Recurring concern

Unreliable mental health referral pathways

First to latest report 4 Sep 2013 — 25 Jun 2026

Reports that mention this concern: 110
Times this concern has been raised: 136
Stated actions linked to this concern: 173

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.

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

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

Reports and published responses 110 reports

See individual reports that have raised this concern, and the actions taken in response

7 Oct2016
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Norman Arthur BEARD · 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

Norman Arthur BEARD suffered a fall, was admitted to hospital, and later transferred to Daisy Bank Nursing Home, where he developed serious pressure sores, dehydration and significant weight loss. He died at Abbey Court Nursing Home on 14 February 2015. Concerns included delayed referral and inadequate treatment of pressure sores, shortages of staff and essential supplies, incomplete care records, inadequate response to weight loss and minimal GP involvement.

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 refer to mental health services
Wider context from the report
“(6) Mr Beard lost a significant amount of weight. There was no referral to a dietician, physiotherapist, mental health services or involvement of District Nursing Teams. ”
Source location
Norman Arthur BEARD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Jul2016
Wiltshire and Swindon
Concerns raised2
1. Lack of an audit trail for faxed referrals to the Community Mental Health Team
2. Failure to consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals
Linked responses

Department of Health and Social Care
The Endless Street Doctors’ Surgery
Stated actions 1
1. The Endless Street Doctors’ Surgery
  Institute an urgent-fax SOP requiring sender logging, transmission and recipient confirmation, record scanning, and automatic notification to the referring doctor.
Respondent positions 2
1. Department of Health and Social Care
  The strengthened and robust local referral system is considered sufficient to address referrals to the Community Mental Health Team.
  Existing arrangements considered sufficient
1. Department of Health and Social Care
  Responsibility for addressing the referral process rests locally with the surgery rather than centrally.
  Redirects responsibility
AI-generated summary

Miles Benedict Abel · 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

On 14 January 2016, Miles Benedict Abel died after placing a ligature around his neck while at home. The concerns related to the referral process from a GP surgery to the Community Mental Health Team, including the absence of an audit trail confirming that referral faxes were sent and inconsistent follow-up calls to check receipt.

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 an audit trail for faxed referrals to the Community Mental Health Team
Wider context from the report
“(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent. (2 ) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed. (3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental Health Team would be unaware of the fact a patient had been referred to them. ”
Source location
Miles Benedict Abel · 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 consistently telephone the Community Mental Health Team to confirm receipt of faxed referrals
Wider context from the report
“(1)The procedure in place at the time of Miles death where a GP from the surgery wished to refer a patient to the Community Mental Health Team was to fax the request but no audit trail was kept to show the fax had been sent. (2 ) Although a telephone call was supposed to be made by the surgery to check that the fax had been received this was not always followed. (3) Hence if for any reason the fax was not sent and the follow up telephone call was not made the Community Mental Health Team would be unaware of the fact a patient had been referred to them. ”
Source location
Miles Benedict Abel · Prevention of Future Deaths report
Page 1 · 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
Institute an urgent-fax SOP requiring sender logging, transmission and recipient confirmation, record scanning, and automatic notification to the referring doctor.

Verbatim wording from the response
“Following the Critical Reporting Incident that followed the recent death of a patient, we have reviewed the system above and have instituted the new system – (Standard Operating Procedure - SOP enclosed):”

Source location
2016-0277-Response-by-The-Endless-Street-Doctors-Surgery
Page 1 · response
Published 29 July 2016
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 strengthened and robust local referral system is considered sufficient to address referrals to the Community Mental Health Team.

Verbatim wording from the response
“Your concern relates to the process followed at the Endless Street Surgery for referring patients to the Community Mental Health Team. I am aware that the Surgery has responded to your concerns, confirming that a strengthened and robust system for referral of patients to the Community Mental Health Team is now in place.”

Source location
2016-0277-Response-by-Department-of-Health
Page 1 · response
Published 29 July 2016
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
Responsibility for addressing the referral process rests locally with the surgery rather than centrally.

Verbatim wording from the response
“Your concern relates to the process followed at the Endless Street Surgery for referring patients to the Community Mental Health Team. I am aware that the Surgery has responded to your concerns, confirming that a strengthened and robust system for referral of patients to the Community Mental Health Team is now in place.”

Source location
2016-0277-Response-by-Department-of-Health
Page 1 · response
Published 29 July 2016
Open published response
26 Jul2016
Manchester West
Concerns raised1
1. 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.
Linked response

North West Boroughs Healthcare NHS Foundation Trust
Stated actions 2
1. North West Boroughs Healthcare NHS Foundation Trust
  Review referral-processing procedures, including telephone message handling, referral responsibility and recording arrangements.
2. North West Boroughs Healthcare NHS Foundation Trust
  Re-circulate Wigan Recovery North’s correct contact details and telephone number to partner agencies.
Respondent positions 2
1. North West Boroughs Healthcare NHS Foundation Trust
  The service does not use an answerphone before 5pm, and the message may have been left at an incorrect number.
  Disputes the concern
1. North West Boroughs Healthcare NHS Foundation Trust
  Established referral procedures and regular message checks provide an adequate system for handling telephone referrals.
  Existing arrangements considered sufficient
AI-generated summary

Lee Francis Grimes · 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

Lee Francis Grimes, who was known to misuse cocaine and had schizophrenia, was found collapsed and unresponsive at home on 21 March 2016. Before his death, he disclosed on two occasions that he had taken an overdose of prescribed medication, but the disclosures did not result in assessment or treatment, and a message to the Community Mental Health Team was not followed up or acted upon. The report raised concerns about failures in responding to overdose disclosures and referral messages, and about staff training and procedures.

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 process and action referrals to the community mental health team
Wider context from the report
“i. That no action was taken by an employee of Next Stage following Mr Grimes’ disclosure of an overdose of medication on Thursday the 17th March. I have further concern that when action was taken on the Friday 18th March, a message was left for the Community Mental Health Team which was not followed up by Next Stage, or answered and actioned by the Community Mental Health Team. Although Mr Grimes’ death was not as a result of an overdose, he did not receive any assessment, or treatment, in respect of the overdose he disclosed. In view of the fact that there was no contact from the Next Stage or the Community Mental Health team over the weekend, he was vulnerable to taking a further overdose of medication. ii. I have concerns that if this situation occurs in the future, another person could die. In view of that I would ask that the current policies and procedures in place at Next Stage to deal with the disclosure of an overdose of medication by a service user, are reviewed, and cascaded down to all employees. I would also request that a review is carried out by 5 Boroughs Partnership of the policies and procedures in place regarding the processing of referrals to Wigan Recovery North given the fact that the message left by ████████ on the Friday morning was never acted upon, as if this were to happen again in the future I believe there could be a further death. ”
Source location
Lee Francis Grimes · Prevention of Future Deaths report
Page 3 · 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 referral-processing procedures, including telephone message handling, referral responsibility and recording arrangements.

Verbatim wording from the response
“In response to your request to review the policies and procedures in place regarding the processing of referrals to Wigan Recovery North, I can confirm that a review of these procedures has been undertaken by ████████, Matron for Quality, in conjunction with the respective team manager.”

Source location
2016-0268-Response-5-Borough-Partnership-NHS-Trust
Page 1 · response
Published 26 July 2016
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
Re-circulate Wigan Recovery North’s correct contact details and telephone number to partner agencies.

Verbatim wording from the response
“In exercising learning from this review, we have ensured that the team’s correct contact details, including the telephone number, has been re-circulated to all our partner agencies and that the lessons learned from this inquest are shared.”

Source location
2016-0268-Response-5-Borough-Partnership-NHS-Trust
Page 2 · response
Published 26 July 2016
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 service does not use an answerphone before 5pm, and the message may have been left at an incorrect number.

Verbatim wording from the response
“We note from the evidence presented at the hearing that an answerphone message was left for the team on the morning of Friday 18 March 2016 at approximately 10 am, however it has not been possible to determine where the message was left.”

Source location
2016-0268-Response-5-Borough-Partnership-NHS-Trust
Page 2 · response
Published 26 July 2016
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
Established referral procedures and regular message checks provide an adequate system for handling telephone referrals.

Verbatim wording from the response
“In response to your request to review the policies and procedures in place regarding the processing of referrals to Wigan Recovery North, I can confirm that a review of these procedures has been undertaken by ████████, Matron for Quality, in conjunction with the respective team manager.”

Source location
2016-0268-Response-5-Borough-Partnership-NHS-Trust
Page 1 · response
Published 26 July 2016
Open published response
13 Jun2016
Preston and West Lancashire
Concerns raised1
1. 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Andrew Gus PEEBLES · 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

The circumstances of Andrew Gus Peebles’s death are said to be set out in the attached summing up, jury findings and conclusion; the inquest concluded on 18 May 2016. The substantive concerns included failures to record or undertake mental-health assessments and referrals, inadequate review of relevant documentation, and insufficient evidence of supervision or retraining after the concerns were identified.

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 undertake referred psychiatric assessment
Wider context from the report
“(7) on referral on 25 May 2013 by and RGN who was concerned about Mr Peebles psychiatric state to two RMNs no record was made in the medical record of any such referral having taken place and no referral or assessment did subsequently take place ”
Source location
Andrew Gus PEEBLES · Prevention of Future Deaths report
Page 1 · concerns
Open source report
13 Jun2016
London (East)
Concerns raised1
1. 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Laura McRory · 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

Laura McRory, who had a history of anxiety, depression and alcohol misuse, was assessed at hospital on 20 June 2015 after deterioration in her mental state and increased alcohol consumption. She was discharged without immediate follow-up or continued observation and was found unresponsive the following day; she died from alcohol and mixed drug consumption. The principal concerns were the adequacy of the discharge safety plan and the lack of a clear process for referring NELFT staff seeking mental healthcare to another Trust when they were unwilling to share information with colleagues.

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 a system for prompt referral of staff to another Trust for mental healthcare
Wider context from the report
“• ████████ did not consider there to be an adequate safety plan in place for Mrs McRory. He also considered that there needed to be a system in place for staff to be promptly referred to a different Trust where they present with mental health difficulties and request services from a different Trust. ████████ did confirm that he was in the process of drafting a protocol to deal with this issue. A copy of the draft protocol was not provided. ”
Source location
Laura McRory · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Apr2016
Birmingham and Solihull
Concerns raised1
1. 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.
Linked response

Black Country Healthcare NHS Foundation Trust
Stated actions 3
1. Black Country Healthcare NHS Foundation Trust
  Implement an MHLS checklist prompting postcode reviews to prevent incorrect referral routes.
2. Black Country Healthcare NHS Foundation Trust
  Revise the SPOR duty system to prevent inappropriate referrals being returned, enable direct onward signposting, and confirm referral receipt by telephone.
3. Black Country Healthcare NHS Foundation Trust
  Review the MHLS protocol to introduce the Common Assessment Tool and Clustering Tool for direct referrals.
AI-generated summary

Richard Paul Martin Grant · 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

Richard Paul Martin Grant was found deceased in his car in his garage on 7 January 2016 following inhalation of helium gas. He had previously self-harmed and threatened suicide, but his counselling referral was sent to the wrong team and an appointment was arranged for 22 February 2016. The report identified concerns about delays and failures in referring him to the appropriate mental health service and in informing his GP about the assessment and its 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
Failure to refer patients who have attempted suicide to the right mental health team within a reasonable time
Wider context from the report
“(1) Mental Health Nurse Catherine Collins of the Oak Unit Mental Health Liaison Team gave evidence that the referral to the Black Country Partnership Single Point of Referral (‘SPOR’) team was faxed on the 7th December 2015. Only when Mr. Grant chased with Oak Unit why he had not received an appointment or further contact from Mental Health Services on the 4th January 2016 was it identified that his referral ought to have been sent to the Birmingham and Solihull Mental Health NHS Foundation Trust single point of access team. Ms. Collins and the Black Country Partnership have provided no explanation for what happened to Mr. Grant’s referral between it being sent on the 7th December and the 4th January 2016. A clear risk to life clearly arises from patients who have been referred because of suicide attempt not being referred to the right team within a reasonable time. ”
Source location
Richard Paul Martin Grant · Prevention of Future Deaths report
Page 1 · 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
Implement an MHLS checklist prompting postcode reviews to prevent incorrect referral routes.

Verbatim wording from the response
“1. A MHLS checklist is being developed and shared through team meetings which include prompts to review postcodes of patients to avoid incorrect referral route – Timescale for completion May 2016. (Completed)”

Source location
2016-0157-Response-by-Black-Country-NHS
Page 3 · response
Published 21 April 2016
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
Revise the SPOR duty system to prevent inappropriate referrals being returned, enable direct onward signposting, and confirm referral receipt by telephone.

Verbatim wording from the response
“2. Review of SPOR duty system is underway and will include ceasing practice of sending inappropriate referrals back to referrer. Clinician will continue to review all referrals and will forward / signpost referrals directly onwards. System will also include confirmation of receipt by telephone call. Timescale for completion May 2016. (Completed)”

Source location
2016-0157-Response-by-Black-Country-NHS
Page 3 · response
Published 21 April 2016
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
Review the MHLS protocol to introduce the Common Assessment Tool and Clustering Tool for direct referrals.

Verbatim wording from the response
“3. MHLS protocol being reviewed to encompass use of Common Assessment Tool and Clustering Tool to enable direct referrals from MHLS. Timescale for completion August 2016.”

Source location
2016-0157-Response-by-Black-Country-NHS
Page 3 · response
Published 21 April 2016
Open published response
2 Feb2016
Plymouth, Torbay and South Devon
Concerns raised2
1. Failure to re-refer patients to the Mental Health Team when clinically appropriate
2. 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.
Linked responses

Knowle House Surgery
Livewell Southwest
Stated actions 2
1. Livewell Southwest
  Review the process for urgent referrals.
2. Knowle House Surgery
  Meet with secondary-care psychiatry colleagues to discuss referral rejection and complete a Significant Event analysis of the death.
Respondent positions 1
1. Knowle House Surgery
  The hunger strike was considered likely to result in a slow suicide, so the urgent referral was not considered to require an immediate response.
  Disputes the concern
AI-generated summary

Michael John Valentine · 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 John Valentine was found deceased on 16 September 2015 after a period in which he disclosed that he was not eating and stated that he had been on hunger strike. The concerns included an urgent mental health assessment referral being rejected without being brought to the relevant clinician’s attention, the failure to make a second referral after he reported not eating for 25 days, and the absence of discussion of these issues in the surgery’s significant events meeting.

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 re-refer patients to the Mental Health Team when clinically appropriate
Wider context from the report
“(1) A fax rejecting the request for a mental health assessment was sent back to the Surgery. This was classed as routine and was not brought to the attention of ████████. It was left in a tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until after the death of Mr Valentine. (2) After the telephone consultation on 10 September, ████████ agreed that it would have been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his disclosure that he had not eaten for 25 days. (3) ████████ told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected. ”
Source location
Michael John Valentine · 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 review decisions not to re-refer patients to the Mental Health Team
Wider context from the report
“(1) A fax rejecting the request for a mental health assessment was sent back to the Surgery. This was classed as routine and was not brought to the attention of ████████. It was left in a tray for dealing (filing) but, unfortunately, due to staff absence, this did not come to light until after the death of Mr Valentine. (2) After the telephone consultation on 10 September, ████████ agreed that it would have been appropriate to refer Mr Valentine to the Mental Health Team for a second time given his disclosure that he had not eaten for 25 days. (3) ████████ told the Court that there had been a significant events meeting which had looked at the administrative shortcomings in the Surgery. There had been no discussion, however, of her decision not to re-refer following the 10 September telephone contact. Similarly, there has been no discussion of what to do where an application for a mental health assessment has been rejected. ”
Source location
Michael John Valentine · 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 process for urgent referrals.

Verbatim wording from the response
“I am writing in response to your letter sent to our Medical Director. In order to progress this we have had a meeting with Senior Management of Livewell South West and myself as Clinical Director of Adult Mental Health and have reviewed the case. We have reviewed the process of urgent referrals. We note that Knowle House Surgery considered this as part of their Significant Event Process and we met with the practice on Friday 18th March. We understand that the practice will forward a record of the meeting to you.”

Source location
Michael-Valentine-Response2
Page 1 · response
Published 2 February 2016
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
Meet with secondary-care psychiatry colleagues to discuss referral rejection and complete a Significant Event analysis of the death.

Verbatim wording from the response
“We met with our Secondary Care Psychiatry colleagues on 18th March 2016 and discussed the rejection process as well as carrying out a Significant Event analysis on Mr Valentine’s death.”

Source location
Michael-Valentine-Response
Page 1 · response
Published 2 February 2016
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 hunger strike was considered likely to result in a slow suicide, so the urgent referral was not considered to require an immediate response.

Verbatim wording from the response
“After discussion it was confirmed that the referral requested was a Mental Capacity Assessment and not a Mental Health Act Assessment. Although the referral was put through as urgent the fact that he was on hunger strike meant that his suicide was likely to be slow and the request for a physical health examination was reasonable.”

Source location
Michael-Valentine-Response
Page 2 · response
Published 2 February 2016
Open published response
16 Nov2015
East London
Concerns raised3
1. Failure to refer patients from the Intake team to an appropriate service
2. Lack of clarity about retaining patients or referring them to other services
3. 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.
Linked response

North East London NHS Foundation Trust
Stated actions 1
1. North East London NHS Foundation Trust
  Review and implement AABIT standard operating procedures.
AI-generated summary

EMMA LOUISE BRAY · 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

Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

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 refer patients from the Intake team to an appropriate service
Wider context from the report
“During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”
Source location
EMMA LOUISE BRAY · 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 clarity about retaining patients or referring them to other services
Wider context from the report
“During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”
Source location
EMMA LOUISE BRAY · 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
Delays in psychiatric referral and assessment after initial assessment
Wider context from the report
“During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”
Source location
EMMA LOUISE BRAY · 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 and implement AABIT standard operating procedures.

Verbatim wording from the response
“The plan has five broad objectives within which your specific concerns have been addressed. These are:”

Source location
2015-0438-Response-by-NELFT-NHS-Trust
Page 1 · response
Published 16 November 2015
Open published response
2 Nov2015
Blackburn, Hyndburn and Ribble Valley
Concerns raised2
1. Lack of emergency department visibility of referral acceptance and assessment timing
2. 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.
Linked response

Lancashire & South Cumbria NHS Foundation Trust
Stated actions 1
1. Lancashire & South Cumbria NHS Foundation Trust
  Explore developing an email referral system providing receipt confirmation and an approximate assessment time.
AI-generated summary

Jacqueline Williams · 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

On 26 January 2015, Jacqueline Williams was taken to Royal Blackburn Hospital and assessed as being at moderate risk of self-harm, but a referral to the Mental Health Liaison Team was not accepted because of a communication breakdown. She subsequently hanged herself in an emergency department cubicle; concerns related to referral errors and systems that did not make missed or unaccepted referrals readily identifiable and rectifiable.

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 emergency department visibility of referral acceptance and assessment timing
Wider context from the report
“That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment. ”
Source location
Jacqueline Williams · 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 of the referral process to identify and rectify errors
Wider context from the report
“That the process of referral to the Mental Health Liaison Team was subject to human error and that the systems in place failed to provide for such mistakes to be easily identified and rectified. In particular there was no opportunity for staff in the emergency department to see confirmation that a referral had been accepted, the time of that referral and the expected time when a mental health assessment would take place. Likewise the Mental Health Liaison Team did not have a process that whereby they were able to identify those patients that the staff in the emergency department believed had been referred and were awaiting assessment. ”
Source location
Jacqueline Williams · Prevention of Future Deaths report
Page 1 · 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
Explore developing an email referral system providing receipt confirmation and an approximate assessment time.

Verbatim wording from the response
“A further option we are exploring is the development of a system whereby East Lancashire Hospital NHS Trust staff email the Mental Health Liaison Team with the patient's details and a brief reason for referral. The Mental Health Liaison Team would then acknowledge receipt of the email and also give approximate time of assessment. The referral information is already recorded within the Mental Health Liaison referral log book, however this approach we are looking to implement will ensure that positive confirmation is provided to Emergency Department staff.”

Source location
2015-0421-Response-by-Lancashire-Care-NHS-Trust
Page 2 · response
Published 2 November 2015
Open published response
1 Jun2015
Inner North London
Concerns raised1
1. 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.
Linked response

North London NHS Foundation Trust
Stated actions 1
1. North London NHS Foundation Trust
  Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.
AI-generated summary

Mark Patrick DANIELS · 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

Mark Patrick Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. The principal concerns were failures to carry out and record planned visits, communicate within the team and with crisis houses, progress a crisis-house referral promptly, and consider hospital admission despite identified suicide risk and Mr Daniels stating that he did not feel safe at home.

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
Delays in progressing referrals to a crisis house
Wider context from the report
“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”
Source location
Mark Patrick DANIELS · 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
Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.

Verbatim wording from the response
“████████ Associate Divisional Director for the Acute division has considered your concerns and put in place a comprehensive action plan to address them – the action plan is appended at the end of this letter. As you can see from the action plan updates, several”

Source location
2015-0208-Response-by-Camden-and-Islington-NHS-Trust
Page 1 · response
Published 1 June 2015
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to refer to mental health services

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

Linked responses

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to process and action referrals to the community mental health team

Linked response

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to undertake referred psychiatric assessment

Concerns raised1

Lack of a system for prompt referral of staff to another Trust for mental healthcare

Concerns raised1

Failure to refer patients who have attempted suicide to the right mental health team within a reasonable time

Linked response

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

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

Linked responses

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

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

Linked response

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

Stated actions 1

Respondent positions 2

Stated actions 2

Respondent positions 2

Stated actions 3

Stated actions 2

Respondent positions 1

Stated actions 1