First reported 8 May 2015•Latest report 25 Nov 2025
Definition
What this concern includes
Includes failures by healthcare, social-care, custodial or other care staff to recognise, understand, respect or apply Mental Capacity Act principles in decisions about treatment, nutrition, medication, restraint, conveyance, care or welfare for people who may lack capacity.
Not included
Excludes generic legal, policy or staff-training deficiencies unless they directly concern application of Mental Capacity Act principles in a care decision.
Excludes mental-capacity assessment failures where the Mental Capacity Act principles were not the deficient control.
Excludes Mental Health Act, Deprivation of Liberty Safeguards or other statutory frameworks unless the assertion specifically identifies failure to apply Mental Capacity Act principles.
Excludes care-quality, communication or treatment failures unrelated to a person's capacity or the application of Mental Capacity Act principles.
Reports
10
Distinct published reports
Individual concerns
16
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
14
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Care Quality Commission2
Advocacy Together Hub Rochdale1
Bedfordshire Hospitals NHS Foundation Trust1
Bedfordshire Police1
Calderdale and Huddersfield NHS Foundation Trust1
Herefordshire and Worcestershire Health and Care NHS Trust1
Heywood Health1
HM Prison and Probation Service1
NHS England1
Pennine Care NHS Foundation Trust1
Priory Group1
Rochdale Adult Care1
Sheffield Teaching Hospitals NHS Foundation Trust1
South Western Ambulance Service NHS Foundation Trust1
South West Yorkshire Partnership Teaching NHS Foundation Trust1
NHS trust7
Health and social care service regulator2
Domiciliary care provider1
Executive agency1
Executive non-departmental public body1
Healthcare site1
Independent healthcare provider1
Police force1
Social-care provider1
Sub-organisation1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Bedfordshire and Luton
Concerns raised1
Lack of knowledge and/or concern regarding Mental Capacity Act requirements for using force and restraint
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Deliver mandatory Mental Capacity Act training to all frontline police officers, including capacity assessment, lawful restraint and recording requirements.
Stated by Bedfordshire PoliceStated completedThe respondent said that this action was complete when they made their response on 2 December 2025.
Action
Provide mandatory Personal Safety Training incorporating the Acute Behavioural Disturbance programme and guidance on recognition, restraint risks, monitoring and multi-agency working.
Stated by Bedfordshire PoliceStated completedThe respondent said that this action was complete when they made their response on 2 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Police officers may defer to attending health professionals’ capacity assessments and rely on their advice when applying force.
Stated by Bedfordshire PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Kent and Medway
Concerns raised1
Lack of prison officers’ understanding of when the Mental Capacity Act applies in custody
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Healthcare professionals, not officers, are responsible for assessing prisoners’ mental capacity when staff have concerns.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire (Western)
Concerns raised1
Failure to apply Mental Capacity Act principle 2 in clinical decision-making
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Reinforce Mental Capacity Act principles 1 and 2 through training and monitor application through the revised audit programme.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2025.
Action
Develop a monthly audit of Mental Capacity Act application for patients with learning disabilities.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
Action
Enhance Learning Disabilities and Mental Capacity Act content in induction and preceptorship, and develop clinical bite-sized learning and briefings.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
Lancashire and Blackburn with Darwen
Concerns raised1
Failure to sufficiently consider powers under the Mental Capacity Act 2005 when patients detained under the Mental Health Act refuse necessary and appropriate medical treatment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Bedfordshire and Luton
Concerns raised1
Failure to train staff in the application of the Mental Capacity Act during patient transfers
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Review Emergency Department staff provision for Mental Capacity Act and restraint training with ELFT colleagues.
Stated by Bedfordshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Update Mental Capacity Act and restraint training for Emergency Department junior doctors.
Stated by Bedfordshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Worcestershire
Concerns raised1
Failure to apply the correct Mental Capacity Act 2005 test when assessing capacity for medication decisions
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (Western)
Concerns raised3
Failure to seek parents' views in Mental Capacity Act-compliant decision-making
Failure of senior clinicians to understand and apply Mental Capacity Act requirements
Lack of knowledge, respect and application of Mental Capacity Act principles among staff treating patients who may lack decision-making capacity
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Run MCA and Best Interests audits to assess practical application, recording, patient and family involvement, and Health Passport use.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021.
Action
Roll out advanced MCA training to senior decision-makers, initially targeting Clinical Directors, and monitor uptake.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
Action
Make MCA and DoLS questions available for senior clinician interviews to assess relevant skills and knowledge.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2021.
Action
Strengthen MCA training so all front-line clinical staff have the required knowledge.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
Action
Provide accessible intranet resources covering MCA guidance, staff awareness and specialist support contacts.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
Action
Disseminate MCA information across relevant staff groups to raise awareness.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
Action
Further develop MCA training and supporting resources after Liberty Protection Safeguards are introduced.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Clinical Directors will decide how advanced Mental Capacity Act training is delivered within their respective directorates.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Western)
Concerns raised1
Lack of understanding of the Mental Capacity Act in care delivery
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A decision to cease operating prevents provision of a detailed response to the indicated corrective actions.
Stated by Stars Social Support LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester North
Concerns raised4
Inadequate Mental Capacity Act training for decisions concerning life-sustaining treatment
Failure to identify and consult relevant consultees in Mental Capacity Act decisions
Failure to correctly apply Mental Capacity Act capacity requirements to decisions about investigations
Failure to follow the required order of Mental Capacity Act best-interest decision-making steps
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Avon
Concerns raised2
Failure to maintain ambulance service policy appropriately addressing the Mental Capacity Act
Failure to provide ambulance service training appropriately addressing the Mental Capacity Act
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures by healthcare, social-care, custodial or other care staff to recognise, understand, respect or apply Mental Capacity Act principles in decisions about treatment, nutrition, medication, restraint, conveyance, care or welfare for people who may lack capacity.
