Aaron Deeley

1. 1. lack of assigned responsible clinician for patients held under section 5(2)

   “Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act”

2. 2. absence of mental health liaison attendance during 72‑hour hold

   “During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm”

3. 3. untrained staff conducting mental health assessment

   “The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm”

4. 4. confusing policy on 1:1 observation for detained patients

   “There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like [the deceased]”

5. 5. absence of joint protocol between trusts

   “There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations”

6. 6. gap in care for patients needing both physical and mental health services

   “There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety”

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