Kimberley Lindfield

1. 1. automatic referral without audit leading to failures of care

   “all patients presenting with symptoms of mental illness/ mental disorder and/or after reported self harm/suicidal behaviour will now be automatically referred for a mental health assessment to be conducted as soon as possible”

2. 2. absence of written protocol for observation and recording

   “there should be a clear written policy or protocol setting out what those observations actually involve (e.g.”

3. 3. missing written guidance for care plan changes

   “there is currently no written protocol or guidance where there is an appropriate clinical review and there should be a change in the care and management plan”

4. 4. inadequate record keeping standards

   “all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care”

5. 5. lack of awareness among other NHS trusts about this case

   “any other NHS Trusts in England and Wales who may have similar policies/protocols or working practices about referral for mental health assessment when a patient is "medically fit" and presenting with apparent menial illness/mental disorder and/or after self harming /suicidal behaviour should be informed about this case”

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