First reported 12 Sep 2013•Latest report 27 May 2026
Definition
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
Distinct published reports
Individual concerns
39
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
36
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.
Department of Health and Social Care6
NHS England4
Norfolk and Suffolk NHS Foundation Trust3
North East London NHS Foundation Trust3
Birmingham and Solihull Mental Health NHS Foundation Trust2
East London NHS Foundation Trust2
NHS Birmingham and Solihull Integrated Care Board2
NHS Greater Manchester Integrated Care Board2
Oxleas NHS Foundation Trust2
Pennine Care NHS Foundation Trust2
South London and Maudsley NHS Foundation Trust2
West Midlands Police2
Betsi Cadwaladr University LHB1
Birmingham City Council1
Black Country Healthcare NHS Foundation Trust1
NHS trust27
Integrated care board6
Ministerial department6
Executive non-departmental public body4
Police force3
English county council2
Type not available2
Coronial office1
English district council1
English metropolitan district council1
Health and social care service regulator1
Independent healthcare provider1
Local health board1
Registered charity1
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.
Surrey
Concerns raised2
Discharge from the Home Treatment team on ineffective medication
Failure to provide coherent community-care planning and care-coordinator involvement at discharge
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 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
Implement SBAR in Home Treatment Team practice and update its operational policy to strengthen multidisciplinary medical-review documentation and decision-making.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
Action
Update CPA and Acute Care Services policies to require a pre-discharge CPA meeting for every homeless inpatient.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 April 2021.
East London
Concerns raised1
Failure to ensure effective referral from the ward to the community home treatment team
This report raised 1 other concern. 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
Update the HTT Service Operational Procedure to require HTT or ACAT assessment before relevant patient discharges.
Stated by TrustStated plannedThe respondent said that this action was planned when they made their response on 8 March 2021.
Action
Update the Clinical Handover of Care and Discharge Policy to improve discharge safety and referral completion.
Stated by TrustStated plannedThe respondent said that this action was planned when they made their response on 8 March 2021.
Lincolnshire
Concerns raised1
Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis
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 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.4
Action
Review Dual Diagnosis pathways across the treatment system jointly with partner organisations and commissioners.
Stated by WithYouStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.
Action
Review and revise the joint working protocol and implement a more robust referral pathway across mental health and substance misuse services.
Stated by Lincolnshire County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2020.
Action
Strengthen dual-diagnosis policies and protocols to provide an enhanced Care Programme Approach with joint substance-misuse working.
Stated by Lincolnshire Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.
Action
Review internal policies and protocols and embed care pathways with We Are With You, including discussion with commissioners about required investment.
Stated by Lincolnshire Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.
Inner South London
Concerns raised1
Referral to Crisis Resolution and Home Treatment Teams depending on officers' recognition of urgency
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 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.1
Action
Operate a 24-hour mental-health advice and support line for the public, police and ambulance service, staffed by mental-health professionals who can initiate rapid joint assessment.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
Norfolk
Concerns raised1
Failure to offer or explore home treatment
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex
Concerns raised1
Failure to appoint a Lead Practitioner when transferring patients between the CRHTT and ATS
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
Implement a transfer process for allocating Lead Practitioners and providing interim treatment, support, contact details and follow-up plans when immediate allocation is unavailable.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2019.
Action
Monitor weekly patients transferred between teams who remain without an allocated Lead Practitioner.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
There is no delay in patients receiving treatment when transferred between the CRHTT and ATS.
Stated by Sussex Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing monitoring and Duty Worker arrangements are sufficient while a Lead Practitioner is identified after transfer.
Stated by Sussex Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised1
Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community
This report raised 9 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.1
Action
Revise, approve and cascade the Home Treatment Team operational procedure to align safeguards with the Bed Management Policy.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Birmingham and Solihull
Concerns raised1
Failure to attempt timely assessment after a high-risk patient re-establishes contact
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 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
Increase Home Treatment Team workforce capacity through additional managers, practitioners, medical staff, psychologists and administrative staff.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2019.
Action
Review the Home Treatment Team operating protocol to strengthen nurse-led triage, assessment screening and escalation to consultant psychiatrists.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Care and treatment concerns are largely for provider organisations to resolve.
Stated by NHS Birmingham and Solihull Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local NHS agencies are expected to address the report’s local concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner South London
Concerns raised1
Failure of the Home Treatment Team to see referred patients
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 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
The patient was not referred to the Home Treatment Team, so the concern that he was referred but not seen is factually incorrect.
Stated by Oxleas NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner South London
Concerns raised4
Failure of the HTT to obtain a written discharge plan from the hospital
Failure to liaise with the HTT before discharge
Failure to formulate a written discharge plan identifying the responsible community HTT
Failure to identify a responsible HTT for the discharge address
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.4
Action
Review the transfer-of-care protocol to address obtaining missing information from referring or receiving services.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Disseminate the reviewed transfer-of-care protocol through the clinical effectiveness governance process.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2018.
Action
Review and relaunch the discharge policy, strengthening family involvement, care-plan circulation, service identification and written acceptance of follow-up responsibility.
Stated by Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Deliver a rolling webinar training programme highlighting discharge-planning policy, family communication, care-plan circulation and follow-up service responsibilities.
Stated by Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 12 February 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The fourth and fifth concerns relate to Oxleas Mental Health NHS Trust rather than Priory Group.
Stated by Recipient name withheldRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
