Julie Beasley

1. 1. lack of V4 mental health assessment and medication scrutiny

   “Mrs [name redacted] was seen at home following a call to the mental health crisis team and required a full V4 mental health assessment that did not take place and instead an SBAR review was completed, and the nurse did not scrutinise the medications and medication changes that had been previously made and made errors about the doses. Mrs [name redacted] was informed she was discharged back to her GP, but no actions were sent by the mental health Trust to the GP.”

2. 2. lack of psychiatric assessment following crisis contact

   “Mrs [name redacted] contacted crisis mental health explaining that she had vital information that she had not shared following a visit by a psychiatric nurse at her home. Mrs [name redacted] was not asked what the information was. Mrs [name redacted] contacted the crisis team again a few days later repeating that she had not shared information and again was not asked what the information was and was not given an appointment. Mrs [name redacted] telephone contacts were noted in her medical record with no details recorded as to”

3. 3. failure to recognise urgent assessment need after overdose

   “Review of the mental health Trust medical records would have shown that Mrs [name redacted] had an SBAR review rather than a V4 mental health assessment. This should have alerted staff to the fact that an urgent assessment was required when Mrs [name redacted] attended mental health liaison following an overdose of her medication. This did not happen.”

4. 4. inadequate communication about urgent appointment needs

   “Mrs [name redacted] had been requesting an urgent appoint and responded immediately to a letter from the Trust informing her she needed an urgent psychiatric appointment. When Mrs [name redacted] contacted the crisis team, she was again informed incorrectly that she had recently had a V4 psychiatric assessment and did not require an urgent appointment. The crisis team were not communicating effectively either with Mrs [name redacted], her GP or internally within their own team.”

5. 5. lack of professional curiosity and poor record keeping

   “Multiple experienced members of the mental health teams had contact with Mrs [name redacted] between January and March and did not make detailed entries into the medical or ask questions of Mrs [name redacted] about what additional information she had to provide about her risks of harm and suicidal ideation, review of her medication given her deteriorating mental health and calls to the crisis team disclosing increasing suicidal thoughts and ideation accompanied by acts and plans. There was a lack of professional”

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