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.
Manchester South
Concerns raised2
Failure to allow direct referral from general practice to the HBTT for urgent high-risk referrals
Delays in assessment and referral for urgent mental health referrals
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.5
Action
Issue a Practice Note clarifying that primary care mental health practitioners can directly refer patients to HBTT across all Trust boroughs.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.
Action
Include direct HBTT referral guidance in the Trust Patient Safety Newsletter distributed electronically to all staff.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2026.
Action
Hold an urgent-care away day to review and confirm the HBTT SOP and reinforce referral pathways and operational expectations, including direct referrals by primary care networks.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2026.
Action
Finalise the Referral and Assessment hub SOP by the end of May 2026.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2026.
Action
Establish a functioning Referral and Assessment hub in every Trust area by the end of August 2026 to provide a single external referral point.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Mental health practitioners in general practice can directly refer to HBTT across all Trust boroughs after assessing the person’s mental health.
Stated by Greater Manchester Mental Health NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised1
Failure to make urgent mental health referrals
This report raised 13 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.4
Action
Establish and staff a dedicated Early Days in Custody Nurse role to oversee reception screening, risk assessment, information sharing, escalation, supervision, and quality assurance.
Stated by HCRG Care GroupStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Deliver targeted mental-health awareness training and support reception nurses to identify suicide, self-harm, acute distress, and appropriate ACCT observation levels.
Stated by HCRG Care GroupStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Review mental-health operational procedures and referral processes to clarify urgent-referral thresholds, escalation routes, and expected 24-hour response times.
Stated by HCRG Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Reissue mandatory escalation guidance and introduce MDT agendas and case-presentation templates for changing risk or uncertainty.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Kent and Medway
Concerns raised1
Limited out-of-hours availability of MHT+ support for Rapid Response Team referrals
This report raised 9 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.
Essex
Concerns raised1
Failure to provide an appropriate urgent psychiatric appointment
This report raised 10 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
Route crisis-team communications and psychiatrist review requests to multidisciplinary team mailboxes.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 June 2025.
Action
Provide three senior leads to support the crisis team.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 June 2025.
Northamptonshire
Concerns raised1
Failure to accept a referral despite available information indicating escalating suicide risk
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.2
Action
Develop new risk management processes, including policy updates and revised risk documentation, for UCAT and crisis and community services.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 January 2025.
Action
Enable UCAT and Talking Therapies staff to access full records for service users in their care.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 January 2025.
Suffolk
Concerns raised1
Delays in Crisis Resolution and Home Treatment Team review for Mental Health Unit admission
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Crisis Team remains responsible for inpatient assessments under national practice to ensure community alternatives are considered before admission.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Suffolk
Concerns raised1
Failure to enable AMHPs to make direct referrals to the emergency Crisis Resolution and Home Treatment Team
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
Develop and disseminate concise guidance to Suffolk AMHPs on CRHTT referral criteria and processes.
Stated by Suffolk County CouncilStated completedThe respondent said that this action was complete when they made their response on 10 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
AMHPs were able to refer directly to the CRHTT, and the NSFT 111 Service could also make such referrals.
Stated by Suffolk County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Western)
Concerns raised1
Failure to identify urgency in referrals involving paranoia, delusions and suicidal ideation
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
No further action is proposed for Single Point of Access referrals because that service no longer operates and referrals now enter individual services.
Stated by Sheffield Health Partnership University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Unclear urgent and crisis referral pathways from private practitioners to NHS services
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.
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
Maintain a ratified Private Providers Shared Care Policy defining Trust and private-provider roles and responsibilities.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
Action
Make the Private Providers Shared Care Policy accessible on the Trust website and communicate its existence internally and through local GP networks.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Improve and publish prominent website information directing healthcare professionals to urgent mental-health crisis referrals, including the 24/7 crisis line.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
Action
Share crisis-referral information externally through social media, website news articles, and campaign materials.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
Action
Remind staff about the Urgent Care Pathway, checking private treatment and consent, and the Private Providers Shared Care Policy through a Monthly Learning Bulletin and local GP networks.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Review the interface between NHS and non-NHS-funded independent health providers.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
Action
Expand urgent and emergency mental health care and access to crisis services.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
No national or local system provides contact details for every private provider, so referral information cannot feasibly reach all providers.
Stated by South West London and St George'S Mental Health NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Private providers can refer patients directly to crisis services through the Mental Health Crisis Line, 111, 999 or A&E.
Stated by South West London and St George'S Mental Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
National review of psychiatric referral pathways is considered a matter for the Department of Health and NHS England.
Stated by South West London and St George'S Mental Health NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The relevant NHS mental health trust is responsible for providing further information about its emergency referral signposting for private providers.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised1
Inadequate risk assessment in response to urgent referrals
This report raised 12 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
Update the Clinical Risk Assessment and Management Policy through governance, publish it, and progress its implementation plan.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
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Includes delayed, inconsistent, inaccessible or poorly coordinated urgent and out-of-hours referrals for specialist mental-health assessment.
