Recurring concern

Inadequate mental health assessment before care decisions

First to latest report 15 Jul 2015 — 1 Feb 2026

Reports that mention this concern
12
Times this concern has been raised
12
Stated actions linked to this concern
28

What this concern includes

Includes failures to obtain, review or use sufficient information and assessment before consequential mental health care decisions, including multidisciplinary reviews, discharge clearance and conclusions about whether a mental health condition is present.

What is not included
  • Excludes physical-health, mental-capacity and generic risk assessments unless the assertion specifically concerns assessment of mental health before a care decision.
  • Excludes failures limited to multidisciplinary meeting attendance, documentation or communication where the underlying mental health assessment was adequate.
  • Excludes treatment, admission, discharge or follow-up failures occurring after a sufficiently complete mental health assessment and decision.
  • Excludes generic mental-health staffing, training or service-capacity deficiencies unless they directly make the pre-decision mental health assessment inadequate.

Reports and published responses 12 reports

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

  1. Preston and West Lancashire

    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

    Formation of mental health conclusions without reviewing relevant documentation or undertaking mental health assessment

    Wider context from the report

    “(6) RMN formed the view that Mr Peebles was not suffering from any mental health condition without having reviewed the ACC T documentation, discipline documentation or undertaking any mental health assessment prior to informing the deceased of her decision. ”

    Source location

    Andrew Gus PEEBLES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. City of London

    AI-generated summary

    Karen O’Brien · 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

    Karen O’Brien suffered from chronic pain and depression and had disclosed thoughts of self-harm. After a mental health referral, SEPT determined that a face-to-face assessment was not required; she later jumped into the path of an underground train, and the inquest concluded that she killed herself, with multiple injuries as the medical cause of death. The principal concerns were the lack of further inquiry or face-to-face assessment and the basis on which SEPT overrode the GP’s request, including its interpretation of NICE guidance.

    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 adequate clinical inquiry and mental health assessment before making a clinical determination

    Wider context from the report

    “It is difficult to understand how there can be a clinical determination by SEPT without more inquiry and, preferably, some face-to-face assessment of the patient by a mental health professional. The NICE guidance is stated to be a recommendation. It must therefore be presumed not to be applied slavishly without careful assessment. The patient’s GP had asked for her to be seen. On what basis did SEPT decide to override the GP’s request? ”

    Source location

    Karen O’Brien · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

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Data last updated 7 September 2026