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
Delays in AMHPS referral and assessment across weekends and bank holidays
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
Improve staff and manager fluency in routes and response expectations for general mental health and Mental Health Act assessments.
Stated by East London NHS Foundation Trust and London Borough of HackneyStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2018.
Manchester South
Concerns raised1
Unavailability of out-of-hours GP referral routes for emergency mental health care in Trafford
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.4
Action
Maintain reciprocal commissioning arrangements so patients can access mental health services across Manchester and Trafford borders.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 April 2018.
Action
Align Manchester and Trafford mental health service specifications and agree clear cross-border arrangements with other Greater Manchester commissioners and trusts.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 4 April 2018.
Action
Escalate disputed referrals promptly to service managers for timely resolution and use the Cross Border Matrix to clarify registration and residency responsibilities.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 April 2018.
Action
Maintain reciprocal additional funding for cross-boundary specialist mental health services, including crisis out-of-hours support.
Stated by Matt ColledgeStated completedThe respondent said that this action was complete when they made their response on 4 April 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The breakdown was not due to inappropriate differential commissioning models between Trafford CCG and Manchester commissioners.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Somerset
Concerns raised1
Failure to obtain urgent psychiatric input
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
Restructure initial-assessment clinics to support staff decision-making and involve psychiatrists and senior clinicians earlier.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
Action
Hold weekly multidisciplinary meetings with psychiatrists to guide complex case discussions and identify cases requiring psychiatric input.
Stated by Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
Action
Provide psychiatric liaison nurses at Somerset acute hospitals to assess self-harm and suicidal presentations and coordinate follow-up or paediatric admission.
Stated by Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
Action
Operate a jointly funded CAMHS Enhanced Outreach Service providing multidisciplinary support seven days a week, including psychiatric support.
Stated by NHS Somerset Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
Action
Provide practitioners with open access to a multidisciplinary team including a psychiatrist through the Single Point of Access.
Stated by NHS Somerset Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
Action
Operate an out-of-hours CAMHS Enhanced Outreach Team to accept urgent referrals and provide intensive home support.
Stated by NHS Somerset Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
Action
Distribute the on-call psychiatrist rota electronically across the service.
Stated by NHS Somerset Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Limited psychiatrist numbers mean psychiatrists cannot see every case involving suicidal ideation; experienced senior clinicians therefore assess and manage many cases.
Stated by Somerset NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
London Inner (West)
Concerns raised1
Lack of a procedure for following up urgent GP concerns or referrals
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.2
Action
Formalise guidance for GPs on raising urgent concerns and referrals with lead CCG involvement.
Stated by South West London and St George'S Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2017.
Action
Share the formalised GP concerns and referrals guidance with GP colleagues after sign-off.
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 3 October 2017.
City of London
Concerns raised1
Delays in granting urgent psychiatric assessments
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Delays in obtaining urgent Consultant Psychiatrist assessment for a person with a dual diagnosis
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised1
Lack of an intermediate urgent mental health referral timeframe
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
Enable Triage Team Leaders to book priority appointments directly.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 February 2016.
Action
Require daily review of out-of-hours referrals and arrange appointments within 24 hours when clinically indicated.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 February 2016.
Action
Fast-track referrals to the first available appointment based on risk assessment.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 February 2016.
Action
Develop a Coastal West Sussex protocol documenting the improved referral system, with the inquest checklist and flowchart appended.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 February 2016.
Action
Meet West Sussex mental health commissioners to jointly review the urgent care pathway in light of the improvements and current practice.
Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 February 2016.
Brighton and Hove
Concerns raised1
Delays in responding to urgent concerns about known vulnerable patients
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.3
Action
Co-locate urgent-response and assessment teams and establish an information-sharing protocol and shared communication tools.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 June 2015.
Action
Provide a daily Duty Lead to prioritise incoming work, support call-taker decisions, and maintain team communication records.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 June 2015.
Action
Introduce face-to-face assessment for East ATS service users making three calls within two weeks, subject to senior clinical review and documented rationale for exceptions.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 June 2015.
Norfolk
Concerns raised1
Unavailability of timely urgent mental health assessment during increased demand
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.1
Action
Review locality escalation plans for Crisis Resolution and Home Treatment and Dementia Intensive Support Team services to strengthen capacity escalation and contingency responses.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 March 2015.
Worcestershire
Concerns raised1
Failure to treat clinically identified urgent referrals as urgent
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.4
Action
Develop a countywide standardised urgent-referral system with performance measures and a policy defining urgent and routine response timescales.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2015.
Action
Implement the standardised urgent-referral process in Wyre Forest.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2015.
Action
Operate the Redditch and Bromsgrove urgent-referral protocol, including triage within 24 hours and face-to-face assessment within 24 hours where required.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2015.
Action
Gather data and review the effectiveness of the recently implemented referral process, identifying issues requiring attention.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2015.
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Includes delayed, inconsistent, inaccessible or poorly coordinated urgent and out-of-hours referrals for specialist mental-health assessment.
