First reported 21 Nov 2013•Latest report 4 Mar 2026
Definition
What this concern includes
Includes delayed, inconsistent, inaccessible or poorly coordinated urgent and out-of-hours referrals for specialist mental-health assessment.
Not included
Excludes routine non-urgent appointments and follow-up.
Excludes failures within a separately named crisis, liaison or home-treatment service unless the urgent referral and assessment pathway is itself deficient.
Reports
36
Distinct published reports
Individual concerns
40
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
68
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 Care5
Essex Partnership University NHS Foundation Trust4
Herefordshire and Worcestershire Health and Care NHS Trust4
Norfolk and Suffolk NHS Foundation Trust4
NHS England3
South West London and St George'S Mental Health NHS Trust2
Sussex Partnership NHS Foundation Trust2
Black Country Healthcare NHS Foundation Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Bloomfield Medical Centre1
CRG Medical Services1
Cricket Green Medical Practice1
East London NHS Foundation Trust1
General Medical Council1
Gloucestershire Health and Care NHS Foundation Trust1
NHS trust29
Ministerial department6
Integrated care board4
Executive non-departmental public body3
Healthcare site3
English county council2
Independent healthcare provider2
English metropolitan district council1
English unitary authority1
Executive agency1
Health and care professional regulator1
London borough council1
Mayoral policing body1
Police force1
Prison or young offender institution1
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.
Inner North London
Concerns raised1
Failure to act on urgent psychiatric review referrals
This report raised 6 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.
Blackpool and the Fylde
Concerns raised1
Lack of clinician understanding of how to make urgent referrals into the PIMHT
This report raised 5 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.
Worcestershire
Concerns raised1
Lack of staff understanding of cross-trust urgent mental health referral procedures
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.7
Action
Update the CRT operational policy to define inter-Trust referrals, urgency levels, transfer responsibilities, documentation, and comprehensive information for receiving services.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2023.
Action
Communicate the updated inter-Trust referral and transfer arrangements to staff in the affected services by email.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2023.
Action
Meet with the other trust’s senior urgent-care managers and share Crisis Team operational policies to clarify services, referrals and triage.
Stated by Gloucestershire Health and Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2023.
Action
Strengthen the Mental Health Liaison Team SOP by defining referral service agreements, intervention timeframes, confirmation emails, assessment and outcome records, and EPR entries.
Stated by Gloucestershire Health and Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2023.
Action
Share the revised Mental Health Liaison Team SOP changes with all team members through team meetings.
Stated by Gloucestershire Health and Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2023.
Action
Ratify the revised Mental Health Liaison Team SOP at the scheduled governance and performance meeting.
Stated by Gloucestershire Health and Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 June 2023.
Action
Undertake a dip-sample audit of Mental Health Liaison Team referrals in six months to test practice and embed learning.
Stated by Gloucestershire Health and Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 June 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust considers its updated inter-Trust referral system robust and sufficient to prevent recurrence.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised2
Failure to arrange mental health practitioner contact without placing the burden on patients in crisis
Lack of GP awareness of how to request urgent psychiatric reviews
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.2
Action
Use the Medical Leadership Forum to reiterate the urgent referral process and address concerns.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 20 December 2022.
Action
Disseminate information to GPs about urgent psychiatric review routes through direct communications, Teamnet and primary care network meetings.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 December 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Patients in crisis are not expected to initiate contact; Home Treatment or Crisis Teams contact patients after referral and triage.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The established urgent-access process, including Single Point of Access, Home Treatment, Crisis Team and out-of-hours arrangements, is considered sufficient.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Home Treatment or Crisis clinicians, rather than GPs, determine and arrange urgent psychiatric medical review following assessment.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and NHS Herefordshire and Worcestershire Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Teesside and Hartlepool
Concerns raised1
Failure to provide timely access to second (s.12) doctors out of office hours for MHA assessments
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
Review local availability of section 12 doctors through regional teams and identify further national mitigation for out-of-hours access.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 16 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Integrated care systems are responsible for managing local section 12 doctor rotas and ensuring 24/7 availability.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Worcestershire
Concerns raised3
Unavailability of timely urgent TAG referral handling at weekends
Reliance on internal post for urgent TAG referrals
Delays in reaching and opening urgent TAG referrals
This report raised 15 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
Add urgent mental health referral routes, service hours and escalation contact details to mental health team email signatures.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Action
Provide and operate an answerphone for urgent referrals when staff lack immediate computer access, with messages logged and forwarded by the administration team.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Action
End paper TAG referrals and transition referrals to the electronic process.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Specific operational queries about mental health provision at HMP Hewell should be directed to Midlands Partnership NHS Foundation Trust.
Stated by Practice Plus GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The paper referral process could not immediately be stopped because transition without communication risked referrals being missed.
Stated by Practice Plus GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised1
Lack of clarity about the meaning of “urgent” referrals to the Access and Assessment Team
This report raised 2 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.
Inner South London
Concerns raised1
Referral to Crisis Resolution and Home Treatment Teams depending on officers' recognition of urgency
This report raised 2 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
Operate a 24-hour mental-health advice and support line for the public, police and ambulance service, staffed by mental-health professionals who can initiate rapid joint assessment.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
Black Country
Concerns raised1
Urgent referral mechanisms via safeguarding teams and GPs failing to work effectively
This report raised 6 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
Create a joint database or protocol containing current service contacts, organisational hierarchies, governance arrangements and escalation processes.
Stated by Black Country Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
Action
Review current joint agency protocols with the Urgent Care Manager and Mental Health Trust.
Stated by Sandwell Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
London Inner South
Concerns raised1
Failure to provide urgent psychiatric referral when clinically needed
This report raised 5 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.
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Includes delayed, inconsistent, inaccessible or poorly coordinated urgent and out-of-hours referrals for specialist mental-health assessment.
