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Found 200 results
  1. Content Article
    Nicholas Gerasimidis had a history of mental illness manifesting as obsessive compulsive disorder (OCD) and anxiety. In 2022, his condition deteriorated. His GP referred him twice to the Community Mental Health Team but the referrals were rejected with medication being prescribed instead, together with advice to contact Talking Therapies.   He was taken on to CMHT workload after being assessed by the Psychiatric Liaison Team in Royal Cornwall Hospital in November 2022. The preferred course of treatment was psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention. There was a waiting list of a year. In May 2023, Mr Gerasimidis became worse. It was felt an informal admission to hospital was required but a bed was not available. He was found hanged at his home address on 3 June 2023.
  2. Content Article
    This annual report published by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) contains findings relating to people aged 10 and above who died by suicide between 2011 and 2021 across all of the UK. View an infographic outlining the report's key findings.
  3. Content Article
    There is currently a lack of research addressing the impact of patient suicide on GPs. This qualitative study in BMJ Open aimed to examine the personal and professional impact of patient suicide, as well as the availability of support and why GPs did or did not use it. The authors found that GPs are impacted both personally and professionally when they lose a patient to suicide, but may not access formal help due to commonly held idealised notions of a ‘good’ GP who is regarded as being unshakable. Fear of professional repercussions also plays a major role in deterring help-seeking. A systemic culture shift which allows GPs to seek support when their physical or mental health requires it is needed, and this may help prevent stress, burnout and early retirement.
  4. Content Article
    Primary care appointments may provide an opportunity to identify patients at higher risk of suicide. This study in the British Journal of General Practice aimed to explore primary care consultation patterns in the five years before suicide to identify suicide high-risk groups and common reasons for seeing a healthcare professional. The authors found that frequent consultations (more than once per month in the final year) were associated with increased suicide risk. The associated rise in suicide risk was seen across all sociodemographic groups as well as in those with and without psychiatric comorbidities. However, specific groups were more influenced by the effect of high-frequency consultation, including females, patients experiencing less socioeconomic deprivation and those with psychiatric conditions. The commonest reasons that patients who went on to commit suicide requested consultations in the year before their death, were medication review, depression and pain.
  5. News Article
    A suicidal man died hours after being discharged from a scandal-hit hospital which is at the centre of a probe into the care of Nottingham triple killer Valdo Calocane. Daniel Tucker was released from a mental health ward at Highbury Hospital in Nottingham last year and died shortly afterwards, having taken a toxic substance he had purchased online. An inquest into his death last week found there were multiple failings by Nottinghamshire Healthcare Foundation Trust in the lead-up to Tucker’s death, with no appropriate care plan or risk assessment in place for him before or after his discharge. The 10-day hearing heard he had been discharged from the hospital on 22 April, despite having shared suicidal intentions with staff just days before. The jury concluded that failures by staff to ensure an appropriate plan for him contributed to his death. It comes after health secretary Victoria Atkins ordered the Care Quality Commission to carry out an inquiry into Nottinghamshire Healthcare. The probe will look at the handling of Calocane, who had been discharged from Highbury Hospital and was a patient under the trust’s community crisis services when he stabbed three people to death in a brutal knife rampage. Read full story Source: The Independent, 18 February 2024
  6. Content Article
    On 29 December 2022, Shahzadi Khan was detained under section 2 of the Mental Health Act due to her mental state and the risks she presented. She was found to have had a manic episode with psychotic symptoms. Due to a lack of beds, she was placed in a privately-run mental health hospital in Norfolk. She remained there until her discharge to the family home on 26 January 2023. She was commenced on Olanzapine and Zopiclone for her mental health whilst an inpatient.   Her diagnosis on discharge was mania with psychotic symptoms. She was to remain on olanzapine in the community. Her placement out of area contributed to disjointed and inadequate discharge planning to support her in the community and was exacerbated by poor communication between the team managing out of area placements and the local team. As a consequence, the aftercare planning did not take place in accordance with S117 Mental Health Act.   This was exacerbated by a failure by all health professionals involved in her care within the mental health trust to recognise that she needed to be referred on to the Trafford Shared Care pathway. A referral would have ensured she received support and care for at least 12 weeks when she returned to the community. There is no clear reason for this failure. She was seen by the Home-Based Treatment Team (HBTT) on 28 January and 2 February, then discharged back to her GP. Within a week of that discharge from HBTT, which meant she had been left with no mental health support, she had deteriorated significantly. On 9 February her GP sent her to hospital for emergency assessment due to her presentation. She was discharged home to be seen by the Home- Based Treatment Team on 11th February. She was seen by that team on 11, 12, and 13 February. There was still no recognition of the fact that the Trafford policy was not being followed. She had indicated her lack of compliance with olanzapine, suicidal thoughts and her behaviour on 13th February was erratic. On 14 February 2023 she took a fatal overdose of prescribed zopiclone at her home address.
  7. News Article
    The doctor in charge of medical training for NHS England has apologised unreservedly to the family of a medic who took her own life. Dr Vaish Kumar, a junior doctor, left a suicide note blaming her death entirely on the hospital where she worked, her family revealed last year. Dr Kumar, 35, was wrongly told she needed to do a further six months of training before starting a new role. It meant she was forced to stay at Queen Elizabeth Hospital (QE) in Birmingham, where she had been belittled by colleagues, an inquest heard. In a letter to Dr Kumar's family, seen by the BBC, NHS bosses admitted she did not need to do the extra training. Dr Navina Evans, chief workforce and training education officer for England, told the family in the letter: "I wish to unreservedly apologise for these mistakes and for the impact they would have had. "As an organisation we are determined to learn... not only across the Midlands but across England as a whole." Read full story Source: BBC News, 13 February 2024
  8. Content Article
    Doctors in Distress is a UK-based independent charity that promotes and protects the mental health of all healthcare workers and prevents suicides in the medical profession. It was set up in 2018 by Amandip Sidhu following the suicide of his brother Jagdip, a consultant cardiologist, with the aim of providing support for healthcare staff facing burnout and mental health difficulties. The charity runs free online support groups and webinars for healthcare professionals and students. Previous webinars can be viewed on the Doctors in Distress YouTube channel.
  9. News Article
    Mental health services are failing to keep patients safe from suicide and harm after leaving hospital, the Parliamentary and Health Service Ombudsman (PHSO) has warned. It also identified failings around planning and communication when patients are discharged, and has urged the Government to strengthen the Mental Health Act. The warning comes after the Department for Health and Social Care was forced to announce a Care Quality Commission (CQC) rapid review into mental health services in Nottingham following the killings of students Grace O’Malley-Kumar and Barnaby Webber, both 19, and school caretaker Ian Coates, 65, in June last year, by Valdo Calocane. Knifeman Calocane had paranoid schizophrenia and had been a regular patient of Highbury Hospital with mental health problems. In a report last week, The Independent revealed separate investigations into Highbury Hospital which have led to the suspension of more than 30 staff over allegations of falsifying records and harming patients. The latest report by the Parliamentary and Health Service Ombudsman (PHSO), following a report in 2018, looked at more than 100 complaints between 2020 and 2023 where it had identified failings in mental health care. Lucy Schonegevel, director of policy and practice at the charity Rethink Mental Illness, said: “Someone being discharged from a mental health service, potentially into unsafe housing, financial insecurity or distanced from family and friends, is likely to face the prospect with anxiety and a sense of dread rather than positivity. Mistakes or oversights during this process can have devastating consequences. This report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community, by improving communication and the ways in which different teams work together to provide essential care.” Read full story Read PHSO report Discharge from mental health care: making it safe and patient-centred (PHSO, 1 February 2024) Source: Independent (1 February 2024)
  10. Content Article
    In this report the Parliamentary and Health Service Ombudsman (PHSO) looks at patient safety concerns relating to the care and discharge of mental health patients. Its findings are based on the analysis of more than 100 complaints that the Ombudsman has investigated between April 2020 and September 2023 where it found failings in care that involved mental health care.
  11. Content Article
    This report, authored by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), was commissioned by NHS England/NHS Improvement in response to a report by the Office for National Statistics that identified female nurses as having a risk of suicide 23% above the risk in women in other occupations. This was a brief study aimed to establish preliminary data about women who died by suicide while employed as nurses. To do this, NCISH carried out an examination of Office for National Statistics (ONS) data on female nurses who died by suicide during a six-year period (2011-2016) was carried out with a detailed analysis of female nurse suicides using the NCISH database of people who died by suicide within 12 months of mental health service contact, including comparison with other female patients.
  12. News Article
    One of Britain’s three high-security hospitals – where notorious people including Ian Huntley and Charles Bronson have been detained – is so understaffed that neither workers nor patients are safe, a damning new report has found. Rampton Hospital in Nottingham faces severe staff shortages, leading workers to restrain patients and lock them away in their rooms and putting patients at risk of self harm, according to the Care Quality Commission. In a report looking into the hospital, inspectors – who rated the hospital as inadequate – said there were around half the staff needed on one ward. In one example of those at the hospital being at risk, a patient self-harmed with glass from their watch, while another was able to harm themselves with a CD while they were confined to their room. One deaf patient was secluded several times on another ward for “being loud”, according to the CQC. “We spoke with people in the learning disabilities services who told us they sometimes get locked in their room from dinner time until the next morning,” the report said. “They told us that they don’t like being locked in their rooms.” Read full story Source: The Independent, 17 January 2024
  13. News Article
    Women who experience depression during pregnancy or in the year after giving birth are at a higher risk of suicide and attempting suicide, researchers have warned. The British Medical Journal study warned that women who develop perinatal depression are twice as likely to die compared to those who don’t experience depression. Suicide was the leading cause of death for women in the UK in 2022 between six weeks and one year after birth, while deaths from psychiatric causes accounted for almost 40 per cent of maternal deaths overall, according to a Perinatal Mortality Surveillance report. Last year an analysis by Labour revealed 30,000 women who were pregnant were on waiting lists for specialist mental health support. The number of women waiting rose by 40 per cent between August 2022 and March 2023. The most recent NHS data shows in September 2023, 61,000 women accessed perinatal mental health services. For 2023-24, the health service must hit a target to have 66,000 women accessing care. In August 2023, the Royal College of Midwives published a research warning half of anxiety and depression cases among new and expectant mothers were being missed amid NHS staff shortages in maternity care. Read full story Source: The Independent, 11 January 2024
  14. Content Article
    This study published in the BMJ found that women with clinically diagnosed perinatal depression were associated with an increased risk of death, particularly during the first year after diagnosis and because of suicide. Women who are affected, their families, and health professionals should be aware of these severe health hazards after perinatal depression.
  15. News Article
    The senior midwife tasked by the government and NHS to investigate serious maternity scandals has warned that new mothers are being driven to suicide and backed an MP’s review into birth trauma. Donna Ockenden said it was “appalling” that women who should be in the “happiest times of their lives” were taking their own lives, after it was found suicide was the leading direct cause of deaths up to 12 months after giving birth. Ockenden, who has exposed poor maternity care across the country, is preparing to give evidence to an inquiry launched by Theo Clarke, the Conservative MP for Stafford, on birth trauma. Clarke thought she was going to die after giving birth to her daughter Arabella last year, having suffered a third-degree tear. But it was the lack of help available that opened her eyes to the estimated 200,000 women a year who experience birth trauma. Ockenden told The Times she had “huge respect” for Clarke’s inquiry and said: “I think that this whole issue of maternal trauma, sometimes long-term psychological trauma for families as well post a difficult maternity experience, is not necessarily given enough air time.” Read full story (paywalled) Source: The Times, 8 January 2023
  16. News Article
    A coroner overseeing a teenager's inquest has warned there will be more deaths unless mental health services improve for autistic people at risk of self-harm. Morgan-Rose Hart, 18, who had ADHD, autism and a history of mental illness had been a patient at a unit in Harlow, Essex, for three weeks. An inquest jury concluded she died by misadventure contributed to by neglect. Ms Hart, from Chelmsford, died in hospital six days after she was found unresponsive in the bathroom of her mental health accommodation in the Derwent Centre in Harlow, Essex in July 2022. The inquest into her death heard staff observations were falsified and critical observations were missed. In her Prevention of Future Deaths report, Ms Hayes said: "There is a significant shortfall of appropriate placements for people with autism who have mental health and self-harm risks in Essex both inpatient and in the community." She added: "During the course of the inquest the evidence revealed matters giving rise to concern. "In my opinion, there is a risk that future deaths will occur unless action is taken." Read full story Source: BBC News, 8 January 2024
  17. Content Article
    Morgan-Rose Hart died after she was found unresponsive while being detained under section 3 of the Mental Health Act at the Derwent Centre at the Princess Alexandra Hospital in Essex. Morgan-Rose was last clinically observed at 14.06 on 6 July 2022 and in between the last observation and when Morgan-Rose was discovered the Coroner notes that multiple failings in her care took place, including consecutive hours observations being incorrect and falsified.
  18. News Article
    The Care Quality Commission (CQC) has apologised after admitting it failed to act on whistleblowing concerns “in a timely manner”. Allegations had been made to the CQC about staff at Cambridgeshire and Peterborough Foundation Trust tampering with a patient’s record after they had died by suicide. As previously reported, the accusations by whistleblower Des McVey have sparked a review of the trust’s conduct in more than 60 suicide cases. Mr McVey says the trust only took action following media coverage and that the CQC had ignored his concerns. The regulator has now upheld a complaint from him, with operations manager James DeCothi writing to Mr McVey: “I have established that [the relevant CQC inspector] did not share your concerns with the provider in a timely manner and that our contact with you from July 2022 to June 2023 was inconsistent. I apologise on behalf of CQC for this. [The CQC inspector] has reflected on this and has asked me to offer her apologies to you also. “I can confirm that CQC have followed up the areas of concern that you have shared, and we will continue to use the information you have shared to inform future regulatory activity. I would like to thank you again for sharing this information with us.” Read full story (paywalled) Source: HSJ, 11 December 2023
  19. Content Article
    Mr Malone was diagnosed with treatment resistant schizophrenia in 1983 and had been sectioned multiple times. In May 2023 he was diagnosed with adult autism. At a review on 31 May he was considered to be stable. On 15 June a routine clozapine review identified sub-therapeutic levels but this was not notified to his clinicians. Sub-therapeutic levels of clozapine are likely to have contributed to a worsening in his symptoms. Around 24 June he was noted to have suffered a significant deterioration – with symptoms of thought disorder, anxiety, and responding to hallucinations – and following a mental health act assessment on 28 June clinicians wanted to detain him under section 2. No inpatient psychiatric bed was available. Whilst he awaited a bed, he remained in the community with daily visits from the mental health team. Last contact was on 1 July when he accepted his medication and appeared more settled. There was no answer when he was visited on 2 July. His room at supported accommodation was entered on 3 July and he was found deceased. Recently he had expressed no suicidal ideation. Post-mortem examination confirmed the medical cause of death was:  1a Cervical spinal cord injury. 1b Laceration. The conclusion of the inquest was that death was the consequence of suicide.
  20. Content Article
    Peter had a long history of depression, anxiety, and reported suicide attempts. He had acknowledged his reluctance to always engage fully with the treatment offered. On 3 August 2022 he was referred to the home treatment team for crisis intervention. After poor engagement he was transferred back to the community mental health team. On the 14 October he was detained by police under section 136 mental health act after expressing suicidal ideation. He told a psychiatric liaison service nurse he had no ongoing suicidal ideation and was referred to the community mental health team and his GP. He then contacted services further a number of times. On 10 November 2022 Peter was found deceased in his flat having taken a deliberate overdose of his prescribed medication. At the time of his death he was on the waiting list to be allocated a mental health care co-ordinator and there had been no multi-disciplinary meeting with all teams involved to agree how best to work with Peter. His cause of death was confirmed at post-mortem: 1a Carbamazepine toxicity. The conclusion reached was death was a consequence of suicide.
  21. Content Article
    A new report published by Carers Scotland shows the devasting impact the health and social care crisis is having on the health of Scotland’s 800,000 unpaid carers. 
  22. News Article
    A third of carers with poor mental health have considered suicide or self-harm, data shows. Figures given to the Liberal Democrats by Carers UK reveal that many of the UK’s millions of carers who look after relatives have bad mental health, with some “at breaking point”. In a survey of nearly 11,000 unpaid carers, the vast majority said they were stressed or anxious, while half felt depressed and lonely. More than a quarter said they had bad or very bad mental health. Of these, more than a third said that they had thoughts related to self-harm or suicide, while nearly three-quarters of those felt they were at breaking point. Helen Walker, the chief executive of Carers UK, said: “Unpaid carers make an enormous contribution to society, but far too regularly feel unseen, undervalued and completely forgotten by services that are supposed to be there to support them. “Not being able to take breaks from caring, being able to prioritise their own health or earn enough money to make ends meet is causing many to hit rock bottom.” Read full story Source: The Guardian, 22 November 2023
  23. News Article
    Two young people facing mental health crises were left on paediatric wards for months while different agencies across a health system struggled to find appropriate placements. The patients – who were both autistic and had learning disabilities, with special educational needs – were admitted to Maidstone and Tunbridge Wells Trust (MTW) last year after attending emergency departments more than 10 times within a two-month period. They were left on a paediatric ward – one of the patients for four months – as this was the “only available place of safety as opposed to the optimum setting to meet their needs,” according to Kent and Medway Integrated Care Board’s “learning review” of children and young people with complex needs, which the two cases prompted. The review, which HSJ obtained under a Freedom of Information request, revealed several problems with joint working, despite a multidisciplinary team meeting regularly to discuss the young patients’ needs. Since the review, a new escalation process has been introduced, urgent mental health risk assessments in the community have been enhanced and a three-month pilot of a self-harm service has been implemented at Tunbridge Wells Hospital, part of MTW. Read full story (paywalled) Source: HSJ, 17 November 2023
  24. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. To mark Men's Health Awareness Month, we are sharing 10 resources relating to men's health, including information about male cancers, how to engage men earlier and insights around the impact of traditional ideas of masculinity on patient safety.
  25. News Article
    Children feel they have to attempt suicide multiple times before they get treatment from NHS mental health services, the former children’s commissioner has warned. Anne Longfield said that schoolchildren were aware that NHS mental health infrastructure was “buckling and far from being able to cope with the demand”. She told the Times Health Commission: “When I first became children’s commissioner in 2015, the thing that children talked about most often was mental health. They said they knew they couldn’t get help and treatment easily, because there just wasn’t enough help to go around. “Some said, we know that we’ve almost got to try and take our own life before we can get help. And I thought that was pretty shocking at the time. Now, young people are saying not only do they have to try to take their own life, they have to try and take their own life several times, and they say there will be an assessment of levels of intent within that.” Read full story Source: The Times, 1 November 2023
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