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
Failure to refer to mental health services
This report raised 15 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 raised2
Lack of an audit trail for faxed referrals to the Community Mental Health Team
Failure to consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals
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
Institute an urgent-fax SOP requiring sender logging, transmission and recipient confirmation, record scanning, and automatic notification to the referring doctor.
Stated by The Endless Street Doctors’ Surgery
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
The strengthened and robust local referral system is considered sufficient to address referrals to the Community Mental Health Team.
Stated by Department of Health and Social Care
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Position
Responsibility for addressing the referral process rests locally with the surgery rather than centrally.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to process and action referrals to the community mental health team
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.
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
Review referral-processing procedures, including telephone message handling, referral responsibility and recording arrangements.
Stated by North West Boroughs Healthcare NHS Foundation Trust -
Action
Re-circulate Wigan Recovery North’s correct contact details and telephone number to partner agencies.
Stated by North West Boroughs Healthcare NHS Foundation Trust
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
The service does not use an answerphone before 5pm, and the message may have been left at an incorrect number.
Stated by North West Boroughs Healthcare NHS Foundation Trust
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Position
Established referral procedures and regular message checks provide an adequate system for handling telephone referrals.
Stated by North West Boroughs Healthcare NHS Foundation Trust
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Concerns raised1
Failure to undertake referred psychiatric assessment
This report raised 10 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
Lack of a system for prompt referral of staff to another Trust for mental healthcare
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 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 refer patients who have attempted suicide to the right mental health team within a reasonable time
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.
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
Implement an MHLS checklist prompting postcode reviews to prevent incorrect referral routes.
Stated by Black Country Healthcare NHS Foundation Trust -
Action
Revise the SPOR duty system to prevent inappropriate referrals being returned, enable direct onward signposting, and confirm referral receipt by telephone.
Stated by Black Country Healthcare NHS Foundation Trust -
Action
Review the MHLS protocol to introduce the Common Assessment Tool and Clustering Tool for direct referrals.
Stated by Black Country Healthcare NHS Foundation Trust
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Concerns raised2
Failure to re-refer patients to the Mental Health Team when clinically appropriate
Failure to review decisions not to re-refer patients to the Mental Health Team
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 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
Review the process for urgent referrals.
Stated by Livewell Southwest -
Action
Meet with secondary-care psychiatry colleagues to discuss referral rejection and complete a Significant Event analysis of the death.
Stated by Knowle House Surgery
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 hunger strike was considered likely to result in a slow suicide, so the urgent referral was not considered to require an immediate response.
Stated by Knowle House Surgery
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Concerns raised3
Failure to refer patients from the Intake team to an appropriate service
Lack of clarity about retaining patients or referring them to other services
Delays in psychiatric referral and assessment after initial assessment
This report raised 14 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 implement AABIT standard operating procedures.
Stated by North East London NHS Foundation Trust
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Concerns raised2
Lack of emergency department visibility of referral acceptance and assessment timing
Failure of the referral process to identify and rectify errors
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.
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
Explore developing an email referral system providing receipt confirmation and an approximate assessment time.
Stated by Lancashire & South Cumbria NHS Foundation Trust
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Concerns raised1
Delays in progressing referrals to a crisis house
This report raised 6 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
Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.
Stated by North London NHS Foundation Trust
Data last updated 7 September 2026