Recurring concern

Unreliable community Home Treatment Team care pathways

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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

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

    John Haines · 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

    John Haines was admitted to a mental health ward in March 2017 after his anxiety and depression deteriorated, and was discharged on 14 June 2017 with planned follow-up. He was found deceased at home on 17 June 2017 after failing to respond to contact. The report raised concerns about in-patients and Home Treatment Team patients being unable to access qualified psychological therapy, including delays in accessing Healthy Minds.

    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 access to qualified psychological therapy for patients under the care of the Home Treatment Team

    Wider context from the report

    “2. Similarly, patients cannot access a qualified Psychologist whilst under the care of the Home Treatment Team (‘HTT’) etc. The only way for patients to get access to a Psychologist is through referral to ‘Healthy Minds’. Healthy Minds cannot provide access where the patient remains under the care of the HTT etc. ”

    Source location

    John Haines · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Jamie Neil Elliott · 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

    Jamie Neil Elliott died by hanging at his home on 18 November 2016, with an inquest conclusion of suicide. Before his death, he had expressed clear, detailed and escalating suicidal ideation and had declined offered voluntary inpatient admission. Concerns included failures to contact his private therapist and to provide a face-to-face psychiatric assessment after his condition deteriorated.

    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 provide timely face-to-face psychiatric assessment after worsened-condition referral

    Wider context from the report

    “2. There should be a psychiatric assessment, by a Consultant Psychiatrist in circumstances where there is a referral to the Home Treatment Team where a patient’s condition has worsened. Ideally this should be within 48 hours and should be a face to face psychiatric assessment. ”

    Source location

    Jamie Neil Elliott · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 Consultant Psychiatrist assessment for worsened conditions referred to the Home Treatment Team

    Wider context from the report

    “2. There should be a psychiatric assessment, by a Consultant Psychiatrist in circumstances where there is a referral to the Home Treatment Team where a patient’s condition has worsened. Ideally this should be within 48 hours and should be a face to face psychiatric assessment. ”

    Source location

    Jamie Neil Elliott · Prevention of Future Deaths report
    Page 3 · 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

    Require escalation of Home Treatment referrals not seen within 48 hours to a consultant psychiatrist or team manager for prioritised review.

    Verbatim wording from the response

    “In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:”

    Source location

    2017-0135-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 10 July 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

    Provide routine doctor review within 72 hours for Home Treatment referrals without prior professional assessment, with out-of-hours emergency review by on-call psychiatry.

    Verbatim wording from the response

    “In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:”

    Source location

    2017-0135-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 10 July 2017

    Open published response

  3. East London

    AI-generated summary

    Peter Daniel Usher · 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

    Peter Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.

    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 include a Home Treatment Team member in Section 136 assessments

    Wider context from the report

    “2. The Trust policy requires that the assessment should be carried out by the duty doctor and member of the Home Treatment Team. The policy also requires that the doctor must inform the on-call doctor of the arrival and discuss the outcome of the assessment with them. The Home Treatment Team member was not present during the course of the assessment. He was gathering relevant clinical information from a previous Section 136 attendance. The information appears to have been requested shortly after 03:00 and not received until around 04:47. This was partly due to safe haven procedures which had to be complied with before a fax could be sent. The Home Treatment team member attended as the assessment was wrapping up. The on-call doctor was not informed of Mr Usher. ”

    Source location

    Peter Daniel Usher · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. South Yorkshire (Eastern)

    AI-generated summary

    John Atkinson · 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

    John Atkinson received psychiatric services after contacting the Mental Health Team in crisis in July 2014 and died by suicide by hanging. The report identified concerns about outdated risk assessments, failures to recognise changing presentation and risk, inadequate arrangements when staff left, poor communication, and difficulty accessing Home Treatment Team services.

    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

    Difficulty in consultant psychiatrists accessing Home Treatment Team Services when needed

    Wider context from the report

    “(5) Difficulty in consultant psychiatrists accessing Home Treatment Team Services when they considered a need (since a change in emphasis in interpreting the guidelines from the end of 2014). ”

    Source location

    John Atkinson · Prevention of Future Deaths report
    Page 1 · 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

    Audit Home Treatment Team access through criteria review, prospective review and a referrer accessibility survey.

    Verbatim wording from the response

    “The Trust has reviewed the Home Treatment Team criteria and undertaking a prospective audit in January 2017 to ascertain if any teams perceive a difficulty accessing home treatment. A survey of all referrers to ascertain views on accessibility will be undertaken using a SurveyMonkey® audit. A group of consultant psychiatrists and the Rotherham Associate Nurse Director have been tasked with undertaking this review. As far as we are aware there has been no change of emphasis in the guidance for access to home treatment therefore we are identifying if there is a cultural or perception aspect to this concern. I have attached the current guidance in Appendix B.”

    Source location

    2016-0429-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
    Page 6 · response
    Published 12 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 Trust found no change in home-treatment guidance and is assessing whether reported access difficulties reflect cultural or perceptual factors.

    Verbatim wording from the response

    “The Trust has reviewed the Home Treatment Team criteria and undertaking a prospective audit in January 2017 to ascertain if any teams perceive a difficulty accessing home treatment. A survey of all referrers to ascertain views on accessibility will be undertaken using a SurveyMonkey® audit. A group of consultant psychiatrists and the Rotherham Associate Nurse Director have been tasked with undertaking this review. As far as we are aware there has been no change of emphasis in the guidance for access to home treatment therefore we are identifying if there is a cultural or perception aspect to this concern. I have attached the current guidance in Appendix B.”

    Source location

    2016-0429-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
    Page 6 · response
    Published 12 February 2017

    Open published response

  5. Cornwall and Isles of Scilly

    AI-generated summary

    David Knight · 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

    David Knight, who was detained under the Mental Health Act for chronic mental health issues, died on 23 May 2015 after walking onto a railway track in front of an oncoming train while on Section 17 leave. Concerns included a limited risk assessment before leave, no notification to local community and home treatment teams, and the difficulties associated with his out-of-county placement, including reduced family involvement and communication challenges.

    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 notify local community and home treatment teams of S17 leave

    Wider context from the report

    “S17 leave is prescribed by the Responsible Medical Officer as part of the treatment to the hospitalised patient in order facilitate them re-integrating back into the community in a structured, safe and supported way. Typically this would start off with escorted leave in the grounds of the hospital and hospital locality, moving to unescorted leave and then to home leave. Latterly the community mental health services and Home Treatment Team are involved to ensure a smooth transition of the patient back to community living. When Mr Knight's mental health deteriorated whilst on leave, there were concerns that a limited risk assessment was carried out by Cygnet Hospital prior to S17 leave on 21st May 2015 and there was no communication with the local community mental health team and Home Treatment Team in Cornwall notifying them of the leave. This meant that when Mr Knight's mental health deteriorated while on leave, there was no method of reducing the risk of self-harm or harm to others, as no mitigation plan had been put in place in advance of the leave and the Cornwall Community Mental Health Team and the Home Treatment Team were unaware he was on S17 leave in their area. The expert psychiatrists considered that although misjudgement about leave could occur in any hospital setting, the fact that Mr Knight was being treated out of County would have increased the risk of poor communication with the community treatment teams as the hospital would not be familiar with local service and it was very likely that this had a bearing on Mr Knight's death (████████). ”

    Source location

    David Knight · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Cornwall and Isles of Scilly

    AI-generated summary

    Simon Jonathon Klemberg · 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

    Simon Jonathon Klemberg died in the early hours of 7 June 2015 following a reckless and impulsive overdose of prescription medication taken to address acute head pain, possibly related to his psychological condition. He had serious mental health problems, and individual psychological therapy recommended in February 2015 was delayed and never commenced. The report raised concerns about psychiatric bed availability, resources and thresholds for the home treatment team, and the prioritisation of high-risk patients awaiting psychological therapy.

    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 ensure an appropriate threshold for offering home treatment support

    Wider context from the report

    “(2) To review the allocation of resources to the home treatment team, with particular reference to the threshold for offering support. Both Kernow Clinical Commissioning group (KCCG) and Cornwall Partnership NHS Foundation Trust (CFT) to respond ”

    Source location

    Simon Jonathon Klemberg · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    Roseanne Cooke · 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

    Roseanne Cooke experienced a marked deterioration in her mental health, including suicidal thoughts, and was found having taken her own life at her mother’s home on 1 May 2014. The report identified concerns about unavailable inpatient psychological input, confusion and delays regarding psychological-service referrals, the absence of the Recovery Team from a discharge-planning meeting, and inadequate communication of the family’s concerns about her safety.

    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 communicate the full extent of family-reported suicide-related concerns to the Recovery Team

    Wider context from the report

    “On the 28th April, the deceased’s family contacted the Home Treatment Team out of hours numbers available to them as they had concerns about the deceased being in the house on her own the following day as she was having suicidal thoughts. Their understanding of the request was that someone from the Recovery Team would visit her the following day. The message passed to the Recovery Team was simply to make contact with the deceased, which was done over the phone. The extent of the concerns raised by the family was not communicated to the Recovery Team. ”

    Source location

    Roseanne Cooke · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Worcestershire

    AI-generated summary

    Sean Christopher Seabourne · 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

    Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.

    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 define and communicate mental health teams' roles and responsibilities for onward care

    Wider context from the report

    “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests. (2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient. (3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team. It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself. It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself. Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case. ”

    Source location

    Sean Christopher Seabourne · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Norfolk

    AI-generated summary

    Matthew Christopher Dunham · 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 Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.

    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 of team referral roles and interfaces

    Wider context from the report

    “b) There appears not to have been a clear shared understanding between professionals as to which team it was appropriate to refer Mr Dunham too. There was some lack of understanding revealed as to whether a referral to the assessment team or the crisis resolution and home treatment team was appropriate. This highlights the need for there to be a clear understanding about the roles of each team and the interface between them. ”

    Source location

    Matthew Christopher Dunham · 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

    Base a Crisis Resolution and Home Treatment team member within the Access and Assessment Team to support prompt joint working and care transitions.

    Verbatim wording from the response

    “To enhance the interface between the two clinical teams, Access and Assessment Team (AAT) and CRHT, a member of the CRHT is now based within the AAT. This enables joint working without any delay, supporting transition of care between the two teams. The Trust is monitoring its effectiveness in identifying people in need of this crisis support.”

    Source location

    Response
    Page 2 · response
    Published 26 January 2014

    Open published response
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Data last updated 7 September 2026