Recurring concern

Unreliable communication to referrers about referral service access and expectations

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First reported 12 Feb 2015•Latest report 24 Nov 2023

Definition

What this concern includes

Includes failures in a named referral service's process for communicating referral status, expected first contact or assessment timing, capacity constraints, delays and necessary alternative routes to referrers.

Not included

  • Excludes failures in the clinical assessment or treatment provided after the referral service has accepted and contacted the patient.
  • Excludes generic inter-agency communication, staffing or capacity deficiencies unless they directly impair communication to referrers about referral access or expectations.
  • Excludes patient-facing appointment reminders and follow-up communication where the concern is not communication with the referring service.
  • Excludes referral delays or rejected referrals where no failure to communicate referral status, expectations or capacity to referrers is identified.
Reports
6

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2015–2023

First to latest report issue date

Stated actions
10

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.

Pennine Care NHS Foundation Trust2
Birmingham and Solihull Integrated Care System1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Clarion Housing Group Limited1
Grosvenor Medical Centre1
Killick Street Health Centre1
London Borough of Bromley1
North London NHS Foundation Trust1
Oxleas NHS Foundation Trust1
Sussex Partnership NHS Foundation Trust1
Tameside Borough Council1
Tameside General Hospital1

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.

  1. Manchester North

    AI-generated summary

    Teresa Chmielek · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Teresa Chmielek took her own life at home on 17 June 2023, after a referral to mental health services concerning her suicide risk was rejected without contact or a face-to-face review. The concerns included failure to identify or recognise the reported recent suicide attempt, lack of meaningful multidisciplinary discussion and direct contact, inadequate referral arrangements and documentation, and the absence of procedures and auditing for referral decisions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record and confirm communication of referral rejection reasons

    Wider context from the report

    “(4) The Consultant Psychiatrist present at the MDT meeting has no recollection of discussing the referral and whilst the evidence was that a letter to the GP practice explaining the reason for rejecting the referral was generated there is no record of this letter on the Trust's electronic systems or having been received by the GP practice ”

    Source location

    Teresa Chmielek · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  2. Birmingham and Solihull

    AI-generated summary

    Leva Amra ADRIS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Leva Amra Adris was pronounced deceased on 18 March 2023 after suffering a fitting episode, and post-mortem testing identified toxicity following an overdose of medication used for anxiety. The report raised concerns that a GP referral requesting secondary mental health assessment was not considered by secondary services, that the GP was not informed it had been rejected, and that the significance of worsening mental health symptoms may have been underestimated.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to inform referring GPs when referrals to secondary services are rejected

    Wider context from the report

    “6. I am equally concerned that not all GPs are aware that their referral to secondary services will not necessarily be considered by secondary services and that the GP making the referral was not informed that it had, in effect, been rejected. ”

    Source location

    Leva Amra ADRIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish effective working relationships and clarify referral processes between mental health services and general practice.

    Verbatim wording from the response

    “Firstly, may I apologise for the delay in our response and assure you that our organisation takes the findings seriously. We appreciate the thoroughness of your investigation and the comprehensive matters of concern outlined in your report. We are committed to working with partner to address these concerns and we note the response from Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) dated 15th December 2023. In particular, we will ensure that BSMHFT and General Practice have effective working relationships with clarity of referral processes between the two providers particularly with regards to the transformed Community Mental Health and Wellbeing Service and the associated referral form and processes.”

    Source location

    Response from Birmingham and Solihull
    Page 1 · response
    Published 13 November 2023

    Open published response
  3. South London

    AI-generated summary

    Samuel Robert Pearson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Samuel Robert Pearson had complex mental and physical needs and was moved to temporary accommodation after a van crashed into his home. The inquest narrative stated that the accident and accommodation increased his anxiety, and that he accidentally died after taking an overdose and alcohol on 6 July 2021. Concerns included inadequate multi-agency working and information sharing during the emergency move, and a referral-screening backlog that was not communicated to his GP.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to inform referrers when referral services cannot meet usual service expectations

    Wider context from the report

    “(2) In respect of Oxleas NHS Foundation Trust, a referral was made by Mr Pearson’s GP to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues. A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations. ”

    Source location

    Samuel Robert Pearson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete the ADAPT Operational Policy to define waiting-time information provided to service users and referrers after referral receipt.

    Verbatim wording from the response

    “At the inquest we confirmed that we had been reviewing our ADAPT Operational Policy, however, it had not concluded in terms of how we would inform referrers about service expectations. Our new policy is now complete, and it now clearly sets out the expectations of what information services users and the referrer will receive once the Team receive the referral in terms of waiting times. A copy of the new Operational Policy incorporating this new process is enclosed with this response.”

    Source location

    Response from Oxleas NHS Foundation Trust
    Page 1 · response
    Published 11 November 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Generate automated referral acknowledgements and send service users and referrers letters stating current waiting times and escalation advice for urgent referrals.

    Verbatim wording from the response

    “An automated email will be generated and sent to the referrer:”

    Source location

    Response from Oxleas NHS Foundation Trust
    Page 1 · response
    Published 11 November 2022

    Open published response
  4. West Sussex

    AI-generated summary

    Matthew Christopher Roberts · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Matthew Christopher Roberts, a music student with a history of psychosis and a previous intentional insulin overdose, took a large overdose of insulin and prescribed psychotropic medication after returning to Sussex. He was admitted to intensive care in a coma with significant hypoxic brain damage and later died from a major haemorrhage at the tracheostomy site caused by acute arteritis of the innominate artery. Concerns included failures to log and scrutinise referral faxes, consider written clinical and risk information before assessing urgency, confirm the date of first contact, and formally review the death and seek relevant learning.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to clearly confirm the planned contact date with referrers

    Wider context from the report

    “(3) That there was no relevant policy, procedure or practice whereby the Bognor EI team would clearly confirm with the referrer the date on which contact with a newly referred patient would be made. ”

    Source location

    Matthew Christopher Roberts · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Finalize, approve, disseminate and embed shared EIP referral standards covering information review, risk assessment, contact planning and recordkeeping.

    Verbatim wording from the response

    “The EIP Team Leaders and Senior Clinicians within the EIP service have reflected on this and have developed a clear set of shared standards for accepting referrals. Key elements of the standards are:”

    Source location

    2017-0028-Response-by-Sussex-Partnership-NHS-Trust
    Page 2 · response
    Published 26 February 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The service cannot always confirm the contact date at referral because appointments depend on risk assessment and patient choice.

    Verbatim wording from the response

    “appointment times and venues for meetings. This helps the service to achieve higher rates of engagement with service users and better outcomes in relation to patient safety and service user recovery. Following a referral to the service, an EIP Practitioner will aim to make telephone contact with the referred client, based on their risk assessment, the next working day to agree a date and venue for their initial appointment. It is therefore not always possible to clarify at the point of referral, when the service user will be seen. I am pleased to say we achieved 95% in February 2017 for the new target for EIP access and waiting times for assessment and treatment to be within 14 days.”

    Source location

    2017-0028-Response-by-Sussex-Partnership-NHS-Trust
    Page 3 · response
    Published 26 February 2017

    Open published response
  5. Manchester South

    AI-generated summary

    Rachal Marie Murphy · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rachal Marie Murphy died at home on 8 September 2015 after taking medication prescribed to other family members; the medical cause of death was recorded as acute hypoxia due to morphine overdose, and the conclusion was that she had taken her own life. The report identified concerns about fragmented inter-agency care, failures and delays in referrals and investigations, overlooked CAF documentation, and delays in Early Help case allocation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clarity about referral routes and acceptance by Psychological services

    Wider context from the report

    “1. There was a lack of understanding between medical professionals as to the means by which someone could be referred to Psychological services and whether there was a unclear message from Psychological services as to whether they were accepting referrals. ”

    Source location

    Rachal Marie Murphy · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Manage Healthy Young Minds referrals through a single point of entry and allocate them according to children’s needs.

    Verbatim wording from the response

    “As part of the Trust’s quality improvement work during early 2016 the Trust implemented a new referral process for all aspects of Tameside and Glossop Healthy Young Minds Services (formally CAMHS). All referrals are now managed via one single point of entry and then allocated to a range of possible professionals dependant on the child/young person’s needs e.g. Psychologists, Nurse, Psychiatrist or 3rd sector services. This allows for greater clarity and understanding of where to direct requests for help to for all professionals.”

    Source location

    2016-0401-Responses
    Page 3 · response
    Published 19 February 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Produce and widely disseminate a Healthy Young Minds service offer document explaining referrals, advice access and appropriate referral problems.

    Verbatim wording from the response

    “The Trust have also produced a service offer document which details, how to make a referral, how to contact the service for advice and importantly the document contains information of the types of problems that are appropriate to refer to Tameside and”

    Source location

    2016-0401-Responses
    Page 3 · response
    Published 19 February 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Expand the service offer document to name a contact for paediatric colleagues seeking advice and consultation.

    Verbatim wording from the response

    “The document has just recently been reviewed and will be expanded to provide a named contact for colleagues in the Paediatric medical services to contact for advice and consultation. The Trust believes that this addresses the confusion and lack of understanding that you have identified in relation to Rachel’s care and treatment.”

    Source location

    2016-0401-Responses
    Page 4 · response
    Published 19 February 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Make written CAMHS referrals whenever paediatricians have reasonable cause for concern, without filtering referrals or predicting acceptance.

    Verbatim wording from the response

    “The Trust have in response to this case, made changes to their practices to ensure that referrals to CAMHS are made in writing in any case where the Consultant Paediatrician has reasonable cause for concern in respect of a child’s psychological wellbeing. The Consultants no longer filter referrals through Pennine Care staff nor do they consider the likely acceptance of referrals before making them. The referral is made and it is for CAMHS to determine how to proceed. I am informed that this change in approach has been successful to date with CAMHS appearing to be accepting more referrals in response.”

    Source location

    2016-0401-Responses
    Page 6 · response
    Published 19 February 2017

    Open published response
  6. Inner North London

    AI-generated summary

    Andrew Elliot FROST · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Andrew Elliot Frost, aged 34, took his own life after jumping in front of an underground train on 25 September 2014. The report identified concerns about a lack of shared understanding between the crisis team and general practitioner, incomplete recording of information, and an inadequate pager messaging service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of shared understanding between referrers and crisis teams about crisis team capabilities and limitations

    Wider context from the report

    “During the second encounter on 24 September 2014, whilst police and paramedics were at Mr Frost’s home, you and he spoke on the telephone. You were worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. You were told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him. However, there was no shared understanding between you and the crisis team about what the crisis team could and could not do. You thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day. You regarded the crisis team as an emergency service, which the team leader told me in court is not the case. It seems that you, your partners, and other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis teams about their service, including its limitations. I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else. ”

    Source location

    Andrew Elliot FROST · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Meet with Crisis Team managers to discuss service provision.

    Verbatim wording from the response

    “Following your requirement for our service to meet with the Crisis Team, I can confirm that we have now met with them on the 19th March and discussed the service provision with the Crisis Team. I met up with ████████ both senior Managers at the Crisis team. Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP’s at the practice and also to enable us to discuss individual clients.”

    Source location

    2015-0119-Response-by-Killick-Street-Health-Centre
    Page 1 · response
    Published 12 February 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish regular meetings between practice GPs and the Crisis Team to discuss service provision and individual clients.

    Verbatim wording from the response

    “Following your requirement for our service to meet with the Crisis Team, I can confirm that we have now met with them on the 19th March and discussed the service provision with the Crisis Team. I met up with ████████ both senior Managers at the Crisis team. Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP’s at the practice and also to enable us to discuss individual clients.”

    Source location

    2015-0119-Response-by-Killick-Street-Health-Centre
    Page 1 · response
    Published 12 February 2015

    Open published response
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Data last updated 7 September 2026