Recurring concern

Unreliable urgent mental health referral and assessment pathways

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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

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.

  1. Inner North London

    AI-generated summary

    Sandra Bodrožič’ · 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

    Sandra Bodrožič’ died after running to the attic, saying goodbye and jumping from a window, landing three storeys below. She had previously been detained under the Mental Health Act and treated in hospital and the community. The substantive concerns included delays in finding a hospital bed, arranging a Mental Health Act assessment, and the absence of clear urgency or timeframe protocols for such assessments.

    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 arranging urgent Mental Health Act assessments

    Wider context from the report

    “3. The approved mental health professional (AMHP), a social worker, who visited Ms Bodrožič’ on Wednesday, 25 June 2014, decided that she needed a Mental Health Act assessment and immediately made the appropriate referral. However, once the referral was made, it took until the following week for this to be arranged, and Ms Bodrožič’ had killed herself in the meantime, on Sunday, 29 June. Healthcare professionals explained in court that Mental Health Act assessments are, by their very nature, urgent, yet there seemed to be a general acceptance by the team that they will usually take several days to take place, in this case from a Wednesday until the following Tuesday. The provision for assessment is open ended, with no apparent sense of urgency, and there is no protocol for the timeframe within which this should take place, nor is a time agreed as appropriate with patient or family. Ms Bodrožič’s family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit. ”

    Source location

    Sandra Bodrožič’ · 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

    Record in the electronic patient record how risks from delays in Mental Health Act assessments will be mitigated.

    Verbatim wording from the response

    “3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 3 · response
    Published 24 November 2014

    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

    Escalate delays caused by unavailable external agencies to senior management and add recurrent delays to the Trust risk register.

    Verbatim wording from the response

    “3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 3 · response
    Published 24 November 2014

    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

    Alert commissioners to London Ambulance Service delays and poor GP attendance at Mental Health Act assessments.

    Verbatim wording from the response

    “d) An alert to delays by the London Ambulance Service to attend MHA assessments have been made to the Joint Commissioner in Camden, and also of the poor attendance of GP’s to MHA assessments with the Joint Commissioners in the London Borough of Islington.”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 3 · response
    Published 24 November 2014

    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

    A specific agreed timeframe for mental health act assessments was not possible because coordinating multiple agencies with competing priorities can be difficult.

    Verbatim wording from the response

    “3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

    Source location

    2014-0560-Camden-Islington-NHS-Trust
    Page 3 · response
    Published 24 November 2014

    Open published response

  2. Norfolk

    AI-generated summary

    Graeme Alexander Kidd · 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

    Graeme Alexander Kidd was found hanging at home on 6 March 2014 and died in hospital on 7 March 2014. The report identified concerns about locum doctors’ access to records and knowledge of local mental health services, delays in GP referrals, the lack of medication advice when the prescribing doctor was unavailable, and the delayed implementation of an action plan addressing these matters.

    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 urgent mental health referrals caused by a mandatory physical health check

    Wider context from the report

    “(3) GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay in cases requiring urgent referral ”

    Source location

    Graeme Alexander Kidd · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. West Yorkshire (East)

    AI-generated summary

    Mary WANYA · 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

    Mary Wanya died after falling through a hospital window on 1 November 2011 while in an acutely confused and agitated state. The window restrictor was defective, allowing the window to be fully opened. Concerns included delays in psychiatric assessment, the assessment and treatment of mental illness on the Medical Admissions Unit, her earlier diagnosis and discharge, and the inadequacy of the Trust’s investigation report.

    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 obtaining urgent psychiatric assessments

    Wider context from the report

    “1. (i) There was a considerable delay of over 60 hours before a psychiatrist attended St James’s University Hospital to assess Mary Wanya. In fact the psychiatrist arrived 5 minutes after her fall had occurred and hence she never received a psychiatric assessment. (ii) The Trust should review the system for obtaining urgent psychiatric assessments, particularly out of hours, with a view to speeding up and providing a more efficient service. (iii) In view of the size and scale of the St James’s University site the Trust should consider having an on site resident psychiatrist to avoid the obvious delay in bringing psychiatrists from St Mary’s Hospital, which is some distance away and will exacerbate delay. (iv) The Trust should consider making arrangements with the Mental Health Trust responsible for the Becklin Centre so that the Becklin Centre staff should be involved with such patients, particularly out of hours, to avoid delay and to provide earlier diagnosis and treatment. Had Mrs Wanya been transferred to the Becklin Centre and been psychiatrically assessed and her treatment had commenced much earlier, it is likely that this death could have been avoided. (v) There is an inferior system for the assessment and treatment of patients on the Medical Admissions Unit of patients suffering from mental illness in comparison with those who are physically ill. The Trust should therefore review this urgently and ensure that the systems are developed to provide for a faster system to rule out physical illness that might cause or contribute to mental disturbance and when this has been achieved to provide a prompt assessment, diagnosis and treatment for such patients in respect of their obvious mental illness. ”

    Source location

    Mary WANYA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester West

    AI-generated summary

    Kyle Ashley Smith · 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

    Kyle Ashley Smith was found unresponsive by his wife on 19 October 2013 and was pronounced dead by ambulance staff. A post-mortem found that his death was due to the combined toxic effects of Tramadol, Codeine and Zopiclone; concerns included a delay in an urgent mental-health referral reaching the assessment team, the reason for which had not been investigated and was not known.

    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 urgent referrals reaching the Mental Health Assessment Team

    Wider context from the report

    “(1) Mr Smith’s GP was concerned about his mental health when she saw him on the 15th of October 2013, to the degree that she decided to refer him urgently to the Mental Health Assessment Team. (2) That referral did not reach the Team until the 18th of October. (3) The reason for this delay has not been investigated and is not currently known. ”

    Source location

    Kyle Ashley Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Worcestershire

    AI-generated summary

    Sean Christopher Seabourne · 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

    Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.

    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 provide timely face-to-face assessment of patients at high risk of concealed suicide

    Wider context from the report

    “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests. (2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient. (3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team. It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself. It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself. Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case. ”

    Source location

    Sean Christopher Seabourne · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Sunderland

    AI-generated summary

    Peter Galea · 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

    Peter Galea, a 51-year-old man, attended hospital and other agencies repeatedly over a 72-hour period and was assessed as low risk on three occasions. On 11 June, after leaving his GP surgery and threatening to jump from a bridge, his body was found under the Queen Alexandra Bridge and he was pronounced dead. Concerns included limited mechanisms for breaking referral cycles, restrictions on direct GP referral for admission to a place of safety, and whether different action might have prevented the 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

    Limitations on GPs making direct referrals for admission to a place of safety

    Wider context from the report

    “Mr Galea was not known to mental health services and experienced multiple presentations to a number of professionals and agencies within a 72 hour period and had 3 mental health assessments, all of which placed him at a low risk. Whilst it is a tragedy that the professionals and agencies did not have more of an opportunity to work with Mr Galea before he took his own life, I was concerned, that: - 1) there appeared to be limited mechanisms available to break the cycle of referrals between agencies without more positive action being taken whereby Mr Galea could be in a safe place whilst a more detailed assessment of his needs could be carried out possibly involving a psychiatrist. The family described the referral between agencies as “ping pong”. 2) there were limitations upon the GP making a direct referral to have Mr Galea admitted to Cherry Knowle Hospital, because to do so Mr Galea would have had to go back to the Mental Health Team, with whom he had had three contacts within a 72 hour period. From the evidence it was clear that the GP had a positive relationship with his patient (for 4 years) and although prospectively acquiescing to the patient’s wishes, in exceptional circumstances, it may be that a GP should be able to achieve an admission to a place of safety, even if only for a limited period of time. I readily acknowledge some of the disadvantages which may come into play by way of admission but in raising it there may also be advantages which would promote a patient’s welfare. 3) I was grateful for the assistance of ████████ Consultant Psychiatrist, but he was not able to offer to me any view about what may have been done differently for Mr Galea to avoid this very tragic outcome. In raising the matter with you, it may be that some solution to enhance patient’s welfare and wellbeing can be found to prevent future deaths. ”

    Source location

    Peter Galea · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026