Recurring concern
Unreliable mental health referral pathways
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Request correctionFirst reported 4 Sep 2013•Latest report 25 Jun 2026
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
- Individual concerns
- 136
- Date range
- 2013–2026
- Stated actions
- 173
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Lack of clear arrangements for emergency psychiatric referral following presentations involving self-harm, suicidal thoughts or hallucinations
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 concernsEach statement is shown once, even when linked to more than one 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
Lack of a reliable documentary system for communicating mental health referral information
Responses linked to these concernsEach 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
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Action
Implement a prison-wide written mental-health referral system, requiring written follow-up after emergency telephone referrals and providing forms electronically and on all prison wings.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
High threshold for CAMHS referral
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 concernsEach 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
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Action
Operate a CAMHS Single Point of Access to screen referrals consistently, provide referrer advice, and monitor thresholds.
Stated by Somerset NHS Foundation Trust -
Action
Benchmark CAMHS Tier 3 thresholds against national definitions and commissioned provision to identify whether thresholds require adjustment.
Stated by Somerset NHS Foundation Trust -
Action
Operate a single point of access for CAMHS referrals, with oversight, governance and signposting for referrals below the access threshold.
Stated by NHS Somerset Clinical Commissioning Group
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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Position
Limited Tier 3 CAMHS capacity constrains adopting a lower referral threshold and providing earlier proactive intervention.
Stated by Somerset NHS Foundation Trust
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Position
The CAMHS access threshold cannot presently be lowered because available funding is insufficient.
Stated by NHS Somerset Clinical Commissioning Group
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Concerns raised1
Failure to make formal post-discharge referral or contact with community mental health services and general practitioner
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 concernsEach statement is shown once, even when linked to more than one 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 complete and communicate general-practitioner referrals
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 concernsEach 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
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Action
Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.
Stated by Royal Free London NHS Foundation Trust -
Action
Write GPs an accompanying note identifying any specific action required of them when the mental health liaison team sends a referral or discharge summary.
Stated by North London NHS Foundation Trust
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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Position
CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.
Stated by Royal Free London NHS Foundation Trust
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Concerns raised1
Failure to provide coordinated direct referrals and continuity of care during mental health service transfers
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 concernsEach statement is shown once, even when linked to more than one 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 make further referrals back to the Mental Health Liaison Service after hospital discharge
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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 make mental health team referrals
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Investigate the First Reception Health Screen referral process and associated templates to identify how referral completion can be enforced.
Stated by Care UK -
Action
Use a revised mandatory First Reception Health Screen template requiring confirmation of mental-health referral and electronically refer directly to the mental-health in-reach team at HMP Pentonville.
Stated by Care UK -
Action
Consider implementing the revised First Reception Health Screen template at all prisons where Care UK conducts the assessment.
Stated by Care UK
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Concerns raised3
Failure to consider and action referrals to Adult General Psychiatry
Insufficient detail in GP referral documentation to identify case complexity
Inappropriate referral of complex PTSD presentations to Healthy Minds
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 concernsEach 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
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Action
Review and establish clear mental-health support pathways for people with complex needs, identify gaps, and take findings forward in commissioning intentions.
Stated by NHS Greater Manchester Integrated Care Board
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Concerns raised2
Lack of clarity about referral routes and acceptance by Psychological services
Lack of understanding of cases suitable for CAMHS referral
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 concernsEach 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
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Action
Manage Healthy Young Minds referrals through a single point of entry and allocate them according to children’s needs.
Stated by Pennine Care NHS Foundation Trust -
Action
Produce and widely disseminate a Healthy Young Minds service offer document explaining referrals, advice access and appropriate referral problems.
Stated by Pennine Care NHS Foundation Trust -
Action
Expand the service offer document to name a contact for paediatric colleagues seeking advice and consultation.
Stated by Pennine Care NHS Foundation Trust
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Action
Make written CAMHS referrals whenever paediatricians have reasonable cause for concern, without filtering referrals or predicting acceptance.
Stated by the Trust -
Action
Apply epilepsy mental-health safeguards through tailored care plans, specialist nurse review and liaison, CAMHS referral, and immediate admission for high-risk self-harm or suicide concerns.
Stated by the Trust
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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Position
The Trust disputes that medical professionals lacked understanding of CAMHS referrals, stating evidence showed the process was understood.
Stated by the Trust
Data last updated 7 September 2026