Recurring concern

Unreliable mental health referral pathways

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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

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.

  1. Norfolk

    AI-generated summary

    SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sol Hadhasseh had a complex mental health history and was found unresponsive at her flat on 28 November 2013 after concerns were raised for her welfare. The inquest concluded that she had killed herself, with the medical cause of death recorded as tramadol toxicity; concern was raised that her transfer between mental health trusts had not been arranged through a direct Trust-to-Trust referral.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to make direct written Trust-to-Trust referrals when transferring patients to another Trust

    Wider context from the report

    “I heard at the Inquest from the Acting Deputy Service Manager of Norfolk & Suffolk NHS Foundation Trust’s Access & Assessment Team. In her evidence she stated that in her experience she would have expected the Warwickshire & Coventry Partnership Trust to have made a direct written referral Trust to Trust rather then via the GP, given the complex needs and history of Sol and that this should have been planned in advance. Whilst it can not be known whether had such referral been made the outcome for Sol would have been different, I am nevertheless concerned that a similar circumstance to arise in the future an preventable death might occur and there is a continuing risk that other deaths could occur which could be avoided. I was therefore concerned that procedures for transferring a patient to another Trust should be reviewed by the Warwickshire & Coventry Partnership Trust. ”

    Source location

    SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Manchester North

    AI-generated summary

    Miss Samiyo Sahra Shih Farah · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Miss Samiyo Sahra Shih Farah, who had depression and a history of self-harm, was found unresponsive with a ligature around her neck on 30 December 2012 and was pronounced dead. The principal concerns were the lack of national guidance on observation of children and adolescents in specialist mental health units, inadequate formal protocols for communication during transfers between private and NHS providers, and inconsistent referral arrangements following her attendances at A&E.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inconsistent referral of unwell A&E attenders to a psychiatrist

    Wider context from the report

    “3) There appears to have been an inconsistency of approach following Miss Farah’s admissions to A & E. She was referred directly to a Psychiatrist on the second attendance when she was clearly unwell but had not managed to self-harm but was not on the first attendance when she had taken an overdose. This also raises the question as to whether she ought to have been referred (to a Psychiatrist) on the 31st October 2012. ”

    Source location

    Miss Samiyo Sahra Shih Farah · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Inner West London

    AI-generated summary

    Mr Philip Anthony Dean · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Philip Anthony Dean, who had chronic depressive illness and had become suicidal, jumped from Battersea Bridge into the River Thames on 13 August 2013 and died after being recovered and resuscitated. The principal concerns included inadequate continuity of care, discharge from the Home Treatment Team before psychology referral could be made, failure to record and communicate the GP’s concerns, insufficient assessment by medically qualified personnel, apparent under-resourcing, and an inadequate serious untoward incident investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Discharge-dependent referral to psychology leaving patients without ongoing support

    Wider context from the report

    “(2)That discharge from the HTT is required before referral to psychology can be made, leaving patients without ongoing support in the interim. ”

    Source location

    Mr Philip Anthony Dean · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Wiltshire and Swindon

    AI-generated summary

    Andrew Michael Horgan · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Andrew Michael Horgan died on 16 September 2013 from acute cardiac failure following a Colchicine overdose, with coronary artery atherosclerosis, myocardial fibrosis and focal incomplete hepatic cirrhosis also identified. The principal concern was that hospital staff lacked a clear understanding of referral procedures for mental health assessment following discharge, creating a risk that similar communication failures could contribute to a future death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the communication pathway for engaging mental health professionals to be clear and effective

    Wider context from the report

    “1. Training for Doctors and other medical staff in relation to referring patients for assessment both within the hospital and externally following discharge. – During the course of the Inquest ████████ gave evidence and it was quite clear that he did not have a clear understanding of the referral procedure to involve professionals from the Avon and Wiltshire Mental Health Partnership. He believed his telephone conversation with the Swindon Intensive Services with CPN ████████ would result in the outreach team assessing Andrew in the community. He thought that a telephone call alone would be sufficient in that respect to engage the Mental Healthcare professionals. The importance of a clear and effective communication pathway following recognised and agreed practices and procedures cannot be ignored and I am concerned following the evidence I heard there were knowledge gaps as regards practice and procedures to be followed when engaging Mental Health Partnership personnel. I would be grateful if you could please review the appropriateness and the effectiveness of training in this respect not only for current GWH personnel but also how effective training in this area can be given to personnel in the future. Whilst I was satisfied that this did not contribute to Andrew’s death in this instance my concern is that an issue could arise in the future whereby that may not be the case. ”

    Source location

    Andrew Michael Horgan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of staff knowledge of referral procedures for engaging mental health professionals

    Wider context from the report

    “1. Training for Doctors and other medical staff in relation to referring patients for assessment both within the hospital and externally following discharge. – During the course of the Inquest ████████ gave evidence and it was quite clear that he did not have a clear understanding of the referral procedure to involve professionals from the Avon and Wiltshire Mental Health Partnership. He believed his telephone conversation with the Swindon Intensive Services with CPN ████████ would result in the outreach team assessing Andrew in the community. He thought that a telephone call alone would be sufficient in that respect to engage the Mental Healthcare professionals. The importance of a clear and effective communication pathway following recognised and agreed practices and procedures cannot be ignored and I am concerned following the evidence I heard there were knowledge gaps as regards practice and procedures to be followed when engaging Mental Health Partnership personnel. I would be grateful if you could please review the appropriateness and the effectiveness of training in this respect not only for current GWH personnel but also how effective training in this area can be given to personnel in the future. Whilst I was satisfied that this did not contribute to Andrew’s death in this instance my concern is that an issue could arise in the future whereby that may not be the case. ”

    Source location

    Andrew Michael Horgan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the mental health referral process and current staff training provision, identifying resulting actions in collaboration with AWP.

    Verbatim wording from the response

    “Your letter raised concerns about this case, around the lack of understanding by medical staff about the procedure to engage our mental health provider, the Avon and Wiltshire Mental Health Partnership (AWP). Regulation 28 was issued because during the Inquest ████████ did not provide a clear understanding of the referral procedure needed to initiate an assessment by the community outreach team following Mr Horgan’s self-discharge from hospital. You requested that the Trust should review the appropriateness and effectiveness of training currently provided to all staff.”

    Source location

    2014-0163-Response-by-Great-Western-Hospital-NHS-Foundation-Trust
    Page 1 · response
    Published 8 April 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Include community crisis-intervention access information in the patient leaflet, Mental Health Act training programme and Trust intranet.

    Verbatim wording from the response

    “In Mr Horgan’s case, there was a miscommunication as to whether the contact with the out of hours intensive team was for advice or referral to mental health community services upon Mr Horgan’s self discharge. The Trust and AWP both agreed that this area of practice should be made clearer to all staff. The AWP documentation record has now been updated to include a question making it clear that the telephone call from GWH staff is either for referral, advice or both. In addition, the Trust is advised that community crisis intervention as, in the case of Mr Horgan, is only accessible by the patient contacting the out of hours General Practitioners’ service. The patients’ General Practitioner will normally be informed about their admission or attendance to hospital through the Trust Patient Electronic Discharge Summary system.”

    Source location

    2014-0163-Response-by-Great-Western-Hospital-NHS-Foundation-Trust
    Page 2 · response
    Published 8 April 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The existing referral process for patients requiring mental health services is clear and considered adequate.

    Verbatim wording from the response

    “Referral to mental health services The review of the Trust’s referral process to mental health services showed that there is a clear referral process in place for patients in the Emergency Department or those admitted into Great Western Hospital (GWH). During 2013/14 staff referred 911 patients to the Adults of Working Age Psychiatry Liaison Service; 321 patients to the Adults of Later Years Psychiatry Service and 94 patients to the out of hours intensive team.”

    Source location

    2014-0163-Response-by-Great-Western-Hospital-NHS-Foundation-Trust
    Page 2 · response
    Published 8 April 2014

    Open published response

  5. Manchester North

    AI-generated summary

    David Gary Chatburn · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    David Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing mental health services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to make case-specific referrals through the single point of entry process

    Wider context from the report

    “4. That the GP felt it was sufficient for him to simply discuss the deceased’s care with the practice-based community psychiatrist and thus, no need for a referral to the single point of entry process. Such discussions were not necessarily case specific in any event but rather, general in nature. ”

    Source location

    David Gary Chatburn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to refer patients to psychiatric services for expert diagnosis, opinion, management and treatment planning

    Wider context from the report

    “1. That there was no referral made by the GP to the Psychiatric services for an expert diagnosis/opinion/management and treatment plan. The GP considered that there was no need, as he felt clinically competent to manage the deceased’s care and in any event, had a special interest in mental health, although he conceded that he was not formally recognised as a GP with a Special Interest (‘GPwSPi’) and whilst confident in his ability to manage the deceased’s care, his area of special interest was in fact the management of addictions. Irrespective, he felt that he was best placed to assess, diagnose and treat the deceased on the basis that had he referred Mr Chatburn to the single point of entry system, the person ‘triaging’ would not have been medically qualified and would not have known the deceased as well as he felt he did. ”

    Source location

    David Gary Chatburn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Concerns about the GP’s decisions and actions should be addressed by Pennine Care NHS Trust and York House Surgery.

    Verbatim wording from the response

    “Many of the issues you raise concern the decisions and actions taken by the GP who diagnosed and treated Mr Chatburn. I note that you have sent your report to the Pennine Care NHS Trust and the York House Surgery and I would expect them to properly address these concerns.”

    Source location

    2014-0126-Response-by-Department-of-Health
    Page 3 · response
    Published 18 March 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NHS England’s Performers Screening Group will determine whether specific action is needed regarding the GP’s clinical behaviour.

    Verbatim wording from the response

    “My officials have consulted NHS England, as the main commissioner of primary care services, about your report. NHS England has advised that the GP’s clinical behaviour will be discussed at their next Performers Screening Group (PSG). The PSG will then determine if any specific actions need to be taken.”

    Source location

    2014-0126-Response-by-Department-of-Health
    Page 3 · response
    Published 18 March 2014

    Open published response

  6. Manchester South

    AI-generated summary

    Jonathan Alan Thorpe · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jonathan Alan Thorpe took his own life by hanging from a tree branch in a local cemetery while using illicit drugs and experiencing deteriorating family issues. The report raises concerns that, despite his known history of self-harm and previous involvement with mental health services, his GP consultations did not refer to or seek input from Mental Health Services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to seek advice from or consider further input from Mental Health Services

    Wider context from the report

    “The deceased registered with your GP practice on the 20th March 2013, was seen by ████████ on the 25th March and was issued a ‘sick note’ and was prescribed Amitriptyline for depression (despite being a known self-harmer). He was then seen on the 28th March by ████████ when a further ‘sick note’ was issued, this time back dated for one month. On neither of these consultations was there any reference to Mental Health Services, either for advice as to his previous involvement with them nor as to whether he needed further input from them. ”

    Source location

    Jonathan Alan Thorpe · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Surrey

    AI-generated summary

    Sarah Anne Shepherd · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sarah Anne Shepherd, a patient detained under the Mental Health Act, was found in her room with a plastic bin liner over her head on 12 September 2011 and died in hospital the following day. The report identified concerns about unclear referral processes to the Psychiatric Intensive Care Unit, failures to attempt resuscitation in accordance with guidance, and uncertainty and misleading materials concerning resuscitation training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to establish a clear referral process to the Psychiatric Intensive Care Unit

    Wider context from the report

    “(1) It was clear from the evidence that the Trust has in place an Operational Policy concerning its Psychiatric Intensive Care Services. The Policy in place in September 2011 did not establish a clear process for the referral of an inpatient from an acute ward (or any other patient) to the Psychiatric Intensive Care Unit and it did not require the PICU to provide a written and reasoned response to the referral and to record the same on the patient’s RIO (or other medical) notes. From the evidence heard, it does not seem that these concerns have yet been addressed or sufficiently addressed by amendment of the Operational Policy and consequential staff training. ”

    Source location

    Sarah Anne Shepherd · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to require written and reasoned referral responses and their recording in patient notes

    Wider context from the report

    “(1) It was clear from the evidence that the Trust has in place an Operational Policy concerning its Psychiatric Intensive Care Services. The Policy in place in September 2011 did not establish a clear process for the referral of an inpatient from an acute ward (or any other patient) to the Psychiatric Intensive Care Unit and it did not require the PICU to provide a written and reasoned response to the referral and to record the same on the patient’s RIO (or other medical) notes. From the evidence heard, it does not seem that these concerns have yet been addressed or sufficiently addressed by amendment of the Operational Policy and consequential staff training. ”

    Source location

    Sarah Anne Shepherd · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Sunderland

    AI-generated summary

    Peter Galea · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter Galea, a 51-year-old man, attended hospital and other agencies repeatedly over a 72-hour period and was assessed as low risk on three occasions. On 11 June, after leaving his GP surgery and threatening to jump from a bridge, his body was found under the Queen Alexandra Bridge and he was pronounced dead. Concerns included limited mechanisms for breaking referral cycles, restrictions on direct GP referral for admission to a place of safety, and whether different action might have prevented the outcome.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Limitations on GPs making direct referrals for admission to a place of safety

    Wider context from the report

    “Mr Galea was not known to mental health services and experienced multiple presentations to a number of professionals and agencies within a 72 hour period and had 3 mental health assessments, all of which placed him at a low risk. Whilst it is a tragedy that the professionals and agencies did not have more of an opportunity to work with Mr Galea before he took his own life, I was concerned, that: - 1) there appeared to be limited mechanisms available to break the cycle of referrals between agencies without more positive action being taken whereby Mr Galea could be in a safe place whilst a more detailed assessment of his needs could be carried out possibly involving a psychiatrist. The family described the referral between agencies as “ping pong”. 2) there were limitations upon the GP making a direct referral to have Mr Galea admitted to Cherry Knowle Hospital, because to do so Mr Galea would have had to go back to the Mental Health Team, with whom he had had three contacts within a 72 hour period. From the evidence it was clear that the GP had a positive relationship with his patient (for 4 years) and although prospectively acquiescing to the patient’s wishes, in exceptional circumstances, it may be that a GP should be able to achieve an admission to a place of safety, even if only for a limited period of time. I readily acknowledge some of the disadvantages which may come into play by way of admission but in raising it there may also be advantages which would promote a patient’s welfare. 3) I was grateful for the assistance of ████████ Consultant Psychiatrist, but he was not able to offer to me any view about what may have been done differently for Mr Galea to avoid this very tragic outcome. In raising the matter with you, it may be that some solution to enhance patient’s welfare and wellbeing can be found to prevent future deaths. ”

    Source location

    Peter Galea · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Norfolk

    AI-generated summary

    Matthew Christopher Dunham · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Matthew Christopher Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of shared understanding of team referral roles and interfaces

    Wider context from the report

    “b) There appears not to have been a clear shared understanding between professionals as to which team it was appropriate to refer Mr Dunham too. There was some lack of understanding revealed as to whether a referral to the assessment team or the crisis resolution and home treatment team was appropriate. This highlights the need for there to be a clear understanding about the roles of each team and the interface between them. ”

    Source location

    Matthew Christopher Dunham · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Base a Crisis Resolution and Home Treatment team member within the Access and Assessment Team to support prompt joint working and care transitions.

    Verbatim wording from the response

    “To enhance the interface between the two clinical teams, Access and Assessment Team (AAT) and CRHT, a member of the CRHT is now based within the AAT. This enables joint working without any delay, supporting transition of care between the two teams. The Trust is monitoring its effectiveness in identifying people in need of this crisis support.”

    Source location

    Response
    Page 2 · response
    Published 26 January 2014

    Open published response

  10. Manchester South

    AI-generated summary

    Michael Stuart Irlam · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michael Stuart Irlam was suffering from severe depression and anxiety and had been discharged from the CHRTT while awaiting further contact from IAPT. On 13 November 2012, he hung himself from the banister at his home. The principal concern was that vulnerable patients could experience a feeling of abandonment and deterioration while waiting without a confirmed appointment or clear information about the next stage of treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure referral engagement without patient-initiated action

    Wider context from the report

    “████████ Senior Clinical and Forensic Psychologist was engaged to conduct a Post Incident Review & Report. That report concluded at page 31 - "Putting the patient first - perceived gaps from the patient perspective" that a waiting time of 24 days between discharge from CRHTT and the first appointment with IAPT could not be construed as a delay. This issue arose at the Inquest hearing was the potential for a feeling of abandonment because of the discharge without any knowledge of how long it would be before the next contact; of having to wait for the next stage/step without knowing when that would be. Mrs Irlam was clear that her husband deteriorated over this period despite the close, and loving, support provided by her and their family. That her husband found this a most distressing and difficult time. Even if the General Panel do not consider a waiting time of 3 weeks plus to be a delay for someone with mental health issues I take the view that a waiting time of 2 weeks without knowing the next contact for help/treatment will be is not appropriate. My concern is for the welfare of other patients who will fall into this gap between treatments/counselling who, unlike Mr Irlam, do not have a close and supportive family and the effect on them. During the course of his evidence ████████ explained that the two organisations were working closer together administratively. He was not, however, able to respond to my line of enquiry as to why a patient could not be given an appointment with IAPT on discharge from CHRTT. My concern is this. It seems to me most important and appropriate that a vulnerable patient with mental health issues ought not to be exposed to a feeling of abandonment, likely to lead to a deterioration in their condition, and that they should (where possible) be given an appointment with IAPT on discharge from CHRTT, if that is the agreed next step. That would also deal with the issue that upon receipt of the awaited letter from IAPT the patient has to be proactive to engage the referral to IAPT. (1) That if a follow-up with or referral to IAPT (or any other organisation) is deemed appropriate upon discharge from CRHTT then such an appointment should be arranged before or upon discharge. (2) (3) ”

    Source location

    Michael Stuart Irlam · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026