First reported 4 Sep 2013•Latest report 25 Jun 2026
Definition
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.
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
110
Distinct published reports
Individual concerns
136
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
173
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care19
NHS England15
HM Prison and Probation Service6
NHS Greater Manchester Integrated Care Board6
North East London NHS Foundation Trust5
Greater Manchester Mental Health NHS Foundation Trust4
Pennine Care NHS Foundation Trust4
Surrey and Borders Partnership NHS Foundation Trust4
College of Policing3
Department for Education3
Essex Partnership University NHS Foundation Trust3
Ministry of Justice3
Norfolk and Suffolk NHS Foundation Trust3
North London NHS Foundation Trust3
Nottinghamshire Healthcare NHS Foundation Trust3
NHS trust66
Ministerial department24
Executive non-departmental public body16
Healthcare site15
Integrated care board15
Police force10
Executive agency6
English county council5
Private limited company5
Local health board4
Multi-service care provider4
English unitary authority3
London borough council3
National policing body3
Prison or young offender institution3
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Devon, Plymouth and Torbay
Concerns raised1
Failure to consider referral to secondary or tertiary mental health services
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review records, clinical actions, and processes for supporting, referring, and liaising about high-risk patients with mental health teams.
Stated by The Foxhayes SurgeryStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Initial presentations involving difficult life events are not typically referred to specialist services because consultation support and safety-netting are considered sufficient.
Stated by The Foxhayes SurgeryExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to ensure a formal referral to MHLT
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Require staff to document all contact with mental health professionals on the online referral form and retain a copy in the patient notes.
Stated by Group Chief Medical OfficerStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.
Action
Provide Trust-wide communications highlighting the need to use the online referral form.
Stated by Group Chief Medical OfficerStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.
West Yorkshire (Western)
Concerns raised1
Failure to require referrals to SPA from people with mental health experience
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Develop referral guidance to help referrers recognise risk factors and identify when immediate telephone contact with SPA is required.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 April 2026.
Action
Amend the referral form to direct referrers with positive risk-question responses to contact SPA immediately about the referral.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 April 2026.
Cheshire
Concerns raised1
Use of artificially elevated thresholds for mental health bed referrals
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to allow direct referral from general practice to the HBTT for urgent high-risk referrals
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Issue a Practice Note clarifying that primary care mental health practitioners can directly refer patients to HBTT across all Trust boroughs.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.
Action
Include direct HBTT referral guidance in the Trust Patient Safety Newsletter distributed electronically to all staff.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2026.
Action
Hold an urgent-care away day to review and confirm the HBTT SOP and reinforce referral pathways and operational expectations, including direct referrals by primary care networks.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2026.
Action
Finalise the Referral and Assessment hub SOP by the end of May 2026.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2026.
Action
Establish a functioning Referral and Assessment hub in every Trust area by the end of August 2026 to provide a single external referral point.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Mental health practitioners in general practice can directly refer to HBTT across all Trust boroughs after assessing the person’s mental health.
Stated by Greater Manchester Mental Health NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Kent and Medway
Concerns raised1
Delays in actioning necessary referrals to secondary mental health services
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Facilitate a phased training and support package with NHS Talking Therapies Collaborative to improve referral matching and risk communication.
Stated by Kent and Medway Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2026.
Action
Introduce visual prompts at every call station and workstation directing staff to arrange Rapid Response assessment within four hours when risk is concerning.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Action
Reduce the target timeframe for triaging urgent referrals from 72 hours to 24 hours.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Action
Update the Duty Standard Operating Procedure to require same-day routine referral action and careful consideration of family members’ information.
Stated by Vita Health Group LtdStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Action
Deliver a reflective Duty Team session sharing case learning and the resulting Standard Operating Procedure changes.
Stated by Vita Health Group LtdStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Patients whose needs exceed Talking Therapies’ remit should be referred to Kent and Medway Mental Health NHS Trust or emergency and crisis services.
Stated by Vita Health Group LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
An urgent referral was not indicated because reported deterioration lacked evidence of dynamic risk, risky behaviour, suicide planning or intent.
Stated by Vita Health Group LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised1
Failure to make urgent mental health referrals
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Establish and staff a dedicated Early Days in Custody Nurse role to oversee reception screening, risk assessment, information sharing, escalation, supervision, and quality assurance.
Stated by HCRG Care GroupStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Deliver targeted mental-health awareness training and support reception nurses to identify suicide, self-harm, acute distress, and appropriate ACCT observation levels.
Stated by HCRG Care GroupStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Review mental-health operational procedures and referral processes to clarify urgent-referral thresholds, escalation routes, and expected 24-hour response times.
Stated by HCRG Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Reissue mandatory escalation guidance and introduce MDT agendas and case-presentation templates for changing risk or uncertainty.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Kent and Medway
Concerns raised1
Limited out-of-hours availability of MHT+ support for Rapid Response Team referrals
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Lack of clear arrangements for signposting and contacting emergency mental health services and clarifying their expected response
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Improve identification of mental health needs, accuracy of signposting, and decision-making accountability during contact handling.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Operate an agreed process for GMP call handlers to transfer or signpost people with mental-health welfare concerns to NHS 111 option 2.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Urgent mental health intervention is the responsibility of health-based resources and clinical partners, rather than policing.
Stated by Greater Manchester PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Operational implementation of RCRP, including protocols and emergency arrangements, is the Chief Constable’s responsibility; related Regulation 28 notices should be directed there.
Stated by Deputy Mayor of Greater ManchesterRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Mental health services provide crisis, not emergency, responses; the concern incorrectly treats them as responsible for 999 emergencies.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
999 services, rather than commissioned mental health services, are responsible for emergency responses requiring immediate intervention.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Commissioned mental health services cannot provide 999 emergency responses, contact nonresponsive individuals, or force entry to protect someone at risk.
Stated by NHS Greater Manchester Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Nottinghamshire
Concerns raised1
Lack of training of service providers on the process for referrals for Mental Health Act assessments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Develop and disseminate two flow charts supporting capacity considerations and referral decisions, including display in team offices.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Participate in a multi-agency workstream to develop a joint mechanism or protocol clarifying roles and remits for capacity assessments.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2025.
Action
Share the Trust’s local internal pathways and protocols at the next multi-agency workstream meeting.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 November 2025.
Action
Develop and implement formal referral pathways with mental health trusts for mental health assessments.
Stated by East Midlands Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2025.
Action
Work through a multi-agency group to strengthen decision-making and inter-agency pathways for Mental Health Act and Mental Capacity Act matters.
Stated by East Midlands Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2025.
Action
Provide biennial Mental Health Awareness training covering statutory detention processes, roles and current pathways.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Review Mental Health Awareness training and seek Mental Health Trust input to align it with formalised referral pathways.
Stated by East Midlands Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 5 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Mental Health Act assessment referrals are the responsibility of Approved Mental Health Practitioners within the Local Authority.
Stated by Nottinghamshire Healthcare NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
An established process and pathway for requesting Mental Health Act assessments is already in place across Nottingham City and County.
Stated by Nottinghamshire Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Ambulance crews cannot determine whether a statutory Mental Health Act assessment is required because they are not mental health specialists.
Stated by East Midlands Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Nottinghamshire Healthcare NHS Foundation Trust should reassert processes for acceptable practitioners to initiate urgent referrals.
Stated by Royal College of General PractitionersRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
