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.
Inner West London
Concerns raised1
Failure to routinely pass mental-health-related SPA calls to a suitably qualified clinician for mental health assessment and risk assessment
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.
North West Wales
Concerns raised1
Lack of a standardised LPMHSS referral process for low-risk patients’ interim support
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.1
Action
Progress the unallocated-patient waiting-list protocol through consultation, approval, distribution and team launch.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2023.
East London
Concerns raised1
Lack of direct access for BPAS patients with pregnancy-related mental health decline to perinatal psychiatry teams
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.
North Northumberland
Concerns raised2
Failure to triage mental health self-referrals within 24 hours
Lack of weekend triage for mental health 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.2
Action
Request electronic kiosk referrals with referral-processing timeframes and urgent-contact information from the prison provider.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 November 2022.
Action
Provide self-referral forms, including easy-read versions, with questions enabling triage by service need and urgency.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 November 2022.
Carmarthenshire and Pembrokeshire
Concerns raised1
Lack of a route back into the Mental Health Service after CRHT discharge
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.
West Yorkshire Eastern
Concerns raised1
Failure to make psychiatric referrals because of unavailable responding resources
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
Approach NHS England and discuss seeking additional psychology and psychiatry resource for HMP Leeds.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Action
Submit a business case to Commissioners for increased psychology and psychiatry provision at HMP Leeds.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated plannedThe respondent said that this action was planned when they made their response on 23 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing stepped-care provision and multidisciplinary referral arrangements are considered sufficient to meet patients’ psychiatric needs at current levels.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Lack of guidance on thresholds for referral to secondary mental health services
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
The response disputes that secondary mental health referral was indicated, stating that the patient did not meet referral criteria and remained low risk.
Stated by Farnham Park Health Group and Recipient name withheldDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised3
Failure to establish changed child mental health triage practices in written guidance
Inappropriate closure or referral of child mental health referrals
Automatic categorisation of routine referrals as low risk
This report raised 12 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
Update and approve the Standard Operating Procedure manual to reflect new referral triage practices.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
Action
Apply harm reviews to routine referrals waiting over four weeks and review continuing waits every four weeks until triage.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
Action
Require exceptional referral closure safeguards, including GP and family notification, continued-access information and consideration of safeguarding referral.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing closure safeguards require engagement with the GP, information for families, and consideration of safeguarding before referrals are closed.
Stated by Surrey and Borders Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Routine referrals are not automatically treated as low risk; they are screened as low risk only after assessment and confirmation of protective factors.
Stated by Surrey and Borders Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester North
Concerns raised3
Failures and delays in maintaining and re-referring patients on the Priory waiting list
Unclear Priory referral and admission criteria for medically stable patients with low BMI
Exclusion of patients with BMI below 14 from the Community Eating Disorder Service
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.6
Action
Review the Greater Manchester adult eating disorder pathway and revise protocols and collaboration arrangements.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Broaden the children and young people’s eating disorder working group into an all-age group addressing transitions and consistent referral pathways.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Implement the expanded adult eating disorder service to provide medical monitoring, specialist treatment, consultation and coordinated pathways.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Share and consider revised Priory referral criteria with relevant stakeholders.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Develop a community eating disorder medical-monitoring pathway and accept medically stable patients based on clinical assessment rather than BMI alone.
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 31 December 2021.
Action
Approve and implement an expanded adult community eating disorder service with psychiatric, physical-health, psychological and dietetic capacity.
Stated by NHS Bury Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for addressing Priory referral criteria rests with other organisations.
Stated by NHS Bury Clinical Commissioning GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester City
Concerns raised1
Failure to consider referral back to HBTT when circumstances change
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.
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
Hold daily CMHT multidisciplinary zoning meetings with HBTT participation twice weekly to review crisis support and transfers of care.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 October 2021.
Action
Use an HBTT discharge checklist, including joint CMHT visits, to support transfers into CMHT.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 October 2021.
Action
Conduct quarterly audits of HBTT discharges to check policy-compliant step-downs and adequate support.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 October 2021.
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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.
