Recurring concern

Unreliable mental health referral pathways

First to latest report 4 Sep 2013 — 25 Jun 2026

Reports that mention this concern
110
Times this concern has been raised
136
Stated actions linked to this concern
173

What this concern includes

Includes failures of mental health referral pathways, including identifying when referral is indicated, selecting the correct route, accepting direct referrals, making or re-making referrals, receiving and actioning referrals, and providing clear urgency or follow-up arrangements.

What is not included
  • Excludes failures limited to assessment or treatment after a mental health referral has been successfully received and actioned.
  • Excludes generic social-care, occupational-health or other specialist referrals unless the report explicitly concerns the mental health referral pathway.
  • Excludes generic communication, training or documentation deficiencies that are not directly tied to making, receiving, processing or following up a mental health referral.
  • Excludes urgent mental-health referral and assessment delays where the existing dedicated urgent mental-health pathway concern is the more specific supported boundary.

Reports and published responses 110 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Haydar Jefferies · 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

    Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.

    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 verify completion of requested mental health referrals

    Wider context from the report

    “4. There is no system in place to check that referrals to the mental health teams requested by senior members of the prison staff have in fact been made. ”

    Source location

    Haydar Jefferies · Prevention of Future Deaths report
    Page 5 · 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

    Operate quarterly audited contract-management processes to review and monitor emergency and urgent referrals, reporting urgent issues through Datix for immediate action.

    Verbatim wording from the response

    “Contract Management Processes are in place to ensure that emergency and urgent referrals are reviewed and monitored regularly. This is a quarterly process which is audited and recorded. With regards to any urgent issues identified, these are reported via Datix (a digital system for reporting incidents and risks used to support risk mitigation and regulatory compliance) and acted upon immediately.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 27 December 2024

    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

    Require mental health teams to log all referrals on SystmOne.

    Verbatim wording from the response

    “NHS England’s national health and justice team has also engaged with colleagues from the South East region on the concerns raised in your Report. For improvements to be made, a notice will be issued to healthcare staff that they should record a case note when they ask prisoners if they are having thoughts of self-harm, and they will be advised that negative responses should also be recorded. Good order and discipline reviews will now include questions around prisoners’ thoughts on self-harm and responses will be recorded, and mental health teams will log all referrals on SystmOne. A new template form for mental health referrals is also being designed, which will include prompts to include key information to aid triage and details on what to do with the referral. HMP Coldingley’s Governor will ensure that the new template is circulated to all operational staff.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 27 December 2024

    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

    Redesign and digitise the mental health referral process, requiring documentation of senior referral requests and assigned completion responsibility.

    Verbatim wording from the response

    “Your final concerns relate to prison staff’s awareness of mental health, including making referrals to the mental health team and recognising when a prisoner’s mental health is declining. Following Mr Jefferies’ death, the mental health referral process was reviewed and the referral form was redesigned to simplify the process. The form is now available electronically so that staff can easily access it when needed, and when a referral has been requested by a senior member of staff they must document that this request has been made and record the name of the staff member tasked with completing the referral. Through improved multi-disciplinary working, there are more opportunities to check that referrals to the mental health team have been completed and received by the mental health team.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 27 December 2024

    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

    Limited referral information is acceptable because early referral enables the mental health team to make urgent further enquiries.

    Verbatim wording from the response

    “The prison is committed to ensuring mental health concerns are referred to the mental health team as early as possible. This may mean on occasion that the information is slightly more limited than the mental health team would like in order to gain a comprehensive understanding of the issues, but this at least puts the mental health team in a position to make further enquiries and bring their expertise to the assessment urgently.”

    Source location

    Response from Government Legal Department
    Page 1 · response
    Published 27 December 2024

    Open published response

  2. West Sussex, Brighton and Hove

    AI-generated summary

    Matthew Zak Sheldrick (Matty) · 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 Zak Sheldrick (Matty), who identified as non-binary, had a history of mental health difficulties and was admitted to A&E in crisis on 3 November 2022 after a previous 26-day wait for a psychiatric bed. After being assessed under the Mental Health Act and not detained, Matty left hospital and was found hanging in the hospital grounds. Concerns included shortages and long waits for mental health beds, the unsuitability of A&E for neurodivergent patients, gaps in services and discharge planning, and shortcomings in the mental health assessment.

    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

    Delays in referral to the Assessment and Treatment Service

    Wider context from the report

    “5. There is a significant wait time for referral to the Assessment and Treatment Service. Therefore, any therapeutic input is delayed, and this results in repetitive attendances at A&E when in crisis. ”

    Source location

    Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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

    NHS Sussex ICB is the responsible commissioner for the relevant local services, with the Trust responsible for its action plan.

    Verbatim wording from the response

    “NHS England’s South East regional colleagues have also engaged with NHS Sussex ICB, the responsible commissioner for the services described, on the concerns raised. We are advised that they have identified actions which include the provision of leaflets to patients and carers explaining delays in access to mental health beds, with information and signposting to support lines and apps. There are also now arrangements in place to support escalation and clinical discussion of patient flow and referral reviews. The ICB have requested an update from the Trust on their action plan, following Matty’s death.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 19 December 2024

    Open published response

  3. South Yorkshire (Western)

    AI-generated summary

    Bryan Andrews and Mary Andrews · 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

    Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.

    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

    Delays in triaging and progressing referrals for mental health care

    Wider context from the report

    “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths. This led to significant time lapses in treatment and rejection of referrals, most notably: i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service. ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines. iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this. iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist. v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed. vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out. vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team. viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened. ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner. x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral. The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion. ”

    Source location

    Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
    Page 2 · 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

    Inappropriate rejection of referrals despite evidence of psychosis

    Wider context from the report

    “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths. This led to significant time lapses in treatment and rejection of referrals, most notably: i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service. ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines. iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this. iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist. v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed. vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out. vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team. viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened. ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner. x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral. The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion. ”

    Source location

    Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. West Sussex, Brighton and Hove

    AI-generated summary

    Ryan Louis Ouslem · 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

    Ryan Louis Ouslem was found deceased at home on 1 August 2022 after previously posting a Facebook message that raised concerns for his welfare and indicated that his flat was unsafe to enter. The report raises concerns about police mental-health training and assessment, the sharing of relevant information between police and mental-health services, and the lack of joint training under new working arrangements.

    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 police officers understand mental health issues and referral information requirements

    Wider context from the report

    “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner. An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training. I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police. SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service. I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide. Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask. ”

    Source location

    Ryan Louis Ouslem · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Joint training with SPFT is not considered workable because its cost and logistical requirements are disproportionate at this stage.

    Verbatim wording from the response

    “We have carefully considered whether joint training with SPFT could provide anything additional which could assist officers when referring matters and providing information to them, however we do not believe it is workable step and the cost and logistics of doing so would not be proportionate at this stage.”

    Source location

    Response from Sussex Police 2
    Page 3 · response
    Published 25 September 2024

    Open published response

  5. Manchester South

    AI-generated summary

    David Paul Power · 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 Paul Power, aged 28, intentionally took his own life by hanging on 7 August 2023 after a decline in his mental health. The report found that his deterioration was exacerbated by a letter incorrectly discharging him from a neighbourhood mental health team. Concerns included differing definitions of “stability” between services, which prevented access to talking therapies, and a lack of evidence that subsequent team actions had been embedded or audited.

    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

    Exclusion of referrals from talking therapies based on a stability policy

    Wider context from the report

    “1. I am concerned that the Home Treatment Team referred David to a service to receive psychological/ talking therapies. This was a team called Healthy Minds. This referral took place when the HTT discharged David as they considered him to be sufficiently ‘stable’ under their HTT definitions. 2. However, David was not accepted for by Healthy Minds because they had a policy that they would not accept referrals for individuals who they did not consider to be sufficiently ‘stable’ under their Healthy Minds policies. 3. One of the criteria for stability was that the individual should not have attempted suicide or serious self-harm for 3 months. This was not known to the HTT at the time they made the referral. The effect of this policy meant that David was not accepted for this service, despite him making clear to services that talking therapies was what he needed most to support his mental health. 4. I heard evidence that this policy remains in place within NHS Talking Therapies (the successor to Healthy Minds), but is currently under review. I did not hear any evidence as to if or when it will change. 5. I am concerned that the lack of shared understanding and definition of ‘stability’ for patients along the talking therapies pathway creates a risk of future deaths. ”

    Source location

    David Paul Power · 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 shared definitions of stability across the talking therapies pathway

    Wider context from the report

    “1. I am concerned that the Home Treatment Team referred David to a service to receive psychological/ talking therapies. This was a team called Healthy Minds. This referral took place when the HTT discharged David as they considered him to be sufficiently ‘stable’ under their HTT definitions. 2. However, David was not accepted for by Healthy Minds because they had a policy that they would not accept referrals for individuals who they did not consider to be sufficiently ‘stable’ under their Healthy Minds policies. 3. One of the criteria for stability was that the individual should not have attempted suicide or serious self-harm for 3 months. This was not known to the HTT at the time they made the referral. The effect of this policy meant that David was not accepted for this service, despite him making clear to services that talking therapies was what he needed most to support his mental health. 4. I heard evidence that this policy remains in place within NHS Talking Therapies (the successor to Healthy Minds), but is currently under review. I did not hear any evidence as to if or when it will change. 5. I am concerned that the lack of shared understanding and definition of ‘stability’ for patients along the talking therapies pathway creates a risk of future deaths. ”

    Source location

    David Paul Power · 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

    Remove recent statutory mental-health contact and recent failed-suicide-attempt criteria from NHS Talking Therapies referral screening.

    Verbatim wording from the response

    “The Trust has ensured that our lead for NHS TT has reviewed the SOP and the following clauses (‘Recent contact (less than 3 months) with other statutory mental health services’ and ‘Recent history of failed suicide attempt (less than 3 months)’) have been removed and will no longer be part of the screening as to whether a referral will be accepted or declined.”

    Source location

    Response from Pennine Care Trust
    Page 2 · response
    Published 18 September 2024

    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

    Screen referrals for engagement and safety, assess current stability, and monitor referral decisions through practitioner rationales and managerial checks.

    Verbatim wording from the response

    “The NHS TT Step 2 & 3 is part of primary care, with a focus on needs-led care. The Standard Operating Procedure (SOP) will continue to outline the position that any current and significant self-harm will remain an obstacle to engaging in current therapy but will provide clarification that individuals will be assessed based on current stability, not past conditions, ensuring a streamlined process. Referrals will assess the patient's ability to engage and ensure their safety before admission onto the waiting list for therapy. NHS TT will refer to the appropriate service if their service does not meet an individual’s needs and this will be monitored and checked by the NHS TT Leads and Service Manager via clear rationale that has been provided by the practitioner who has screened the referral.”

    Source location

    Response from Pennine Care Trust
    Page 2 · response
    Published 18 September 2024

    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

    Finalize, discuss and share the NHS Talking Therapies operating procedure with relevant teams.

    Verbatim wording from the response

    “The draft SOP to outline the PCFT’s NHS TT Service and how they operate, is awaiting final review by the Trust’s Quality Group scheduled to take place on 22 November 2024. It will also be taken to the Psychotherapeutic Committee for discussion and then shared with relevant teams.”

    Source location

    Response from Pennine Care Trust
    Page 2 · response
    Published 18 September 2024

    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 NHS Talking Therapies training to Living Well, Home Treatment Team and emergency liaison colleagues on the revised service procedure.

    Verbatim wording from the response

    “The Trust’s NHS TT Teams will provide training to Living Well, HTT and our A&E Liaison colleagues to increase knowledge of how the TT services work in line with the new service SOP, this will foster and develop a much clearer shared understanding of the phrase ‘stable’.”

    Source location

    Response from Pennine Care Trust
    Page 3 · response
    Published 18 September 2024

    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

    Hold Living Well staff reflection and learning sessions on language, stability terminology and person-centred care.

    Verbatim wording from the response

    “The Trust recognises that these terms used do not reflect or align with person centred care approach, nor are these helpful to our service users, or their carers, particularly when understanding a service users’ care journey and why decisions were made. As a Trust we are taking action to support practitioners to change this aspect of describing a person’s current condition. The Living Well services, will be holding reflection and learning sessions for our staff in relation to language, with particular focus on these terms and what they mean and how their use impacts providing person-centred care. These will take place from end of January 2025 onwards.”

    Source location

    Response from Pennine Care Trust
    Page 3 · response
    Published 18 September 2024

    Open published response

  6. Surrey

    AI-generated summary

    Helen Jane Kerr · 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

    Helen Jane Kerr had a history of drug and alcohol abuse, developed psychosis, and died by hanging after being found dead at a refuge on 3 April 2023. The report identified concerns about failures to respond appropriately and promptly to information about her deteriorating mental health, inadequate assessment and treatment, limited out-of-hours information sharing, and failure to inform the refuge about risks associated with her presentation.

    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 appropriately assess declining mental health information and provide timely mental health referrals

    Wider context from the report

    “(1) Cogent information about Ms Kerr’s declining mental health was provided repeatedly to Surrey and Borders Partnership secondary mental health teams from the refuge support workers. It was not explored with them, and insufficient weight was given to it during the triage process. Ms Kerr was not provided with appropriate and timely referrals for mental health treatment. Despite the evident significant changes are being put in place the efficacy of these changes has not yet been evidenced. ”

    Source location

    Helen Jane Kerr · 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 senior oversight of Single Point of Access triage and recording of referrer collateral information.

    Verbatim wording from the response

    “In the PFD report, you highlighted that a considerable amount of evidence has been provided by the Trust of the changes around prescribing referrals into our services. In particular, the PFD report notes that referrals into the Single Point of Access (“SPA”) can now be made by voluntary agencies and new protocols require more senior oversight of triaging decisions and recording of collateral information from referrers.”

    Source location

    Response from Surrey and Borders Partnership
    Page 1 · response
    Published 18 September 2024

    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

    Use revised SBAR documentation to include carer and family views in decision-making.

    Verbatim wording from the response

    “In addition to the above improvements, the Trust website was updated to provide detail to external professionals on the different routes for emergency, urgent and routine referrals. There is now greater collaboration with family and referrers, supported by changes to the SBAR (a structured tool for communicating and sharing information which requires recording of the Situation, Background, Assessment and Recommendation) to now include carer/family views which are factored into decision making.”

    Source location

    Response from Surrey and Borders Partnership
    Page 1 · response
    Published 18 September 2024

    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

    Test new Single Point of Access procedures and apply quality-control review to assess consistent implementation and identify service improvements.

    Verbatim wording from the response

    “The implementation of the new SPA procedures is currently subject to testing in line with our quality improvement approach. The aim of this is to provide assurance that the new processes are applied consistently and are embedded. We have introduced a quality control process within SPA and the ongoing testing and review will allow us to identify other ways in which the service can be optimised. As part of this work, we are taking additional steps to enhance the out of hours offer.”

    Source location

    Response from Surrey and Borders Partnership
    Page 1 · response
    Published 18 September 2024

    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

    Deliver training across i-access services on recognising psychosis and making timely mental-health referrals.

    Verbatim wording from the response

    “Further learning is reflected in the production of training which has been developed and rolled out across our i-access services. This focuses on recognising signs and symptoms of psychosis and the importance of a timely referral to mental health services for assessment. To date, 86% of relevant staff have viewed this training and it is planned that the remaining staff (who have been unable to do so due to absence from work) will have viewed this by 15 November 2024.”

    Source location

    Response from Surrey and Borders Partnership
    Page 2 · response
    Published 18 September 2024

    Open published response

  7. Oxfordshire

    AI-generated summary

    Caroline Diane Harris · 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

    Caroline Diane Harris, who had a long-standing diagnosis of severe mental illness, was found deceased at home on 26 July 2023, and a medical cause of death could not be ascertained because of decomposition. Information about her declining mental health, refusal of medication and concerns raised by police was not shared with the Adult Mental Health Team, which limited its ability to supervise and follow her up. The principal concern was that important information was not shared between agencies and that appropriate interventions may consequently not have been made.

    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

    Inability of Adult Social Care to directly refer to AMHT

    Wider context from the report

    “In March 2023, Thames Valley Police passed on a report about Caroline to the Mult-Agency Safeguarding Hub (MASH) which raised concerns about her behaviour and mental state and dishevelled appearance. The report stated that it was, ‘Shared in the interests of safeguarding as may be having relapse’. MASH undertook a review of the report and concluded that Caroline was not at risk but may have needs for care and support from the local authority. The information was passed to the Council’s Adult Social Care Team who in turn passed the information onto Caroline’s GP. Evidence was given that the Adult Social Care Team were unable to directly refer to AMHT, even if they had considered it necessary. As the GP was not made aware that Caroline had declined to attend the clinic to receive her medication, she saw no need to refer the Police report to AMHT. Evidence was given AMHT took a different view regarding the Police report and would have viewed the report as evidence of Caroline relapsing. AMHT’s view was that such a report met the criteria for being shared with them, with their knowledge of Caroline’s past history of self-neglect and non-compliance with taking medication, it ought to have been shared with them; and had it been done so it would have been followed up assertively and urgently including undertaking home visits and the possible use of compulsory powers under the Mental Health Act. My concern is that important information regarding a deterioration in mental health was not shared with the appropriate Team who may have been able make appropriate interventions and to have taken steps to avoid a fatal outcome. You should consider a review of how such information is assessed and shared between the respective agencies. ”

    Source location

    Caroline Diane Harris · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Essex

    AI-generated summary

    Aaron James DEELEY · 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

    Aaron James Deeley died after deliberately exiting a defective second-floor hospital window on 14 January 2022, sustaining multiple traumatic injuries. The report identified concerns about safeguarding and the removal of 1:1 observation, as well as gaps and confusion in arrangements for patients awaiting a Mental Health Act assessment while receiving physical healthcare.

    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 a joint protocol for working between the two Trusts on Mental Health Act assessment referrals

    Wider context from the report

    “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours. a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team. b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act. c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm. d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm. e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley. f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations. There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety. ”

    Source location

    Aaron James DEELEY · 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

    Develop a joint EPUT–MSE working protocol defining responsibilities for patients awaiting Mental Health Act assessment.

    Verbatim wording from the response

    “As set out in evidence by EPUT during the course of this Inquest; a patient is placed on a section 5(2) MHA by the Acute Trust, there is a requirement for the mental health liaison team at EPUT to be informed to ensure that appropriate mental health support is in place.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 26 June 2024

    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

    Develop a joint protocol with EPUT covering assessment sequencing, referral expectations, and staff roles and responsibilities.

    Verbatim wording from the response

    “The joint working group will meet for the first time on 23 September 2024, and senior colleagues will set out terms of reference including the sequencing of assessments for patients with both a mental and physical health need; a written service level agreement so that staff are clear on when to ask for support, and when to expect it; a document setting out clear roles and responsibilities for staff at both trusts.”

    Source location

    Response from Mid and South Essex NHS
    Page 3 · response
    Published 26 June 2024

    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

    Mental Health Liaison Team provision is commissioned by the ICB under contract with EPUT, requiring those bodies' involvement in service arrangements.

    Verbatim wording from the response

    “We have listened to this concern, and we feel this is a key topic for us to take forward with EPUT in our future working arrangements. As you will be aware, the MHLT service is commissioned by our local Integrated Care Board (ICB), and there exists a contractual arrangement between the ICB and Essex Partnership University Trust (EPUT).”

    Source location

    Response from Mid and South Essex NHS
    Page 3 · response
    Published 26 June 2024

    Open published response

  9. Cornwall and Isles of Scilly

    AI-generated summary

    Sally Poynton · 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

    Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.

    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 distinguish GP requests for advice from referrals

    Wider context from the report

    “2) Community Mental Health Team i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain. I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly. ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice. iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances. iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge. I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above. ”

    Source location

    Sally Poynton · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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

    No further difficulties need to be overcome in the referral pathway into secondary mental health services.

    Verbatim wording from the response

    “• In terms of its function as a referral pathway I do not believe that there are any difficulties which need to be overcome.”

    Source location

    Response from Cornwall Council
    Page 2 · response
    Published 20 May 2024

    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 Integrated Care Board is expected to respond to concerns about the specific care provided.

    Verbatim wording from the response

    “I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.”

    Source location

    2024-0267 Response from Department of Health and Social Care
    Page 1 · response
    Published 20 May 2024

    Open published response

  10. East Sussex

    AI-generated summary

    Jason PULMAN · 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

    Jason Pulman, aged 15, was found dead on 19 April 2022 and the inquest concluded that he died by suicide, by hanging. Evidence indicated that he had not received specialist gender dysphoria treatment while waiting for GIDS and was awaiting further CAMHS assessment. The principal concern was that unclear referral mechanisms and inadequate resources for mental health support during waits for gender services could lead to similar circumstances recurring.

    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 refer young people awaiting gender services for specialist psychiatric support from CAMHS

    Wider context from the report

    “1. I heard evidence at the inquest that Jason did not receive specialist gender dysphoria treatment because he was on the waiting list for the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Trust. There was also evidence that clinicians did not refer Jason for specialist psychiatric support from Child and Adolescent Mental Health Services (CAMHS) in part because the guidance at the time suggested any specialist gender dysphoria treatment should be provided by GIDS. Jason was awaiting a further assessment from CAMHS at the time of his death. ”

    Source location

    Jason PULMAN · 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

    Send referral information for consenting patients to their local children and young people’s mental-health providers.

    Verbatim wording from the response

    “From April 2024 NHSE have established a process whereby all children and young people who are on the waiting list for CYP gender services are contacted by the CSU on behalf of NHSE and offered an assessment by their local NHS Mental Health Services; NHS England has put additional funding into local mental health systems for this purpose. All children and young people who are identified with mental health needs will receive ongoing support from their local services while they remain on the waiting list for CYP gender services. More than a third of patients on the waiting list have consented to be seen by their local mental health service. For consented patients, the CSU will be sending referral information to each CYP MH provider starting towards the end of June 2024. The website was updated in April 2024 to reflect this new supportive offer.”

    Source location

    Response from Arden and Greater East Midlands NHS Commissioning Support Unit
    Page 2 · response
    Published 9 May 2024

    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

    Decide whether to require all Children and Young People’s Gender Service referrals to come through NHS secondary care after public consultation.

    Verbatim wording from the response

    “• Additionally, in order to ensure that a child / young person’s mental and physical health needs are addressed at the point of referral to the CYP gender service NHS England has proposed that in the future all referrals to the Children and Young People’s Gender Service must be made through NHS secondary care services – mental health services or general paediatric services. This new arrangement will ensure that concomitant health needs are addressed by secondary care clinicians while the child or young person is waiting to be assessed by the specialist CYP gender service. NHS England will make a final decision on this proposal in June 2024 following a public consultation on the proposal.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 9 May 2024

    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

    Decide whether to strengthen pre-referral relationships between gender services and local secondary-care services after public consultation.

    Verbatim wording from the response

    “• During the same public consultation, we proposed an enhanced relationship between the Children and Young People’s Gender Service and local secondary care services at the pre-referral stage, so that there is a coordinated approach across the health system in the care of vulnerable children and young people,”

    Source location

    Response from NHS England
    Page 3 · response
    Published 9 May 2024

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026