First reported 31 Oct 2014•Latest report 27 May 2026
Definition
What this concern includes
Includes failures to convene or conduct multi-professional, multi-disciplinary or multi-agency case-planning discussions needed to address a person's identified safety concerns or risks, including the anchor's senior professional planning meeting.
Not included
Excludes generic failures of communication, documentation, staffing or training unless they are directly part of convening and conducting the case-planning discussion.
Excludes post-incident learning meetings, governance working groups and routine meetings not intended to assess or manage an individual's safety concerns.
Excludes failures of a specific clinical, safeguarding or other pathway where the discussion is only an incidental component and the wider named pathway is the supported concern.
Reports
18
Distinct published reports
Individual concerns
19
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
29
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 Care3
University Hospitals Sussex NHS Foundation Trust2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Denbighshire County Council1
Department for Education1
Devon County Council1
East Kent Hospitals University NHS Foundation Trust1
East London NHS Foundation Trust1
Essex Partnership University NHS Foundation Trust1
Greater Manchester Police1
HM Prison and Probation Service1
Home Office1
Kent and Medway Mental Health NHS Trust1
Kent County Council1
NHS trust12
Ministerial department4
English county council2
Executive non-departmental public body2
Company limited by guarantee1
Coronial office1
English metropolitan district council1
English unitary authority1
Executive agency1
Fire and rescue service1
Healthcare site1
Integrated care board1
National policing body1
Police force1
Registered provider of social housing1
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.
Essex
Concerns raised1
Lack of multidisciplinary crisis planning meetings
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Use Dynamic Support Register and Care and Treatment Review referral processes to coordinate enhanced community support and alternatives to hospital admission.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Bedfordshire and Luton
Concerns raised1
Absence of an MDT plan to address anti-psychotic depot medication non-concordance
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Reinforce medication non-concordance policies and procedures requiring weekly MDT discussion and comprehensive electronic-record documentation of missed depot injections or adherence concerns.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Action
Embed depot-medication compliance auditing and weekly monitoring, with findings reported through local and Directorate governance and escalated where required.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Action
Formalise MDT risk oversight for medication non-adherence through risk-register inclusion, weekly RAG review, senior multidisciplinary attendance and recording of decisions and responsible clinicians.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Strengthened medication non-concordance procedures, auditing, monitoring and training are considered sufficient; no further action is required.
Stated by East London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Weekly MDT review, risk-register oversight, escalation and documented accountability are considered sufficient; no further action is required.
Stated by East London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Nottinghamshire
Concerns raised1
Lack of an embedded mechanism for cross-sector MDT meetings and liaison in foreign-body cases
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Trial a joint physical and mental health policy for managing patients who insert foreign bodies, including joint meetings and impact review.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2025.
Action
Implement and approve a new guideline for managing deliberately inserted foreign bodies, including clear MDT and mental-health consultation requirements.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.
Mid Kent and Medway
Concerns raised2
Delays in convening multi-agency safeguarding meetings
Lack of a mechanism to convene urgent multi-agency safeguarding meetings
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Deliver the national rollout of reforms to family help, multi-agency child protection and family group decision-making, including multi-agency child protection teams.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Actions taken by the Integrated Care Board, social services and local authority fall outside the national policy or programme remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Integrated Care Board is responsible for providing a separate system-level response detailing local actions taken.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Failure to convene a multidisciplinary meeting to coordinate the biopsy pathway
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Require bedside Infection Service reviews for complex pressure ulcers and multidisciplinary discussion with ward and Tissue Viability teams, escalating appropriate osteomyelitis cases to the complex bone MDT.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 November 2024.
Gateshead and South Tyneside
Concerns raised1
Failure to co-ordinate care through multi-disciplinary and multi-agency meetings
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Establish and operate a monthly South Tyneside Interface Meeting for cross-agency communication, issue resolution, decision-making and planning.
Stated by South Tyneside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Establish and operate a monthly High Intensity User Group to oversee people with repeat or frequent agency interactions.
Stated by South Tyneside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Establish and convene a Suicide Prevention Group when individuals are identified as being at high risk of suicide.
Stated by South Tyneside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Establish weekly multidisciplinary team meetings to discuss high-risk individuals, allocate responsibilities and agree coordinated risk-reduction support.
Stated by South Tyneside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Establish a weekly Risk Management Forum with service and senior management oversight for people whose risks remain or increase despite interventions.
Stated by South Tyneside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Develop and use the Complex Adult Risk Management approach to coordinate assessment, responsibilities, action plans, monitoring and review for adults at serious risk outside safeguarding criteria.
Stated by South Tyneside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Embed safeguarding and multi-agency meeting consideration in Crisis, ADHD and Community Treatment Team meetings, with MDT meetings following each assessment.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Conduct weekly telephone-triage reviews of selected crisis contacts to assess contact quality, safeguarding actions and whether multi-agency meetings were required.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Embed safeguarding and multi-agency meeting checks in four-weekly clinician supervision case reviews across all teams.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Exeter and Greater Devon
Concerns raised1
Failure to conduct multi-agency and multi-disciplinary discussions about concerns and risks
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Lack of multi-disciplinary team discussion to ensure a safe community plan following discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North East Kent
Concerns raised1
Lack of evidence of multi-agency planning meetings before discharge
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North East Kent
Concerns raised1
Failure to hold multi-agency discharge planning meetings
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Update the hospital discharge policy and operating model, supported by discharge guidance action cards defining responsibilities for key roles.
Stated by Kent County CouncilStated completedThe respondent said that this action was complete when they made their response on 19 August 2021.
Action
Establish named KCC hospital discharge leads to attend discharge management meetings and provide social care advice, guidance and escalation.
Stated by Kent County CouncilStated plannedThe respondent said that this action was planned when they made their response on 19 August 2021.
Pin
Get email alerts
Request correction
Includes failures to convene or conduct multi-professional, multi-disciplinary or multi-agency case-planning discussions needed to address a person's identified safety concerns or risks, including the anchor's senior professional planning meeting.
