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. Exeter and Greater Devon

    AI-generated summary

    Allan Graham Joslin · 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

    Allan Graham Joslin was found deceased partially on top of a tent near the North Devon Leisure Centre, Barnstaple, on 23 May 2018, after not being seen or contacted for several days. The report states that referrals for mental health assessment were not facilitated because of his known previous violent behaviour, and that he therefore received no formal assessment or treatment before his death. Concerns included inadequate facilities and policies for safely assessing patients with complex mental health, substance dependency and potential violence-related needs.

    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 facilitate general practitioners’ referrals for formal mental health assessment and treatment

    Wider context from the report

    “The Devon Partnership NHS Trust had no adequate mental health care facility or safe room to deal with a patient who presented with complex needs including the need for mental health assessment, and drug and alcohol dependency issues, who was potentially violent. There was no policy in place to facilitate the general practitioners’ referrals and therefore Mr Joslin received no formal assessment or treatment prior to his death. This may have impacted on his ability to receive additional services and assistance with his homeless status. Although this Trust have now put policies and facilities in place to safely treat patients presenting with a history of violence, it was clear from the evidence that this is a concern and difficulty in other Trusts across the country and is not a problem unique to Devon. While working with Devon to find a solution to the problem, NHS England confirmed this was problematic for a number of Trusts regarding provision of secondary care. This is clearly a contravention of Equality legislation for those most vulnerable in society. ”

    Source location

    Allan Graham Joslin · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. South Yorkshire (Western)

    AI-generated summary

    Noah Lomax · 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

    Noah Lomax, aged 15, died on 1 August 2018 after jumping from Conisbrough Viaduct, having previously expressed suicidal intentions and made plans to take his own life. His GP referral to CAMHS was closed because it contained insufficient information for a risk assessment, and his family were not notified. The principal concern was that the referral form and process could result in inadequate information being provided and delays in care.

    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 of the CAMHS GP referral form process to capture sufficient information for timely assessment

    Wider context from the report

    “1. As I made clear during the Inquest I was concerned about the adequacy of the CAMHS, GP referral form. ████████, Noah’s GP, was inexperienced she had not completed a CAMHS referral form before. She accepted she had not provided sufficient detail in the form. This resulted in CAMHS being unable to assess Noah’s risk and declining Noah’s referral. This in turn meant that Noah did not receive an appointment with CAMHS before his death. The Trust’s investigation report stated that the evidence “suggests that the current referral form does not capture the information required to process referrals without delay.” ████████, CAMHS Clinical Lead, said that there had not been any other problems with the form with GP’s not completing them sufficiently. I am not sure how ████████ is able to be so confident about this. I was told that redesigning the form had been considered by the Trust but was told that this was not the answer. Instead, further training has been provided to GPs within the area. Guidance is attached to the form to assist GPs in completing the form. Having carefully considered the evidence I am not satisfied that steps have been put in place to ameliorate the risk identified. Given the realities of the pressures on a GP’s day expecting a GP to use their 10 minute appointment to extract sufficient information for the referral and then at some point complete a referral form, with which they may be unfamiliar, creates the risk that relevant information may not be provided. I would invite the Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided which may result in a delay in care. ”

    Source location

    Noah Lomax · 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

    Maintain updated referral guidance for use with CAMHS referrals.

    Verbatim wording from the response

    “During the inquest it was confirmed that the referral guidelines were being updated with input from a General Practitioner. This has now been completed and the guidance is now in place and being used. The current form will continue to be used alongside the new guidance in mitigation until the actions outlined below have been completed.”

    Source location

    2019-0186-Response-by-Sheffields-Childrens-NHS-Trust
    Page 1 · response
    Published 14 August 2019

    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

    Review and amend the CAMHS referral form using General Practitioner and service-user feedback.

    Verbatim wording from the response

    “The CAMHS team have commenced a review of the referral form, and a draft form was sent to the Clinical Director for Mental Health commissioning the Sheffield Clinical Commissioning Group (SCCG), for comments. This draft was reviewed by SCCG’s Clinical Reference Group, which”

    Source location

    2019-0186-Response-by-Sheffields-Childrens-NHS-Trust
    Page 1 · response
    Published 14 August 2019

    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

    Update referral guidance to support the revised CAMHS referral form.

    Verbatim wording from the response

    “consists of a number of General Practitioners and 2 service users. Comments from this group have been collated and are to inform necessary amendments to the referral form. Subsequently the current guidance will be updated to support the new referral form and this will then be distributed to all General Practitioners.”

    Source location

    2019-0186-Response-by-Sheffields-Childrens-NHS-Trust
    Page 2 · response
    Published 14 August 2019

    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

    Distribute the revised CAMHS referral form and supporting guidance to all General Practitioners by 12 July 2019.

    Verbatim wording from the response

    “consists of a number of General Practitioners and 2 service users. Comments from this group have been collated and are to inform necessary amendments to the referral form. Subsequently the current guidance will be updated to support the new referral form and this will then be distributed to all General Practitioners.”

    Source location

    2019-0186-Response-by-Sheffields-Childrens-NHS-Trust
    Page 2 · response
    Published 14 August 2019

    Open published response

  3. Warwickshire

    AI-generated summary

    Mylon Sheppard · 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

    Mylon Sheppard hanged himself at home and was found on 3 October 2018. The report identified concerns about oversight of duty workers' decisions, waiting-list management, non-attendance processes, family involvement in care planning, and the identification of GP and geographical boundaries for local mental health 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

    Failure to maintain a system clearly identifying GP and geographical boundaries for local mental health services

    Wider context from the report

    “(5) Failure to have a system in place that clearly identified GP boundaries and geographical boundaries in respect of local mental health services to minimise the risk of incorrect referrals to the wrong teams.. ”

    Source location

    Mylon Sheppard · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. West Yorkshire (Western)

    AI-generated summary

    Ursula Niamh MacEochaigh Keogh · 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

    On 22 January 2018, 11-year-old Ursula Niamh MacEochaigh Keogh left school, got off the bus early and jumped from North Bridge in Halifax; she was later found in the river and pronounced deceased. The inquest heard concerns about inconsistent advice and communication between health and education professionals regarding referral for assessment of Ursula’s self-harm, as well as preventative measures at North Bridge.

    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 CAMHS referral pathways remain operable where school psychology services are unavailable

    Wider context from the report

    “During the inquest I heard that Ursula’s mother contacted Ursula’s GP at Spring Hall Medical Centre by telephone on 13/11/17 in order to discuss her concerns about Ursula’s history of self-harm and that this resulted in her mother being advised by a GP to get Ursula’s school involved. Although the school subsequently advised Ursula’s mother to contact her GP, during the telephone conversation of 14/12/17 to further discuss Ursula’s self-harming, the GP advised her mother to contact the Psychology Team attached to the school, so that Ursula could be assessed for referral to Child & Adolescent Mental Health Team if necessary, in accord with the protocol previously issued by Calderdale CAMHS referral pathway, notwithstanding that at this time the school did not have the services of a Psychology team to make the referral. ”

    Source location

    Ursula Niamh MacEochaigh Keogh · 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

    Review the CAMHS referral pathway for GPs and schools.

    Verbatim wording from the response

    “1. To review the current practice of referral by GP to the school for consideration as to the appropriateness of referral to CAMHS.”

    Source location

    2018-0370-Response-by-Calderdale-CCG
    Page 1 · response
    Published 10 May 2019

    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

    Establish Mental Health Support Teams in and near schools and colleges through 25 trailblazer sites to provide earlier support for children and young people.

    Verbatim wording from the response

    “On 20 December 2018, the Government announced the first wave of 25 trailblazer sites that will test the plans set out in the Green Paper. These new plans will significantly increase the availability of mental health support to children and young people, including creating new Mental Health Support Teams working in and near schools and colleges to support children and young people with mild to moderate mental health conditions. Mental Health Support Teams will provide brand new”

    Source location

    2018-0370-Response-by-Department-of-Health-and-Social-Care
    Page 2 · response
    Published 10 May 2019

    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 24/7 crisis care access for children, young people and their families through NHS111 by 2023/24.

    Verbatim wording from the response

    “You may also wish to note that the Government published the first cross-Government Suicide Prevention Workplan in January 2019 which set out an ambitious programme to reduce suicides, including in children and young people⁶. Furthermore, setting up 24/7 crisis care provision for children, young people and their families is a key priority for the Government in the NHS Long Term Plan⁷, published on 7 January 2019. All children and young people experiencing crisis will be able to access crisis care 24 hours a day, seven days a week by 2023/24 via NHS111.”

    Source location

    2018-0370-Response-by-Department-of-Health-and-Social-Care
    Page 3 · response
    Published 10 May 2019

    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

    Local NHS services and local authorities are responsible for responding to the concerns and learning from deaths to improve service safety.

    Verbatim wording from the response

    “Your report raises three matters of concern and is directed to NHS Calderdale Clinical Commissioning Group (CCG) and Calderdale Council, as well as the Department of Health and Social Care. I am aware that the Calderdale CCG has responded to your concerns from a local perspective, advising you of a series of actions that are being undertaken in light of the report. We expect the local NHS to take action to respond to concerns and learn from deaths to ensure the safety of healthcare services and I am encouraged that the local NHS is looking into these matters carefully.”

    Source location

    2018-0370-Response-by-Department-of-Health-and-Social-Care
    Page 1 · response
    Published 10 May 2019

    Open published response

  5. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Sheila Graham · 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

    Sheila Graham was admitted to hospital after a fall causing a complicated ankle fracture, subsequently developed infection and clostridium difficile, and died on 13 October 2017 after an upper gastrointestinal bleed. Concerns included the effects of prolonged isolation on her mental and general wellbeing, inadequate recording and monitoring of nutrition despite weight loss, and delayed referral to mental health and dietetic 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

    Lack of a policy for referral to mental health services following prolonged social isolation

    Wider context from the report

    “(1) At the inquest it was evident that the deceased had suffered with clostridium difficile diarrhoea. It was accepted by the patient and the family that she needed to be nursed in a single room. However in her case it was for a very prolonged period. The social isolation had a very significant impact on her health and well-being and was a factor in her failure to recover. No policy appears to be in place for referral to mental health services in such circumstances. Referral in this case was prompted by the family. ”

    Source location

    Sheila Graham · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Inner North London

    AI-generated summary

    Dudley Vincent Brown · 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

    Dudley Vincent Brown had multiple health conditions and his care package was withdrawn after incidents involving threats to carers and a social worker. He was found at home in a state of reduced consciousness during a delayed mental health assessment, taken to hospital with multi-organ failure, and died on 11 January 2018. Concerns included the withdrawal of care without welfare checks, misunderstandings about referral responsibilities, and delays involving the mental health assessment and police risk 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

    Incorrect understanding of referral routes to the Approved Mental Health Practitioner Service

    Wider context from the report

    “(3) The social work team leader dealing with this case was under the impression that referrals to the Approved Mental Health Practitioner Service (AMPHS) had to be made by a GP. ”

    Source location

    Dudley Vincent Brown · 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

    Improve staff and manager fluency in routes and response expectations for general mental health and Mental Health Act assessments.

    Verbatim wording from the response

    “This is a joint response between the Council and East London Foundation Trust. We acknowledge and accept your recommendations in this case, and have worked together to address the concerns, by way of formulating and implementing a multi-agency action plan which is attached for your reference.”

    Source location

    2018-0211-Response-by-Hackney-Borough-Council
    Page 1 · response
    Published 14 August 2018

    Open published response

  7. Surrey

    AI-generated summary

    Stephen Ian William Tidey · 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

    Stephen Ian William Tidey was found deceased on 22 December 2016, having been found hanging from a tree outside the cabin where he was residing, with self-inflicted wounds to both wrists. The report raised concerns that a high-risk MASH referral, made after he lost his job, was not followed up and that there were no safeguards to ensure referrals were acted upon, including outside normal office hours.

    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 safeguards to ensure MASH referrals are followed up by the appropriate Community Mental Health Team

    Wider context from the report

    “On Friday 16th December 2016, Police were made aware that Mr Tidey had lost his job as a consequence of being charged with the offences and therefore that one of the contingent events highlighted in the MASH referral of 3.2.2016 as placing Mr Tidey at higher risk of self-harm had materialised. They therefore completed a further MASH referral form and this was emailed to the MASH hub at 15.40 and forwarded on to Waverley CMHRS at 16.41. On Monday 19th December 2016 at 11.30am, Waverley CMHRS forwarded the MASH report to Guildford CMHRS, but then emailed again at 11.36am to state they noted Waverley CMHRS should actually follow up Mr Tidey. However, for reasons, which cannot be ascertained, no further action was taken. It is not possible to ascertain who the duty worker was who received the referral by email. ████████, Community Services Manager for South West Community Mental Health Recovery Service, stated in evidence that had he received Mr Tidey’s MASH referral on 16th December 2016, he would have taken action the same day, initially via a telephone triage assessment and then via the options available of HTT referral; EDT Mental Health Act Assessment, crisis planning with safe havens or CMHRS non-crisis support, as appropriate. Evidence was given that there were no safeguards in place to check referrals were being acted upon, and that this remains the case. ”

    Source location

    Stephen Ian William Tidey · 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

    Implement a standardised log across community mental health teams for recording received SCARF forms and resulting actions.

    Verbatim wording from the response

    “2. Since Mr Tidey’s death, we have already implemented a standardised log across all of our Community Mental Health Recovery Service (CMHRS) teams, which must be used to record all of the 39/24 forms (now referred to as Single Combined Assessment of Risk Form (SCARF)) that are received by the CMHRS. The log must record the date the SCARF is received, the name to whom the SCARF relates and what action has been taken in response. I have received assurances that these logs are now being completed by the CMHRS teams.”

    Source location

    2018-0140-Response-by-Surrey-Borders-NHS-Trust
    Page 1 · response
    Published 1 July 2018

    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

    Establish a high-risk SCARF checking process requiring MASH practitioners to telephone relevant community mental health teams about receipt and urgent action.

    Verbatim wording from the response

    “3. However, we have also devised a new checking system between the MASH and the CMHRS teams. In the future, when the Trust’s practitioner within the MASH receives a SCARF form which indicates a high risk to an individual and which the practitioner considers requires urgent action by the CMHRS team, a phone call will be made by the MASH practitioner to the relevant CMHRS to check that the SCARF has been received and to notify the CMHRS that action is required urgently.”

    Source location

    2018-0140-Response-by-Surrey-Borders-NHS-Trust
    Page 1 · response
    Published 1 July 2018

    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

    A phone call for every SCARF form was not considered workable because of the volume of forms received and processed.

    Verbatim wording from the response

    “We discussed whether a phone call could be made by the Trust’s MASH practitioner to the CMHRS every time a SCARF form is sent from the MASH to the CMHRS, however due to the volume of SCARF forms received and processed this was not considered to be a workable solution.”

    Source location

    2018-0140-Response-by-Surrey-Borders-NHS-Trust
    Page 1 · response
    Published 1 July 2018

    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

    Ensuring partner agencies act on MASH referrals falls outside the existing Surrey Police and Surrey County Council agreement.

    Verbatim wording from the response

    “Once a referral is made from Surrey Police to a partner agency via the MASH there is no current means for Surrey Police to ensure it is being acted upon and this would be outside of the existing agreement between Surrey Police and Surrey County Council. A partners response to a referral is not monitored by Surrey Police and unfortunately we are unable to respond in detail to this question. Surrey Police therefore respectfully request that this question is passed onto the SABP and Adult Social Care for their response.”

    Source location

    2018-0140-Response-by-Surrey-Police
    Page 2 · response
    Published 1 July 2018

    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

    SABP and Adult Social Care are responsible for responding on whether Community Mental Health Teams follow up MASH referrals.

    Verbatim wording from the response

    “Once a referral is made from Surrey Police to a partner agency via the MASH there is no current means for Surrey Police to ensure it is being acted upon and this would be outside of the existing agreement between Surrey Police and Surrey County Council. A partners response to a referral is not monitored by Surrey Police and unfortunately we are unable to respond in detail to this question. Surrey Police therefore respectfully request that this question is passed onto the SABP and Adult Social Care for their response.”

    Source location

    2018-0140-Response-by-Surrey-Police
    Page 2 · response
    Published 1 July 2018

    Open published response

  8. London (East)

    AI-generated summary

    Maureen Anne CAMPBELL-SCOTT · 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

    Maureen Anne Campbell-Scott died from multiple injuries after falling from a ledge at the Exchange Shopping Centre car park on 16 June 2017. The report identified concerns about delays and errors in mental health referrals, delayed communication of medication changes, prescribing that did not always follow specialist directions, and a lack of joint working between mental health services and the GP practice.

    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 of mental health referral routing between teams

    Wider context from the report

    “(1) The GP had sent the referral to the wrong team of the mental health trust. The referral then got lost between the receiving team and the correct team (the older age mental health team). This resulted in a 4 month delay in Maureen Campbell-Scott receiving an assessment. ”

    Source location

    Maureen Anne CAMPBELL-SCOTT · 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

    Process every NELFT referral and redirect misrouted referrals to the correct team within two working days.

    Verbatim wording from the response

    “1b | NELFT Action | All referrals into NELFT will be processed, if the referral is sent to the wrong team NELFT will ensure the referral goes to the correct team within 2 working days. | NELFT Bob Edwards, ICD for Redbridge | 18/05/18 | Completed”

    Source location

    2018-0090-Response-by-NELFT
    Page 3 · response
    Published 16 June 2018

    Open published response

  9. Somerset

    AI-generated summary

    Edward Arthur Lundy · 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

    Edward Arthur Lundy, who had a history of depression, was found hanging in a barn on 23 August 2016 and could not be revived. The concerns identified included a lack of continuity in his care, no psychiatric assessment despite a referral indicating this was needed, and insufficient documentation and discussion of care options and risks with his family. The report also states that evidence had not been produced showing that the proposed actions had been implemented or shared nationally.

    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 clearly communicate when psychiatric assessment is believed necessary in referrals

    Wider context from the report

    “1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced. 2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings. 3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission. There has been no evidence produced as to compliance with the recommended actions. There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts. That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure. ”

    Source location

    Edward Arthur Lundy · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Cornwall and Isles of Scilly

    AI-generated summary

    Thomas Edward Curtin · 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

    Thomas Edward Curtin, who was detained under the Mental Health Act on an acute mental health ward, absconded during escorted leave and later died in hospital on 20 August 2016 from heroin intoxication. The report raised concern that private locked rehabilitation providers were not subject to a national response-time framework, potentially leaving patients on wards inappropriate for their needs while awaiting placement.

    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 national framework governing private providers’ response times to referrals for locked rehabilitation units

    Wider context from the report

    “At the hearing witnesses from the treating Mental Health Trust advised the court that Mr Curtin was identified as requiring a placement on a locked rehabilitation ward to treat the chronic nature of his illness namely of schizophrenia, with ADHD with harmful misuse of alcohol and drugs and psychoactive substances and to prevent relapse. The majority of such facilities are provided by the private sector. Evidence at inquest revealed that public entities of low and medium security facilities were subject to a National NHS England framework concerning the timing of their response to referrals for specialist units. The evidence at inquest was that private providers of “Locked Rehabilitation Units” were not subject to such a National NHS England framework. This may lead to the risk of future deaths as patients are left on a ward which is inappropriate for their needs while awaiting the private provider’s response to a referral. ”

    Source location

    Thomas Edward Curtin · 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

    Require NHS England-commissioned specialist mental health providers, public and private, to respond to referrals within specified timeframes through standardised contracts.

    Verbatim wording from the response

    “Following the inquest, you raised a concern in your Report to NHS England regarding the requirement for specialist mental health providers to respond to referrals within a given timeframe. Evidence presented at the inquest suggested that this requirement only applies to public providers of low and medium security facilities and not to private providers of ‘Locked Rehabilitation Units’.”

    Source location

    2018-0076-Response-by-NHS-England
    Page 1 · response
    Published 16 June 2018

    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

    For specialist rehabilitation services commissioned by Clinical Commissioning Groups, referral response-time requirements are determined locally by the relevant commissioning CCG.

    Verbatim wording from the response

    “Some specialist mental health services, including specialist mental health rehabilitation services, are the commissioning responsibility of local Clinical Commissioning Groups (“CCG”) and therefore are not subject to similar national frameworks requiring set response times. This enables services to be commissioned in response to local population need, local priorities and plans. As such, the contractual requirement to respond to referrals within a given time would be determined by the commissioning CCG and therefore subject to local variation.”

    Source location

    2018-0076-Response-by-NHS-England
    Page 1 · response
    Published 16 June 2018

    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