Trauma Informed Learning Event: June 2025

Healthwatch Isle of Wight ran a collaborative learning event following a serious incident involving multiple Island services, including the Police, Isle of Wight NHS Trust, Hampshire & IOW Healthcare NHS Foundation Trust, the IOW NHS Trust Ambulance Service, and the Isle of Wight Council. The incident resulted in inadequate care and treatment for a person living with dementia.

During the event, representatives from these organisations discussed the incident from their different perspectives, with a focus on the individual’s experience and the wider system response. 

Several key themes emerged. There were significant breakdowns in care pathways, which meant the individual reached crisis point without earlier intervention. Access to services was inconsistent, with some services unable to respond, leading to an overreliance on ambulance services, emergency departments, and police, even when these were not the most appropriate options. Emergency responders also faced constraints, such as limited ability to manage behavioural crises in the community.

The report highlights a need for better understanding of dementia and trauma-informed care across services, noting that people with dementia may communicate and behave differently and require tailored approaches. It also identifies a widespread tendency to treat hospital admission as the default response, partly because families and carers lack awareness of alternatives. In addition, there are gaps in support for unpaid carers, particularly when they themselves require hospital care. 

Further issues include challenges for police in accessing appropriate mental health support, and the failure of the “no wrong door” principle, with individuals being passed between services without clear ownership of care. The report also notes system-wide pressures and calls for a culture shift toward more empathetic, trauma-informed, and person-centred decision-making. 

The report makes a range of recommendations. These include increasing trauma-informed and dementia-specific training, strengthening joint working across agencies, and improving shared learning from incidents. It also recommends developing integrated dementia care pathways with better crisis planning, reconsidering how dementia services are commissioned, and exploring alternatives to hospital and emergency department use. Additional recommendations focus on reviewing ambulance conveyances, supporting unpaid carers with contingency planning, and making the “no wrong door” approach more effective in practice. 

The next steps involve sharing the findings with partner organisations and following up to ensure that the recommendations are implemented across the system.