Ryan Evans
20 Dec 2023 · Coroner Darren Stewart · Hampshire, Portsmouth and Southampton
The coroner's concerns
1. lack of mental health assessment for self-harm and suicidal ideation
“Referral to Psychiatric Liaison Services for patients presenting with self-harm injuries and suicidal ideation (including those in Police custody) at Frimley Park Hospital A&E, including the extent to which the NICE guidance is complied with or provides effective guidance to staff in such circumstances.”
2. inadequate mental health assessment triggers and refusal handling in custody
“The conduct of Mental Health Assessments in a custody setting by liaison and diversion staff including the adequacy of policy and guidelines relating to triggers to conduct such assessments and the manner in which refusals are dealt with.”
3. ineffective information transfer about mental health concerns of detained persons
“The passage of information both between custody staff, as well as with healthcare staff in relation to concerns of a mental health nature for a detained person including the extent to which the custody record is used as an effective means to communicate concerns/observations of detained persons mental health.”
4. vulnerable person released without adequate safety planning
“The process of release of a vulnerable detained person following disposal, including interaction with family or other persons collecting the detained person.”