Recurring concern
Unreliable mental health referral pathways
- 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 110 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Uncertainty among prison staff about the urgent weekend TAG referral pathway
This report raised 17 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Practice Plus Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Practice Plus Group
Display posters explaining electronic and out-of-hours TAG referral pathways throughout the prison and disseminate the notice to prison staff by global email.
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Practice Plus Group
Add urgent mental health referral routes, service hours and escalation contact details to mental health team email signatures.
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Practice Plus Group
Provide and operate an answerphone for urgent referrals when staff lack immediate computer access, with messages logged and forwarded by the administration team.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Practice Plus Group
Specific operational queries about mental health provision at HMP Hewell should be directed to Midlands Partnership NHS Foundation Trust.
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Concerns raised1
Lack of clear guidance on when GPs should directly refer patients to the crisis team
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- NHS England
- NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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NHS Greater Manchester Integrated Care Board
Operate telephone triage with safety netting and same-day face-to-face appointments for patients reporting mental health concerns.
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NHS Greater Manchester Integrated Care Board
Circulate mental-health referral-options information to Stockport GP practices and distribute it to patients.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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NHS England
Local mental health services and crisis-referral guidance are commissioned and addressed locally by the CCG, which is best placed to respond.
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NHS Greater Manchester Integrated Care Board
Existing triage and safety-netting processes adequately manage telephone mental-health presentations, including same-day assessment and referral information.
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Concerns raised1
Failure to re-refer patients to secondary mental health services when mental health concerns arise
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to assign responsibility for risk management and crisis referral
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sussex Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Sussex Partnership NHS Foundation Trust
Review daily-meeting documentation and audit clinical records to verify recording of identified risk, actions and responsible staff.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Sussex Partnership NHS Foundation Trust
Ongoing audits of red-zone risk recording and crisis referral arrangements were considered sufficient, so no additional action was required.
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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.
Linked response
- Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Trust
Update the HTT Service Operational Procedure to require HTT or ACAT assessment before relevant patient discharges.
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Trust
Update the Clinical Handover of Care and Discharge Policy to improve discharge safety and referral completion.
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Concerns raised1
Failure to use the approved referral form for psychiatric referrals to MPFT
Linked responses
- East Staffordshire Clinical Commissioning Group
- NHS Staffordshire and Stoke-on-Trent Integrated Care Board
- North Staffordshire Clinical Commissioning Group
- Stoke-on-Trent Clinical Commissioning Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning Group
Link the Midlands Partnership Foundation Trust and DQS teams to ensure the latest referral form is uploaded to practice clinical systems.
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East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning Group
Upload the correct Midlands Partnership Foundation Trust referral form to all GP practice clinical systems and remove previous versions.
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East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning Group
Confirm to the CCGs that the correct referral form is available to all GP practices and the old version has been removed.
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East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning Group
Produce and email all GP practices a standard operating procedure for removing old referral forms and managing updated versions.
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East Staffordshire Clinical Commissioning Group and NHS Staffordshire and Stoke-on-Trent Integrated Care Board and North Staffordshire Clinical Commissioning Group and Stoke-on-Trent Clinical Commissioning Group
Develop a governance-approved process across Primary Care, Commissioning and DQS for managing and appropriately updating referral forms.
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Concerns raised1
Failure to ensure that referrals to mental health services are received and traceable
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Greater Manchester Police
- North West Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Greater Manchester Police
Participate in planning and developing future Clinical Assessment Service phases, including consideration of a GMP referral pathway.
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North West Ambulance Service NHS Trust
Operate the Greater Manchester Clinical Assessment Service referral pathway, including NWAS identification and clinical review of eligible Category 3 and 4 mental health incidents.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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North West Ambulance Service NHS Trust
COVID-19 response demands and changing mental health services prevented organisations from fully operationalising the pan-Greater Manchester protocol at that time.
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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.
Linked response
- South London and Maudsley NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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South London and Maudsley NHS Foundation Trust
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.
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Concerns raised1
Failure to refer to Wellbeing Services
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to contact relevant medical or mental health services about identified concerns
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026