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.
Worcestershire
Concerns raised2
Failure to action received mental health referrals
Failure to record a suggested timeframe for action on referrals
This report raised 3 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.3
Action
Develop a countywide standardised urgent-referral system with performance measures and a policy defining urgent and routine response timescales.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2015.
Action
Operate the Redditch and Bromsgrove urgent-referral protocol, including triage within 24 hours and face-to-face assessment within 24 hours where required.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2015.
Action
Gather data and review the effectiveness of the recently implemented referral process, identifying issues requiring attention.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The 4 July referral was received, and urgent follow-up was not initially indicated; it was scheduled for weekly multidisciplinary review.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester North
Concerns raised2
Failure to provide inpatient access to suitably qualified psychological practitioners and referral resources
Delays in community-based psychological therapy referrals after discharge
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
Publish a five-year mental health plan setting out actions to improve access and waiting times for mental health services.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 December 2014.
Action
Take immediate actions to improve mental health access and waiting times, including IAPT treatment within six weeks for 75% and within 18 weeks for 95% of people.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 14 December 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The NHS Trust and Clinical Commissioning Group are responsible for addressing the concerns about local psychological therapy provision.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to provide direct referral to community mental health services for patients without a GP
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A referral to secondary mental health services was considered unnecessary because comprehensive assessments found no indication that this level of input was required.
Stated by East London NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
Brighton and Hove
Concerns raised1
Delays in appropriately addressing referrals within the 28-day period
This report raised 5 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
Recruit an additional triage administrator.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.
Action
Review administration triage processes to reduce triage waiting times.
Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 December 2014.
Action
Strengthen clinical triage meetings through Consultant Psychiatrist, lead nurse, administrator and additional specialist participation.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.
Action
Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.
South Yorkshire (Western)
Concerns raised1
Failure of frontline social services practitioners to identify when and where to make mental health referrals
This report raised 11 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.
South Lincolnshire
Concerns raised1
Failure to make direct mental health referrals when self-referral is not appropriate
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised1
Failure to ensure locum doctors know available local mental health support teams and referral criteria
This report raised 3 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.
Berkshire
Concerns raised1
Lack of appreciation of the need to contact an approved mental health professional promptly for a Mental Health Act assessment
This report raised 3 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.11
Action
Coordinate consultation and completion of the amended interagency protocol for managing mental-health-related Section 136 detentions.
Stated by Thames Valley PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2014.
Action
Work with partner organisations to deliver joint training and awareness on the amended protocol after it is agreed.
Stated by Thames Valley PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Inform police staff to promote partner organisations’ awareness of the protocol and support understanding of their respective responsibilities during incidents.
Stated by Thames Valley PoliceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2014.
Action
Make every effort to ensure British Transport Police understands the Thames Valley mental-health protocol.
Stated by Thames Valley PoliceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Add requirements to keep detainees supervised until formal handover and ensure mental-health professionals and AMHPs are informed.
Stated by British Transport PoliceStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Provide cross-agency training on using the revised Section 136 protocol, flowchart and monitoring forms.
Stated by Royal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Finalize and approve an A&E flowchart identifying Section 136 admission, AMHP contact and patient-management steps.
Stated by Royal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Display the approved Section 136 flowchart prominently in the A&E department.
Stated by Royal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Action
Adopt Section 136 monitoring forms to capture admission information and whether the AMHP has been contacted.
Stated by Royal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Require senior A&E staff to ensure AMHP contact and use Psychological Medicine Service checks to confirm contact and advise on patient management.
Stated by Royal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2014.
Action
Send completed Section 136 monitoring forms to the Trust’s Mental Health Coordinator so care can be audited.
Stated by Royal Berkshire NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
British Transport Police cannot reliably contact AMHPs before arrival because it lacks current on-call contact lists and maintaining them nationally is impractical.
Stated by British Transport PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Health professionals, through the place-of-safety coordinator, are responsible for contacting the AMHP and arranging necessary mental-health assessment arrangements.
Stated by British Transport PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A&E staff retain responsibility for the patient and contacting the AMHP; the Psychological Medicine Service will advise but not assume responsibility.
Stated by Royal Berkshire NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South and East Cumbria
Concerns raised1
Failure of the CAMHS referral system to function adequately
This report raised 7 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
Redesign the CAMHS referral system with a 48-hour urgent-response target and electronic breach flagging and investigation.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 July 2014.
North London
Concerns raised1
Failure of hospital staff to refer discharging patients to community psychological services
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.
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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.
