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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 110 reports
See individual reports that have raised this concern, and the actions taken in response
Gloucestershire
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised1
Lack of a reliable documentary system for communicating mental health referral information
Linked response
Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Essex Partnership University NHS Foundation Trust
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.
Somerset
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.
Linked responses
NHS Somerset Clinical Commissioning Group
Somerset NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Somerset NHS Foundation Trust
Operate a CAMHS Single Point of Access to screen referrals consistently, provide referrer advice, and monitor thresholds.
Somerset NHS Foundation Trust
Benchmark CAMHS Tier 3 thresholds against national definitions and commissioned provision to identify whether thresholds require adjustment.
NHS Somerset Clinical Commissioning Group
Operate a single point of access for CAMHS referrals, with oversight, governance and signposting for referrals below the access threshold.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Somerset NHS Foundation Trust
Limited Tier 3 CAMHS capacity constrains adopting a lower referral threshold and providing earlier proactive intervention.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
NHS Somerset Clinical Commissioning Group
The CAMHS access threshold cannot presently be lowered because available funding is insufficient.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Black Country
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
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.
Linked responses
North London NHS Foundation Trust
Royal Free London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Royal Free London NHS Foundation Trust
Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.
North London NHS Foundation Trust
Write GPs an accompanying note identifying any specific action required of them when the mental health liaison team sends a referral or discharge summary.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Royal Free London NHS Foundation Trust
CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Liverpool and the Wirral
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Black Country
Concerns raised1
Failure to make further referrals back to the Mental Health Liaison Service after hospital discharge
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
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.
Linked response
Care UK
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Care UK
Investigate the First Reception Health Screen referral process and associated templates to identify how referral completion can be enforced.
Care UK
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.
Care UK
Consider implementing the revised First Reception Health Screen template at all prisons where Care UK conducts the assessment.
Manchester South
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.
Linked response
NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
NHS Greater Manchester Integrated Care Board
Review and establish clear mental-health support pathways for people with complex needs, identify gaps, and take findings forward in commissioning intentions.
Manchester South
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.
Linked responses
Pennine Care NHS Foundation Trust
the Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Pennine Care NHS Foundation Trust
Manage Healthy Young Minds referrals through a single point of entry and allocate them according to children’s needs.
Pennine Care NHS Foundation Trust
Produce and widely disseminate a Healthy Young Minds service offer document explaining referrals, advice access and appropriate referral problems.
Pennine Care NHS Foundation Trust
Expand the service offer document to name a contact for paediatric colleagues seeking advice and consultation.
the Trust
Make written CAMHS referrals whenever paediatricians have reasonable cause for concern, without filtering referrals or predicting acceptance.
the Trust
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
the Trust
The Trust disputes that medical professionals lacked understanding of CAMHS referrals, stating evidence showed the process was understood.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.