Recurring concern

Failure to reliably follow up identified mental-health safety concerns

First to latest report 5 May 2013 — 25 Jun 2026

Reports that mention this concern: 17
Times this concern has been raised: 17
Stated actions linked to this concern: 38

What this concern includes

Includes failures in processes for recording, contacting, escalating, tracking and following up identified mental-health safety concerns, including suicide risk, when initial contact attempts fail or a promised clinical response does not occur.

What is not included

Excludes routine psychiatric follow-up or appointment-access failures where no identified mental-health safety concern requires a specific follow-up response.
Excludes failures limited to mental-health risk assessment, treatment or observation when the follow-up and escalation process is not deficient.
Excludes generic communication or documentation deficiencies unless they directly leave an identified mental-health safety concern without follow-up or protective action.
Excludes family-contact failures unrelated to an identified mental-health safety concern.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3

Birmingham and Solihull Mental Health NHS Foundation Trust2

NHS Birmingham and Solihull Integrated Care Board2

Avon and Wiltshire Mental Health Partnership NHS Trust1

Betsi Cadwaladr University LHB1

Birmingham Women'S and Children'S NHS Foundation Trust1

Black Country Healthcare NHS Foundation Trust1

Central and North West London NHS Foundation Trust1

College of Policing1

Counsellor1

Cumbria Constabulary1

Essex Partnership University NHS Foundation Trust1

Foxhayes Surgery GP Practice1

Home Office1

London Borough of Camden1

Reports and published responses 17 reports

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

14 Sep2018
Birmingham and Solihull
Concerns raised1
1. Failure to follow up with receiving services and patients after mental health care transfers
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Daniel Hubert Collins · 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

Daniel Hubert Collins attempted to take his own life by overdose on 07/04/18 and was discharged from hospital and then from the FTB crisis team, with responsibility placed on him to contact counselling services. He went missing on 26/04/18 and was found deceased in woodland on 28/04/18; the medical cause of death was venlafaxine overdose. The report identified concern that the transfer between mental health services was not communicated or followed up, creating a risk that patients in or recently out of crisis could be lost to mental health services.

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 follow up with receiving services and patients after mental health care transfers
Wider context from the report
“One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis. ”
Source location
Daniel Hubert Collins · Prevention of Future Deaths report
Page 1 · concerns
Open source report
27 Jun2017
Staffordshire South
Concerns raised1
1. Failure to provide follow-up after community mental health assessment
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Midlands Partnership University NHS Foundation Trust
Respondent positions 2
1. Midlands Partnership University NHS Foundation Trust
  The assessment found low suicide risk and sufficiently detailed needs assessment, so discharge after one consultation was considered the right decision.
  Disputes the concern
1. Midlands Partnership University NHS Foundation Trust
  Existing self-help resources, GP referral routes and CMHT re-referral contacts were considered sufficient without ongoing CMHT follow-up.
  Existing arrangements considered sufficient
AI-generated summary

Dean Mark Rowland · 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

Dean Mark Rowland, who had a history of two recent self-harm attempts and depression, was found hanging from a bannister on 21 March 2017, and the inquest concluded that his death was suicide. Concerns included his inability to obtain a GP appointment or telephone consultation for nine days when he wished to discuss increasing his antidepressant medication, and his discharge from the community mental health team after one consultation without a follow-up plan beyond returning to primary care.

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 follow-up after community mental health assessment
Wider context from the report
“(2) He was referred to a community mental health team having made two serious previous suicide attempts. He was discharged after only one consultation with no follow up plan other than for him to refer back to primary care. The family perceived he would have benefitted from a further appointment. He was very willing to engage with services. ”
Source location
Dean Mark Rowland · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
The assessment found low suicide risk and sufficiently detailed needs assessment, so discharge after one consultation was considered the right decision.

Verbatim wording from the response
“When seen on 19th August 2016, Mr Rowland had moved to Birmingham in order to reside with his mother, and reported improvements in his mental health due to this change of environment and a now amicable relationship with his ex-wife and access to his children. Mr Rowland described his wellbeing “feel like I have my life back and am like my old self” and reported various self-help methods such as exercise and making time for himself. Importantly he expressed no further ideas of suicide. A Patient Health Questionnaire 9 (PHQ-9) was completed as part of the assessment; this is a 9-item questionnaire to explore current symptoms of depression, yielding a score of between 0 and 27. Mr Rowland scored 8, which is indicative of mild depression that would not usually require treatment; scores of 15 and above are usually seen in individuals requiring the input of a CMHT.”

Source location
2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
Page 2 · response
Published 12 September 2017
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
Existing self-help resources, GP referral routes and CMHT re-referral contacts were considered sufficient without ongoing CMHT follow-up.

Verbatim wording from the response
“Mr Rowland engaged fully in his assessment and coproduced the plan which was later communicated to him by letter. He felt that the difficulties in his mental health had improved and that he did not require input from the CMHT, but was aware that he could be re-referred at any time should this situation change. The letter validated his efforts to be well and detailed online self-help resources to support these efforts, and also recommended that he register with a GP in Birmingham if he wished to continue to reside there, so that he could be referred quickly to his local mental health services in future should the need arise. If the assessment had highlighted the need for ongoing input from the CMHT, this would have been transferred to the service in Birmingham local to Mr Rowland’s new residence, but as described it was not required.”

Source location
2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
Page 2 · response
Published 12 September 2017
Open published response
8 Dec2016
Manchester South
Concerns raised1
1. Failure to attempt timely contact with a Mental Health service user after a suggestion that he needed to leave home immediately
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Pennine Care NHS Foundation Trust
Stated actions 3
1. Pennine Care NHS Foundation Trust
  Complete and use Stockport Community Services’ process for responding to crisis calls as a model for other boroughs’ guidance.
2. Pennine Care NHS Foundation Trust
  Disseminate and deliver a briefing on triggers and escalation processes for responding to crisis calls.
3. Pennine Care NHS Foundation Trust
  Discuss adding crisis-call response guidance as an addendum to each community team’s operational policy at the Tier 4 meeting.
AI-generated summary

Sandra Brotherton · 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 Brotherton was killed at her home on 31 December 2014, shortly after returning from hospital. The inquest heard that she had been the predominant and effectively sole carer for a person with a dual diagnosis of paranoid schizophrenia and Asperger’s Syndrome, who had been alone at home during her hospital stay. Concerns included the lack of a clearly discussed contingency plan, inadequate documentation and sharing of care-plan information with the Personal Assistant, difficulty obtaining an urgent psychiatric appointment, and insufficient follow-up after Sandra requested that he be rehoused immediately.

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 attempt timely contact with a Mental Health service user after a suggestion that he needed to leave home immediately
Wider context from the report
“4) Having heard the evidence as to the events of September 2014 there is no doubt that this was an unusual call to be made by Sandra. Not in itself suggestive of an assault but suggestive of a potential issue involving a Mental Health service user and it is for this reason that I do find that there should have been an attempt to see or speak to ████████ to see how he was, after there had been a suggestion that he needed to leave his home immediately ”
Source location
Sandra Brotherton · Prevention of Future Deaths report
Page 3 · 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
Complete and use Stockport Community Services’ process for responding to crisis calls as a model for other boroughs’ guidance.

Verbatim wording from the response
“Work around responding to crisis calls completed by Stockport Community Services will feed into the Tier 4 meeting for other boroughs to develop similar guidance locally. Confirmation will be sought that community teams in other boroughs have a process for responding to crisis calls.”

Source location
2016-0400-Response-by-Pennine-Care-NHS-Trust
Page 3 · response
Published 26 February 2017
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
Disseminate and deliver a briefing on triggers and escalation processes for responding to crisis calls.

Verbatim wording from the response
“To share the learning highlighted in this regulation a 7 minute briefing regarding response to crisis calls has been developed regarding crisis calls and has been shared with all community based mental health teams in the Trust. The briefing recommends that community teams need to have triggers for responding to crisis calls and an escalation process in place. Community Team Managers have delivered the briefing to teams, to reflect on the findings and recommendations in the briefing, to discuss the implications for individual practitioners practice and for the service or team. They have been asked to outline the steps they will take to improve practice in line with the recommendation.”

Source location
2016-0400-Response-by-Pennine-Care-NHS-Trust
Page 3 · response
Published 26 February 2017
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
Discuss adding crisis-call response guidance as an addendum to each community team’s operational policy at the Tier 4 meeting.

Verbatim wording from the response
“To be discussed at the Tier 4 meeting to discuss adding guidance as an addendum to current operational policy for each community based team.”

Source location
2016-0400-Response-by-Pennine-Care-NHS-Trust
Page 4 · response
Published 26 February 2017
Open published response
26 Jul2016
Manchester West
Concerns raised1
1. Failure by support services to act on and follow up service-user overdose disclosures
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Lee Francis Grimes · 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

Lee Francis Grimes, who was known to misuse cocaine and had schizophrenia, was found collapsed and unresponsive at home on 21 March 2016. Before his death, he disclosed on two occasions that he had taken an overdose of prescribed medication, but the disclosures did not result in assessment or treatment, and a message to the Community Mental Health Team was not followed up or acted upon. The report raised concerns about failures in responding to overdose disclosures and referral messages, and about staff training and procedures.

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 by support services to act on and follow up service-user overdose disclosures
Wider context from the report
“i. That no action was taken by an employee of Next Stage following Mr Grimes’ disclosure of an overdose of medication on Thursday the 17th March. I have further concern that when action was taken on the Friday 18th March, a message was left for the Community Mental Health Team which was not followed up by Next Stage, or answered and actioned by the Community Mental Health Team. Although Mr Grimes’ death was not as a result of an overdose, he did not receive any assessment, or treatment, in respect of the overdose he disclosed. In view of the fact that there was no contact from the Next Stage or the Community Mental Health team over the weekend, he was vulnerable to taking a further overdose of medication. ii. I have concerns that if this situation occurs in the future, another person could die. In view of that I would ask that the current policies and procedures in place at Next Stage to deal with the disclosure of an overdose of medication by a service user, are reviewed, and cascaded down to all employees. I would also request that a review is carried out by 5 Boroughs Partnership of the policies and procedures in place regarding the processing of referrals to Wigan Recovery North given the fact that the message left by ████████ on the Friday morning was never acted upon, as if this were to happen again in the future I believe there could be a further death. ”
Source location
Lee Francis Grimes · Prevention of Future Deaths report
Page 3 · concerns
Open source report
8 Oct2015
Norfolk
Concerns raised1
1. Failure to follow up and act on identified suicide risk
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Norwich Practices Health Centre and Walk-in Centre
Stated actions 6
1. Norwich Practices Health Centre and Walk-in Centre
  Develop a Mental Health Care Plan template for integration into SystmOne.
2. Norwich Practices Health Centre and Walk-in Centre
  Read-code existing Mental Health Care Plans to trigger visible patient-record alerts.
3. Norwich Practices Health Centre and Walk-in Centre
  Review identified patients’ Mental Health Care Plans and discuss concerns at weekly clinical meetings.
1. Norwich Practices Health Centre and Walk-in Centre
  Contact significant-concern patients after mental-health discharge notices and offer GP review appointments about ongoing support.
2. Norwich Practices Health Centre and Walk-in Centre
  Establish and weekly review a Patients of Significant Concern register, removing patients only when concern lessens or resolves.
3. Norwich Practices Health Centre and Walk-in Centre
  Automatically refer suicide attempts by children under 16 to the Safeguarding Team.
AI-generated summary

SOLOMON JAMES BEALEY · 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

Solomon James Bealey, aged 15, was found in his bedroom on 5 February 2015 with a bag over his head and a cord around his neck, having left a note to his family. Concerns included that no action or follow-up was taken after a nurse and doctor became aware of signs of stress and a previous suicide attempt, and that the doctor did not know letters sent to Solomon’s mother had been received.

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 follow up and act on identified suicide risk
Wider context from the report
“(1) Solomon was taken to see a Nurse at the Walk In Clinic on 1 October 2014 for minor medical matters. The Nurse became concerned at signs of stress and was aware that in 2010 Solomon was found preparing to hang himself, and so arranged for an on call Doctor to see him. No action was taken. The Nurse expressed her concerns to a GP in the practice. A telephone call was made to a number believed to be that of the mother of Solomon, but it was a wrong number. The Doctor wrote to Solomon's mother on two occasions and received no reply. The matter was not pursued any further. (2) Although the letters had been received by Solomon's mother who discussed this with Solomon and his father and it was decided to take no further action, the Doctor was unaware that the letters had been received. (3) No follow up action was taken. ”
Source location
SOLOMON JAMES BEALEY · Prevention of Future Deaths report
Page 1 · 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
Develop a Mental Health Care Plan template for integration into SystmOne.

Verbatim wording from the response
“Action – The clinical team are in the process of developing a template for a Mental Health Care Plan to be integrated onto SystmOne, our hosted clinical IT system. As a result of this review, Mental Health Care Plans already in place have been read-coded. This triggers a patient status alert which is visible under the patient demographic box and on the patient’s home screen. Patients that we have identified will have a review of their care plan before 30.11.15 and any concerns will be discussed at our weekly clinical meeting.”

Source location
2015-0403-Response
Page 1 · response
Published 8 October 2015
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
Read-code existing Mental Health Care Plans to trigger visible patient-record alerts.

Verbatim wording from the response
“Action – The clinical team are in the process of developing a template for a Mental Health Care Plan to be integrated onto SystmOne, our hosted clinical IT system. As a result of this review, Mental Health Care Plans already in place have been read-coded. This triggers a patient status alert which is visible under the patient demographic box and on the patient’s home screen. Patients that we have identified will have a review of their care plan before 30.11.15 and any concerns will be discussed at our weekly clinical meeting.”

Source location
2015-0403-Response
Page 1 · response
Published 8 October 2015
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
Review identified patients’ Mental Health Care Plans and discuss concerns at weekly clinical meetings.

Verbatim wording from the response
“Action – The clinical team are in the process of developing a template for a Mental Health Care Plan to be integrated onto SystmOne, our hosted clinical IT system. As a result of this review, Mental Health Care Plans already in place have been read-coded. This triggers a patient status alert which is visible under the patient demographic box and on the patient’s home screen. Patients that we have identified will have a review of their care plan before 30.11.15 and any concerns will be discussed at our weekly clinical meeting.”

Source location
2015-0403-Response
Page 1 · response
Published 8 October 2015
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
Contact significant-concern patients after mental-health discharge notices and offer GP review appointments about ongoing support.

Verbatim wording from the response
“Action – For patients identified as a significant concern, discharge notices from the Mental Health team will trigger contact, via telephone, from the practice to the patient to offer an appointment for GP review to discuss ongoing need for support.”

Source location
2015-0403-Response
Page 2 · response
Published 8 October 2015
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
Establish and weekly review a Patients of Significant Concern register, removing patients only when concern lessens or resolves.

Verbatim wording from the response
“Action - We have a standing agenda item ‘Patients of Concern’ at our weekly clinical meeting. With immediate effect, we have agreed to have a ‘Patients of Significant Concern’ register. Patients will be added as agreed at the clinical meeting and the register will be reviewed weekly. Patients will only be removed from the list if the level of concern has lessened or resolved.”

Source location
2015-0403-Response
Page 2 · response
Published 8 October 2015
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
Automatically refer suicide attempts by children under 16 to the Safeguarding Team.

Verbatim wording from the response
“• Any suicide attempt made by a child under 16years will trigger an automatic referral to the Safeguarding Team.”

Source location
2015-0403-Response
Page 2 · response
Published 8 October 2015
Open published response
4 Jun2015
Cumbria
Concerns raised1
1. Discharge without timely and adequate follow-up care for a person remaining at risk
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Alice Anne McMeekin · 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

Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

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
Discharge without timely and adequate follow-up care for a person remaining at risk
Wider context from the report
“2.The Partnership Trust The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6th June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that day. 3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder. He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence. The evidence at inquest shows that this was a very disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care, which could, as a consequence have made a difference. It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder. ”
Source location
Alice Anne McMeekin · Prevention of Future Deaths report
Page 1 · concerns
Open source report
5 May2013
North London
Concerns raised1
1. Failure to arrange follow-up assessment of the effect of medication with an increased risk of self-harm
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Roshen Abbas Ladak-Ebrahim · 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

Roshen Abbas Ladak-Ebrahim, aged 22, was found having hanged himself at home on the evening of 11 October 2012. The report raised concerns about assessing and recording immediate risk of self-harm, ensuring patients at risk were not left alone, and requiring appropriate medical consultation and follow-up when prescribing medication associated with increased self-harm risk.

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 arrange follow-up assessment of the effect of medication with an increased risk of self-harm
Wider context from the report
“Consideration to be given to guidance whereby a doctor working in the community mental health agencies is required to have a consultation with a patient before prescribing medication that carries an increased risk of self-harm when first prescribed and arranges to see the patient again to assess the effect of the medication. ”
Source location
Roshen Abbas Ladak-Ebrahim · Prevention of Future Deaths report
Page 2 · concerns
Open source report

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to follow up with receiving services and patients after mental health care transfers

Concerns raised1

Failure to provide follow-up after community mental health assessment

Linked response

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to attempt timely contact with a Mental Health service user after a suggestion that he needed to leave home immediately

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure by support services to act on and follow up service-user overdose disclosures

Concerns raised1

Failure to follow up and act on identified suicide risk

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised1

Discharge without timely and adequate follow-up care for a person remaining at risk

Concerns raised1

Failure to arrange follow-up assessment of the effect of medication with an increased risk of self-harm

Respondent positions 2

Stated actions 3

Stated actions 6