Recurring concern
Unreliable community Home Treatment Team care pathways
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Request correctionFirst reported 12 Sep 2013•Latest report 27 May 2026
What this concern includes
Includes failures specifically within Home Treatment Team pathways, including referral, urgent assessment, handover, responsibility for initiating contact, treatment transitions, withdrawal or discharge communication and pathway guidance.
Not included
- Generic community mental-health coordination with no Home Treatment Team pathway
- Home Treatment Team staffing or treatment-quality failures after the pathway controls have operated reliably
- Unrelated mental-health referral, discharge or crisis pathways
- Reports
- 29
- Individual concerns
- 39
- Date range
- 2013–2026
- Stated actions
- 36
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised2
Failure to verify service acceptance and agree an appropriate discharge care plan
Failure to seek Home Treatment Team advice and implement the appropriate crisis pathway
This report raised 17 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.3
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Position
Stepped-up care from the community team was used instead of Home Treatment Team referral because it provided prompt, familiar and consistent support.
Stated by Essex Partnership University NHS Foundation Trust
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Position
The community crisis pathway requires additional community measures to be attempted before referral to the Home Treatment Team.
Stated by Essex Partnership University NHS Foundation Trust -
Position
A Home Treatment Team referral could not be arranged without the patient’s agreement.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised2
Lack of staff awareness of Home Treatment Team policies and required risk information
Failure to pass important risk information to the Home Treatment Team
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Revise the internal-transfer SOP to clarify handover dates, care-package ownership and joint handover meetings.
Stated by NHS Coventry and Warwickshire NHS Trust -
Action
Launch the updated EPR Risk and Safety section with demonstration and quick-reference materials for staff.
Stated by NHS Coventry and Warwickshire NHS Trust -
Action
Audit internal transfers after SOP ratification to assess compliance and identify further improvement opportunities.
Stated by NHS Coventry and Warwickshire NHS Trust
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Concerns raised2
Pre-determined HTT discharge decisions before patient assessment
Failure to include the receiving MHT+ team in HTT discharge decisions
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.4
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Action
Hold twice-weekly multidisciplinary discussions with community services about patient care, including planned Home Treatment Team discharges.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Provide senior Rapid Response clinical input to interface forums for clinically considered decisions and agreed safe discharge plans.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Hold twice-weekly clinical interface meetings with local MHT and MHT+ teams to discuss specific cases and support timely community treatment planning.
Stated by Kent and Medway Mental Health NHS Trust
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Action
Revise procedures to require invitations to MHT+ colleagues, including medics, and audit forum participation quarterly for quality and patient safety.
Stated by Kent and Medway Mental Health NHS Trust
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Concerns raised1
Failure to involve Crisis or Home Treatment teams for immediate safeguarding follow-up
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Position
Doctor referral was not initially indicated because the established pathway covered admission, medication changes and other clinical complexities, with senior psychiatric doctors available continuously.
Stated by South London and Maudsley NHS Foundation Trust
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Concerns raised1
Failure to enable AMHPs to make direct referrals to the emergency Crisis Resolution and Home Treatment Team
Responses linked to these concernsEach 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.1
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Action
Develop and disseminate concise guidance to Suffolk AMHPs on CRHTT referral criteria and processes.
Stated by Suffolk County Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
AMHPs were able to refer directly to the CRHTT, and the NSFT 111 Service could also make such referrals.
Stated by Suffolk County Council
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Concerns raised1
Failure to engage the local Home Based Treatment Team before discharge
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Provide five Band 7 Out of Area Practitioners to monitor private out-of-area placements, coordinate providers and support discharge planning.
Stated by Pennine Care NHS Foundation Trust -
Action
Implement sending-provider oversight of out-of-area patients, including ward-round attendance, appropriate visits, and engagement in discharge and care planning.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Remind staff to confirm and document Community Mental Health Team engagement and follow-up arrangements before discharge.
Stated by Priory Group
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The NHS sending provider is responsible for overseeing individual care, including engagement in communication, discharge and care planning for out-of-area patients.
Stated by NHS Greater Manchester Integrated Care Board
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Position
A review of the Altrincham admission was undertaken and concluded that inpatient care was adequate and discharge was appropriate.
Stated by Priory Group -
Position
Contact with external care organisations depends on the information available and the patient's consent.
Stated by Priory Group
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Concerns raised2
Lack of a documented and robust policy for future treatment and care pathways following referral to the Home Treatment Team
Lack of a documented and robust policy for decision-making and meeting criteria for patients referred to the Home Treatment Team
Responses linked to these concernsEach 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
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Action
Progress review, consultation and ratification of the Home Treatment Team Operational Policy, incorporating the coroner’s concerns and monitored through divisional and corporate governance.
Stated by Betsi Cadwaladr University LHB -
Action
Provide an interim policy addendum addressing the concerns identified at the inquest.
Stated by Betsi Cadwaladr University LHB -
Action
Share the interim policy addendum across the Mental Health and Learning Disability Division to promote consistency across services.
Stated by Betsi Cadwaladr University LHB
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Concerns raised2
Failure to communicate withdrawal of Home Treatment Team input to domiciliary care agencies or family
Lack of multi-disciplinary team discussion to ensure a safe community plan following discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to ensure clinical readiness and rationale for discharge to community HBTT care
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to notify the intensive home-based treatment team of a patient's self-discharge
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 concernsEach 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
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Position
Mid Yorkshire Hospitals NHS Trust will provide its own response regarding the hospital’s notification of the community team after self-discharge.
Stated by South West Yorkshire Partnership Teaching NHS Foundation Trust
Data last updated 7 September 2026