Recurring concern

Failure to ensure physical healthcare staff can safely care for patients with significant mental health needs

First to latest report 14 Feb 2017 — 14 Nov 2017

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
7

What this concern includes

Includes failures to provide, assess or maintain the mental-health competence, preparation and role-specific support needed by physical or non-specialist healthcare staff caring for patients with significant mental health needs, including understanding mental-health presentations, risks, applicable Mental Health Act restrictions and safe care or review decisions.

What is not included
  • Excludes failures involving specialist mental-health staff or specialist mental-health services where physical or non-specialist healthcare staff capability is not the shared condition.
  • Excludes generic staff training, staffing, communication or supervision deficiencies unless they directly impair physical or non-specialist healthcare staff caring for patients with significant mental health needs.
  • Excludes failures limited to the quality of a particular mental-health review, detention decision or treatment decision when staff capability is not the shared unsafe condition.
  • Excludes physical-health clinical competence and treatment failures unrelated to caring for patients with significant mental health needs.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Norfolk

    AI-generated summary

    BRIAN STANNARD · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Brian Stannard was a resident at Eversley Nursing Home and was found drowned on a beach at Great Yarmouth on 14 November 2016 after being seen asleep in his room earlier that morning. The report raised concerns about the nursing home’s capacity to manage his mental ill health and threats of self-harm or suicide, as well as incomplete staff records and limited use of the Lorenzo computer system.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide adequately trained and equipped staff for people with coexisting mental and physical ill-health

    Wider context from the report

    “(1) Mr Stannard had mental ill health and physical ill health. He was placed at a Nursing Home to manage his physical ill health as this was seen as the priority at the time of admission. Staff at the Home were not adequately equipped to deal with his mental ill health as his physical health improved. This not only raises concern with regard to the safety and well-being of the individual concerned, but also with regard to the staff involved in Mr Stannard’s care. They were not trained mental health individuals and were required to deal with attempts at and threats of self-harm and suicide by Mr Stannard. There did not appear to be a Home available where staff were adequately trained to deal with a person’s mental and physical ill-health. ”

    Source location

    BRIAN STANNARD · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with clinical teams to provide sufficient staffing and equipment for consistent, balanced work allocation.

    Verbatim wording from the response

    “Your report confirmed the findings of the RCA report that aspects of Mr Stannard’s health record had not been maintained to the expected standard, notably risk assessment and care plans. The Trust are engaged in a program to improve its performance in this area with active monitoring at all levels of the organisation. The Trust recognises there are many influencing factors affecting this and are working with clinical teams to ensure they have the right number of staff and equipment to ensure work can be allocated in a consistent and balanced way.”

    Source location

    2017-0394-Response
    Page 1 · response
    Published 15 February 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Providing accommodation supporting individuals with complex and fluctuating needs is outside the Trust’s direct control.

    Verbatim wording from the response

    “You raise an important issue regarding the provision of a range of accommodation services that can support individuals with complex and fluctuating needs. Such provision of accommodation is outside of the direct control of the Trust. The Trust’s role is to continually monitor the service user’s presentation and to help facilitate changes where these are required. For Mr Stannard, this would have involved working with him, his family, the care home, continuing healthcare services and the GP. The Trust’s Root Cause Analysis (RCA) investigation identified there was evidence of inter-agency working noting a routine review meeting was held on 7 November 2016. This meeting observed Mr Stannard’s continued physical and mental health presentation, identifying plans to assist with his benefit entitlement and to seek advocacy support to assist with decisions about potential future physical events.”

    Source location

    2017-0394-Response
    Page 1 · response
    Published 15 February 2018

    Open published response

  2. Exeter and Greater Devon

    AI-generated summary

    Wendy Louise Telfer · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Wendy Louise Telfer died on 20 March 2016 in hospital from an overdose of purchased non-prescribed medication taken five days earlier; the medical cause of death was recorded as liver failure due to paracetamol overdose, with asthma also recorded. The report identified concerns about missed opportunities to keep Wendy safe, confusion about applying the Mental Health Act in a physical care setting, and the lack of an available psychiatric inpatient bed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of adequate mental health training for physical healthcare staff

    Wider context from the report

    “(1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. It was also acknowledged that the training of the physical healthcare staff "needs to improve", although it must be said that efforts have been made and are continuing to address this issue. From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment, which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation. ”

    Source location

    Wendy Louise Telfer · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver regular Mental Health Act training to Emergency Department, Site Management, medical and foundation doctor staff.

    Verbatim wording from the response

    “Part of the role of the DPT Liaison Psychiatry team is to offer training to colleagues in the acute hospital. This is done both formally and informally. In 2016, the Liaison Psychiatry Team has formally trained at least 496 staff, having taught 175 teaching sessions.”

    Source location

    2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
    Page 1 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train volunteer clinicians as Mental Health Champions through a five-day programme.

    Verbatim wording from the response

    “• Mental Health Champion Training (x5 full days) to RD&E clinicians who have volunteered themselves as Mental Health Champions for the RD&E. This helps support staff with patients in practice.”

    Source location

    2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
    Page 1 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver a package on managing challenging behaviour and using rapid tranquillisation as a last resort to medical ward staff.

    Verbatim wording from the response

    “• A whole day’s package has just been built and is due to start being delivered later this month called “Management of Challenging Behaviour – Using Rapid Tranquilliser as a last resort” – this refers to use of the MHA in its content. This is being delivered to the medical wards and targeted at registered and non-registered staff where patients with mental health needs alongside physical needs are being nursed.”

    Source location

    2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
    Page 2 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Train a specialist nursing staff pool for dedicated mental health input, reducing reliance on agency staff.

    Verbatim wording from the response

    “Further, the RD&E is training a specialist pool of nursing staff for specific mental health input. This will lessen the need to use agency staff. This will allow the Trust to have better control over the training and expertise of the specialist mental health staff. It will also improve communication between the physical and mental health care professionals.”

    Source location

    2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
    Page 2 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver recurring Liaison Psychiatry training to general-hospital staff, including Emergency Department, site-management, medical-staff, foundation-doctor and Mental Health Champion sessions.

    Verbatim wording from the response

    “As described by our Liaison Psychiatry Clinical Team Leader during the inquest we have continued to support the training of the staff within the RD&E, I have described below the general role of the Liaison Psychiatry Team in training and the specific work undertaken during the last year.”

    Source location

    2017-0046-Response-by-Devon-Partnership-NHS-Trust
    Page 3 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Roll out the newly developed challenging-behaviour and rapid-tranquilisation training package monthly.

    Verbatim wording from the response

    “• A full day package has just been developed called ‘Management of Challenging Behaviour – Rapid Tranquilisation - a last resort!’ and this began monthly roll-out in March 2017, this refers to use of the MHA and Mental Capacity Act in its content.”

    Source location

    2017-0046-Response-by-Devon-Partnership-NHS-Trust
    Page 3 · response
    Published 5 March 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing escalation arrangements require staff to seek specialist psychiatric advice and remain the Trust’s first-line approach for future Mental Health Act concerns.

    Verbatim wording from the response

    “All of the current MHA training requests that if staff have any concerns about a patient’s mental health, then they should contact the specialist Psychiatric Liaison Team for advice on how to manage that patient in normal working hours and the psychiatric on call Crisis Team out of hours. The escalation process also includes contacting the Devon Partnership Trust on call team both in and out of hours if an issue is unresolved. The next stage of the process includes contacting the Devon Partnership Trust on-call Director if required. This is what is practiced throughout the RD&E at the moment. This would also be our first line of advice in any future training.”

    Source location

    2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
    Page 3 · response
    Published 5 March 2017

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026