“While a patient is admitted to an acute Trust ward for treatment for physical health…”

The coroner’s concerns

– While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours. a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team. b. 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 2 Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act. c. 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. d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm. e. 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 Aaron Deeley. f. 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. 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.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0331

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0