Search results for ‘Subject term:"mental health problems"’ Sort:
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Independent Commission on Mental Health and Policing report
- Author:
- INDEPENDENT COMMISSION ON MENTAL HEALTH AND POLICING
- Publisher:
- Independent Commission on Mental Health and Policing
- Publication year:
- 2013
- Pagination:
- 80
- Place of publication:
- London
Reports on the findings of the Independent Commission on Mental Health and Policing, which was set up in September 2012 to review the work of the Metropolitan Police Service with regard to people who have died or been seriously injured following police contact or in police custody. It focuses on their responsibilities in dealing with issues of mental health: In custody; at street encounter; and in response to calls made to police, including call handling processes when dealing with members of the public where there is an indication of mental health. The Commission examined 55 Metropolitan Police Service cases covering a five-year period (2007 - 2012) and interviewed the families of those involved; people with mental health problems; their families, police officers and NHS and social services staff. The report identified failings of the Metropolitan Police in a number of areas, including: a lack of mental health awareness amongst staff and officers; lack of training and policy guidance in suicide prevention; failure of procedures to provide adequate care to vulnerable people in custody; problems of interagency working; disproportionate use of force and restraint; and discriminatory attitudes and behaviour. The Commission makes 28 recommendations for change in the areas of: leadership, frontline policing, and inter-agency working. (Edited publisher abstract)
Safeguarding Adult Review in respect of Mr AA: died January 2014
- Author:
- KLEE Deborah
- Publishers:
- Norfolk Safeguarding Adults Board, Suffolk Safeguarding Adults Board
- Publication year:
- 2015
- Pagination:
- 53
- Place of publication:
- Norwich
A joint Safeguarding Adult Review (SAR) of Mr AA, a Norfolk resident diagnosed as living with paranoid schizophrenia, who died in a Suffolk hospital in January 2014 from bronchopneumonia. The Review was commissioned due to concerns about the intervention he received up until the time of his death. In 2011 as a result of organisational change in the mental health trust, AA lost is long term care coordinator, received reduced levels of care and support, and was discharged from the care programme approach in 2013. This resulted in a series of events that led to his death in 2014, including lack of an informed risk assessment to manage his challenging behaviour, use of physical control to restraint, and the use of seclusion in hospital. The review's analysis focuses on the way in which professionals and services worked together in five areas: self-neglect; care plan approach and person-centred care; information sharing and joint decision making; the use of control and restraint; and attention to physical health needs. The report shows how a number of incidents impacted on each other which meant that staff did not have the information, knowledge or resources to make good decisions. It makes a number of recommendations to ensure that partners can work together to effectively support people who self neglect; involve the person and their family as appropriate in planning care; consider the impact of organisational change on adults at risk; improve the quality of multi-agency risk assessment and joint decision making in complex cases; improve information sharing; and ensure the appropriate use of all types control and restraint methods. (Edited publisher abstract)
Serious case review: family A
- Authors:
- CARMI Edina, WALKER-HALL Nicki
- Publisher:
- Kingston and Richmond Local Safeguarding Children Board
- Publication year:
- 2015
- Pagination:
- 70
- Place of publication:
- Twickenham
A review of the deaths of three children P, Q and R, who were smothered by their birth mother on 22 April 2014. The mother was given a hospital order in November 2014 after admitting manslaughter by diminished responsibility of her daughter and sons. The three youngest children had spinal muscular atrophy type 2, a condition that affects voluntary muscles causing severe muscle weakness, which can result in problems moving, eating, breathing and swallowing. The report provides a summary of the overall context, describes what happened from the perspective of those involved at the time, including both professionals and family, and considers the facts of the children's health needs. It concludes with findings relating to family and professional interactions, professional and organisational culture and safeguarding practice and sets out key recommendations. The review argues that the role of the lead professional is critical in complex cases to co-ordinate the multiagency services and act as a single point of contact and suggests that the consultant paediatrician may not be best suited to undertake this role. (Edited publisher abstract)
W4 serious case review
- Author:
- BAKER Gill
- Publisher:
- Walsall Safeguarding Children Board
- Publication year:
- 2015
- Pagination:
- 51
- Place of publication:
- Walsall
A serious case review of a young person who died as a result of inhalation of products of combustion, having barricaded herself into her bedroom and set fire to the mattress. The scene of the fire was at a care home in Ellesmere, Shropshire where she was the only resident with two adult carers. During her time in care it was found that she had complex needs and continually exhibited challenging, disruptive and risk-taking behaviour. The review found that it was predictable that she would eventually cause serious harm to herself and/or to others. The failure to adequately address the escalation of her unmanageable behaviour may in part be due to issues of gender, carers being afraid of physical assault or of allegations being made against them. However, the review concludes that a more co-ordinated robust holistic multi-agency approach, an earlier and full mental health assessment and formulation, monitoring and reviewing of treatment for ADHD, plus utilising the option of secure accommodation would have provided an opportunity to fully assess and meet her needs in a safe environment which may have contributed to potentially preventing her death. (Edited publisher abstract)
Serious case review: executive summary: relating to Sarah
- Author:
- NOTTINGHAMSHIRE SAFEGUARDING CHILDREN BOARD
- Publisher:
- Nottinghamshire Safeguarding Children Board
- Publication year:
- 2009
- Pagination:
- 9p.
- Place of publication:
- Nottingham
Executive summary of the serious case review of Sarah, a white British child who died aged four months in late 2007. Although Sarah's death was recorded as Sudden Infant Death (SIDS), the circumstances surrounding her death and the discovery that she had suffered fractures, lead to a review of the case being carried out. Prior to Sarah's death, information about the parents and their children were know to many agencies. The father of the children had a history of mental health difficulties, anxiety and depression and a history of dependency on alcohol and drugs. The children’s mother became dependant on drugs after their first child was born.
Doris Walsh: response; compliance as at September 1997
- Author:
- COVENTRY HEALTHCARE NHS TRUST
- Publisher:
- Coventry Health Care NHS Trust
- Publication year:
- 1997
- Pagination:
- 30p.
- Place of publication:
- Coventry
Response from Coventry Healthcare NHS Trust to the recommendations made in the report of the independent inquiry into the treatment and care of Doris Walsh, who had a long history of mental health problems, which lead indirectly to the accidental deaths of two of her neighbours. Outlines areas of compliance with the recommendations and timescales for implementation.
Report of the independent inquiry into the treatment and care of Doris Walsh: September 1997
- Author:
- MISHCON Jane (chair)
- Publisher:
- Coventry Health Authority
- Publication year:
- 1997
- Pagination:
- 75p.
- Place of publication:
- Coventry
Inquiry report examining the community care services provided to Doris Walsh, who had a long history of mental health problems, which lead indirectly to the accidental deaths of two of her neighbours. The quality and extent of collaboration and communication between agencies (Coventry NHS Trust, Coventry SSD, and Coventry Housing and Environmental Services Department) were examined.
Domestic Homicide Review (DHR): case analysis: report for Standing Together
- Authors:
- SHARP-JEFFS Nichola, KELLY Liz
- Publisher:
- Standing Together Against Domestic Violence
- Publication year:
- 2016
- Pagination:
- 109
- Place of publication:
- London
This analysis identifies and explores key themes from a sample of 32 Domestic Homicide Reviews (DHRs), which are carried out after a woman or man has been killed by their partner or ex-partner to identify lessons learned and help prevent future incidents. The analysis was commissioned by the charity Standing Together Against Domestic Violence (STADV), and carried out by the Child and Woman Abuse Studies Unit (CWASU) at London Metropolitan University. The report provides an overview of cases in the two categories of Intimate Partner Homicide (IPH) which made up 24 of the case and Adult Family Homicide (AFH); draws out the similarities and differences between the IPH and AFH cases; presents the feedback from the workshops; and pulls together learning from the project. The six themes most frequently identified were: contact with General Practitioners (GPs); mental health; safeguarding adults; safeguarding children; the role of informal networks in the DHR process and what informal networks knew; and risk assessment. The report presents key findings and recommendations in the following areas: GP practices, mental health services, health services, adult safeguarding, children's social care and schools. It identifies missed opportunities where best practice is understood but not implemented. It also identifies areas where better, safer and more appropriate ways of working need to be established, such as in the areas of mental health, adult child to family abuse, adult safeguarding and support for carers. (Edited publisher abstract)
Serious case review: Baby Z
- Author:
- WONNACOTT Jane
- Publisher:
- Isle of Wight Safeguarding Children Board
- Publication year:
- 2014
- Pagination:
- 29
- Place of publication:
- Newport
Two day old Baby Z died after falling asleep on the sofa with her father who had used both alcohol and drugs that evening. Baby Z's mother had been known to mental health and substance misuse professionals prior to the birth and the father had a history of drug related offences. The family had recently lived in two different areas. Professional groups who had contact with baby Z included: children's social care (social work services); drug and alcohol team; GPs; health visiting services; housing; hospital (midwifery and accident and emergency); mental health services; community midwifery services; and the police. The following practice themes are discussed: using the CAF process to assess the need for early help; lack of consistency in communication and record keeping systems between agencies; integrating information about adults and children; assumptions that other agencies involved would undertake safeguarding assessments; understanding the role of fathers and family support systems for new mothers; and improving understanding of drug use and misuse. (Original abstract)
Serious case review: the Anderson family: overview report
- Authors:
- LOCK Ron, SUFFOLK SAFEGUARDING CHILDREN BOARD
- Publisher:
- Suffolk Safeguarding Children Board
- Publication year:
- 2014
- Pagination:
- 48
- Place of publication:
- Ipswich
This Serious Case Review examined how public agencies worked with Fiona Anderson and her three children, Levina, Addy and Kyden prior to their deaths on 15 April 2013 in Lowestoft. It outlines the facts of the case since June 2009 and the children’s experience. Suffolk County Council Children and Young People Services (CYPS) first started working with Fiona and her partner some 3 years ago, due to concerns about parenting abilities. Court proceedings to remove Levina were commenced; but were withdrawn following challenge, and because at the time there was insufficient evidence. The report acknowledges that this action resulted in the relationship between the family and children’s social care becoming strained from the outset. It identifies that by June 2010, when Levina was aged 12 months, the concerns had diminished sufficiently for formal involvement to cease. Following further concerns, intervention recommenced in August 2011; and Levina and Addy were made subject of Child Protection Plans under the category of ‘neglect’. When Kyden was born in May 2012 he was included in the Plan. The report acknowledges that the child protection process was implemented in line with recognised procedures. However, it was inappropriate for the Child Protection Plans to continue largely unchanged for a period of eighteen months from August 2011 without some form of review and formal revision with the family. The lack of progress was not challenged by managers or other professionals. The SCR analyses the legal strategy and child protection plans; physical and emotional neglect; working with a hard to reach, avoidant family; the impact of work with a complex family; maternal mental health; and organisational factors. Among the 13 lessons learned is that using innovative multi-agency interventions is required when working with hard to reach and avoidant families. Also required is a focus on the children’s experiences to identify whether there is emotional abuse or neglect in a family, otherwise children will be at risk if child protection plans are not continually acted upon. The pivotal role of the child protection conference (CPC) Chair in challenging the management of a case is acknowledged, coupled with managers’ and specialists’ involvement, as well as those professionals directly involved with families. All professionals have responsibility for challenging inappropriate or ineffectual practice; for there to be robust management oversight when dealing with demanding child protection cases; and the importance of having a record of important discussions and agreements. When there are concerns about a parent’s possible mental health problems, a relevant assessment will need to be made, even if the parent does not see the need. The predominant feature of this case was the challenge of how to engage with a hard to reach family, and especially the mother who specifically avoided professional interventions. However, a Public Law Outline (PLO) process or an application for Care Proceedings was never tested. (Edited publisher abstract)