Recurring concern

Failure to commission care for people with overlapping mental-health and complex needs

First to latest report 12 Mar 2022 — 6 May 2026

Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
3

What this concern includes

Includes failures in commissioning or service-design arrangements where single-diagnosis boundaries leave people with materially overlapping mental-health and complex needs without appropriate assessment, treatment, specialist support or an integrated care pathway, including the anchor's eating difficulties and complex emotional needs and the diagnostic-only commissioning of autism and learning-disability services without mental-health treatment.

What is not included
  • Excludes generic mental-health service capacity, funding or access failures where overlapping or complex needs are not material.
  • Excludes failures within a single-diagnosis pathway where the problem is not that co-occurring needs are left without integrated care.
  • Excludes substance-misuse and mental-health dual-diagnosis pathways where that named concern is the supported boundary.
  • Excludes failures in delivery, staffing or coordination after an appropriate integrated service has been commissioned, unless commissioning remains the deficient condition.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Sunny Elise EYMOND · 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

    Sunny Elise EYMOND died at Winchester Hospice on 27 May 2024 after a long history of anorexia nervosa, personality disorder and complex post-traumatic stress disorder, including hospital admissions and periods of forced feeding. The report identified communication and oversight failings during her transfer of care between Hampshire and Bristol services, including the absence of a robust care package, planned 1:1 professional support and a suitable risk management plan. Concerns were raised about the lack of national guidance and treatment pathways for cross-Trust transfers involving people with eating disorders and complex emotional needs.

    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

    Commissioning arrangements failing to accommodate overlapping eating and emotional needs

    Wider context from the report

    “5. There is currently no national specified treatment pathway for individuals who present with co-existing eating difficulties and complex emotional needs. This, in turn, impacts how services are commissioned, as commissioning arrangements are largely organised around set, diagnosis-specific pathways. To ensure patient safety and national consistency, there is a need for national guidance addressing: a) How to develop a pathway/protocol for patients with eating disorders and complex emotional needs b) When bespoke services (such as the creation of Willow Ward at Parklands Hospital in Sunny's case) are required c) How patients with overlapping needs should be assessed and managed using a formulation-led approach, where single- diagnosis pathways are not appropriate ”

    Source location

    Sunny Elise EYMOND · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a national treatment pathway for co-existing eating disorders and complex emotional needs

    Wider context from the report

    “3. Secondly, I am concerned that there is a gap at a national level (identified by both SH and AWP) in terms of a pathway for those with a diagnosis of both an eating disorder and complex emotional needs. This lack of a pathway created difficulties when Sunny was transferred from SH (Hampshire) to AWP (Bristol) in order to attend university. It meant that there was an inability to appropriately 'map' her treatment needs to the available mental health services in Bristol. I believe that this needs to be addressed at a national level and not just left for each Trust in England. It is a real concern, given the very high risk of death associated with those with both Anorexia Nervosa and a personality disorder, as was the case here. ”

    Source location

    Sunny Elise EYMOND · Prevention of Future Deaths report
    Page 4 · 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

    Publish and apply national guidance integrating Children and Young People Eating Disorder Services with mental health teams for young people with co-occurring needs.

    Verbatim wording from the response

    “In January 2026, NHS England published National Guidance for eating disorder services for children and young people. The guidance highlights that Children and Young People Eating Disorder Services (CEDS) are integral to the integrated care pathway. The guidance states it is important that all care pathways are locally co-produced with stakeholders, including Children and Young People and their families, and that they are also involved in care planning with other key stakeholders, as this ensures optimal pathway integration and delivery of evidence-based, outcomes-focused care.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 2 July 2026

    Open published response

  2. North East Kent

    AI-generated summary

    Samuel Alban Stanley · 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

    Samuel Alban Stanley died in hospital on 26 April 2020 from injuries sustained during an episode of high-risk behaviour related to his Prader-Willi syndrome. The report raised concerns about inadequate support for him and his family, limited access to appropriate services, and poor communication between agencies.

    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

    Diagnostic-only commissioning for children with autism and learning disabilities without an overt mental health diagnosis

    Wider context from the report

    “(3) There was evidence given that the mental health team at North East London Foundation Trust were also aware of Sammy’s high-risk behaviours. Support had been provided by a psychology student in the past and he had reportedly responded well to mindfulness therapy and the de-escalation techniques employed by his family. Psychosocial interventions were not offered by the Mental Health Trust and a Care Education and Treatment Review was suggested but not implemented before Sammy’s death. The court heard that such interventions may not have been successful but, in any event, North East London Foundation Trust had not been commissioned to provide anything other than a diagnostic service to children presenting with autism and learning disabilities rather than an overt mental health diagnosis. ”

    Source location

    Samuel Alban Stanley · 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

    Invest £2.1 million in local neurodevelopmental services to improve provision for children and young people.

    Verbatim wording from the response

    “In terms of the commissioning of services, the CCG actively works with partners across the health system to ensure gaps do not exist and that pathways are in place to cater for the presentations and needs of the local communities it serves. NELFT are commissioned to provide more than just diagnostic services including psychological and psychosocial interventions, but the CCG acknowledge that mental health services are under extreme pressure, with increasing referrals that have significantly peaked during and post pandemic. Therefore, the CCG is actively working with NELFT to ensure that services are developed to meet the needs of all children and young people and to identify areas where the service offer can be strengthened and have increased significant levels of investment to help address this.”

    Source location

    Response from Kent and Medway Clinical Commissioning Group
    Page 3 · response
    Published 17 March 2022

    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

    Work with NELFT to develop children’s mental health services and strengthen the service offer for children and young people.

    Verbatim wording from the response

    “In terms of the commissioning of services, the CCG actively works with partners across the health system to ensure gaps do not exist and that pathways are in place to cater for the presentations and needs of the local communities it serves. NELFT are commissioned to provide more than just diagnostic services including psychological and psychosocial interventions, but the CCG acknowledge that mental health services are under extreme pressure, with increasing referrals that have significantly peaked during and post pandemic. Therefore, the CCG is actively working with NELFT to ensure that services are developed to meet the needs of all children and young people and to identify areas where the service offer can be strengthened and have increased significant levels of investment to help address this.”

    Source location

    Response from Kent and Medway Clinical Commissioning Group
    Page 3 · response
    Published 17 March 2022

    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

    NELFT was commissioned to provide psychological and psychosocial interventions, not solely autism and learning-disability diagnostic services.

    Verbatim wording from the response

    “3. Concern that there was a lack of psychosocial and psychological therapies offered in this case. This was compounded by the information shared that NELFT may not have been commissioned to provide anything other than a diagnostic service for those presenting with autism and learning disabilities rather than an overt mental health issue.”

    Source location

    Response from Kent and Medway Clinical Commissioning Group
    Page 3 · response
    Published 17 March 2022

    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

    Commissioners are responsible for ensuring locally appropriate health and social care services, including services for people with complex needs.

    Verbatim wording from the response

    “You may wish to know that under the Equality Act (2010), health and social care organisations must make reasonable adjustments to ensure that disabled people are not disadvantaged. Commissioners are responsible for ensuring the provision of services based on the local needs of their population, including for people with learning disabilities, mental health problems and complex physical needs. Commissioners should take into consideration any relevant guidance, such as those published by the National Institute for Health and Care Excellence in designing their local services.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 17 March 2022

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026