to wait for so long – up to two years – for care they need immediately. Read full story Source: The Guardian, 3 April 2022 -
News Article
Nurses’ well-being: ‘burnout’ too gentle a term for mental distress
Patient Safety Learning posted a news article in News
Burnout is not a strong enough term to describe the severe mental distress nurses and other NHS staff are experiencing, says a doctor who has led efforts to improve care for health professionals. Medical director of the NHS Practitioner Health service Dame Clare Gerada told MPs radical action was needed to improve the mental well-being of NHS staff. She said nurses and other healthcare staff should be entitled to one hour of paid reflective time per month to be written into NHS employees’ contracts, alongside mentoring, careers advice and leadership training built in throughout people’s careers. Dr Gerada was among senior clinicians who gave evidence this week to the Health and Social Care Committee, which is looking at issues around recruitment and retention of staff. She told the committee the term ‘burnout’ simply did not cover the level of stress and mental anguish experienced by NHS workers. ‘Burnout is too gentle a term for the mental distress that is going on amongst our workforce,’ she said. High suicide rates among nurses and doctors, high levels of bullying and staff being sacked because they have long-COVID are all signs the health service is failing to look after its employees, she said. ‘The symptoms we have got are the symptoms of an organisation that is unable to care for its workforce in the way that it should be caring,’ she said. Read full story Source: Nursing Standard, 25 March 2022 -
News Article
Patient at Broadmoor Hospital died after suffocating, inquest hears
Patient Safety Learning posted a news article in News
A patient at Broadmoor Hospital has died after suffocating while staff were chatting outside of his room, an inquest has heard. Aaron Clamp, a patient at the notorious high security mental health hospital Broadmoor, died on 4 January 2021 after asphyxiating whilst in his room. The Independent understands Mr Clamp’s death may have been the first “non-natural” death since the new Broadmoor Hospital, run by West London Trust, opened in December 2019. According to evidence heard at the inquest, staff who were meant to be carrying out continuous “eyesight” observations on Mr Clamp, were having a conversation without direct sight into his room. Mr Clamp’s father told The Independent he was “tormented” by the criminal justice and mental health system which resulted in his “indefinite incarceration.” “Diagnosed with a mental illness, schizoaffective disorder, the purpose of treatment was rehabilitation. Psychiatric treatment is conventionally centred on medication to manage symptoms and risk," his father said. He acknowledged there is a balance to be struck between managing risks and restricting patients, but closer attention of holistic compassionate care should be given. Read full story Source: The Independent, 3 March 2022 -
Content ArticleSamantha Gould was 16 years old when she died by suicide due to an overdose of prescribed medication on 2 September 2018. She had borderline personality disorder that meant she was at risk of deliberate self-harm and suicide. In this report, the Coroner highlights concerns about a systemic weakness in the way in which Child and Adolescent Mental Health Services and primary care communicate with local pharmacies concerning 16-18 year old patients who are at risk of deliberate overdose. In spite of a safety plan agreed with Sam’s consultant psychiatrist whereby Sam’s parents would be responsible for her medication, Sam was able to pick up older prescriptions on 1 September 2018 without challenge, and it was those medications that were fatal in the combined amounts ingested by Sam.
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News Article
Transgender teenager's death preventable, coroner says
Patient Safety Learning posted a news article in News
The death of a "vulnerable" transgender teenager who struggled to get help was preventable, a coroner has said. Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on 3 April 2020. The coroner said his death showed a "dangerous gap" between services. When he died, Mr France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire. The First Response Service, which provides help for people experiencing a mental health crisis, also assessed Mr France but he had been considered not in need of urgent intervention, the coroner's report said. Cambridgeshire County Council had received two safeguarding referrals for Daniel, in October 2019 and January 2020, but had closed both. "It was accepted that the decision to close both referrals was incorrect", Mr Barlow said in his report. Mr Barlow wrote in his report, sent to both the council and CPFT: "My concern in this case is that a vulnerable young person can be known to the county council and [the] mental health trust and yet not receive the support they need pending substantive treatment." He highlighted Daniel was "repeatedly assessed as not meeting the criteria for urgent intervention" but that waiting lists for phycological therapy could mean more than a year between asking for help and being given it. "That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act," Mr Barlow said. Read full story Source: BBC News, 25 February 2022 -
Content ArticleOn 8 April 2020 the coroner commenced an investigation into the death of Daniel France, age 17. Danny was 17 years old and was living at a YMCA hostel. He was on medication for depression and had been referred to secondary mental health services. He had made previous suicide attempts. On 3 April 2020 he took his own life. The medical cause of death was asphyxiation by hanging and the conclusion was suicide. Danny was a vulnerable teenager: he had left home and was living in hostel accommodation; he had changed his GP practice; he was trans, had changed his name and had been referred to the Gender Identity Clinic; he had recently been discharged from secondary mental health services in Suffolk and had been referred to mental health services in Cambridge; he had previously been under CAMHS and was now being referred to adult mental health services; he had diagnoses of anxiety and depression and had been prescribed medication; he had made previous suicide attempts and had long term suicidal thoughts He had been assessed by First Response Service but had been considered as not requiring urgent intervention. Safeguarding referrals about Danny were made to Cambridgeshire County Council in October 2019 and January 2020. Both referrals were closed and it was accepted that the decision to close both referrals was incorrect. In December 2019 Danny’s new GP referred him to Cambridgeshire & Peterborough NHS Foundation Trust (CPFT). He had been seen by the Primary Care Mental Health Services but was still awaiting assessment by the Adult Locality Team at the time of his death.
