Recurring concern

Failure to provide timely psychiatric review through home treatment teams

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First reported 25 Apr 2017•Latest report 19 Sep 2019

Definition

What this concern includes

Includes failures of the home treatment team process for obtaining psychiatric review, including urgent review, dedicated or rota-based consultant access, availability, escalation and arrangements ensuring psychiatrists respond within a clinically safe timeframe.

Not included

Excludes general mental-health service capacity or waiting-time concerns that are not specifically tied to psychiatric review through a home treatment team.
Excludes failures of routine psychiatric appointments, inpatient review or community mental-health review outside the home treatment team.
Excludes deficiencies in the wider crisis-response or home-treatment service, such as accommodation, staffing or admission decisions, unless they directly impair access to required psychiatric review.
Excludes failures limited to the quality of a psychiatric review after it has been provided.

Reports: 3
Individual concerns: 6
Date range: 2017–2019
Stated actions: 5

Reports 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.

East London NHS Foundation Trust1

NHS Birmingham and Solihull Integrated Care Board1

NHS England1

Pennine 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.

19 Sep2019
Manchester South
Concerns raised3
1. Unreliable rota-based access to psychiatric advice for the Home Treatment Team
2. Failure to progress and communicate recruitment arrangements for the dedicated consultant psychiatrist post
3. Lack of a dedicated consultant psychiatrist allocated to the 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 2
1. Action
  Acquire additional CCG funding to extend medical cover for the Home Treatment Team.
  Stated by Dr Henry TichehurstStated completed
2. Action
  Provide part-time interim medical cover to the Home Treatment Team through the Trust Medical Director.
  Stated by Dr Henry TichehurstStated in progress
Respondent positions 1
1. Position
  A dedicated full-time Consultant Psychiatrist is not required; the existing sector consultant model provides Home Treatment Team medical access.
  Stated by Dr Henry TichehurstExisting arrangements considered sufficient
AI-generated summary

Mr Bromley · 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

Mr Bromley was receiving support from the Home Treatment Team after declining an informal hospital admission. He was found dead on 18 February 2019 at his gym, having suspended himself by the neck with a ligature; the inquest recorded a conclusion of suicide. The concerns related to the Home Treatment Team’s lack of a dedicated Consultant Psychiatrist, uncertainty about recruitment to such a post, and the patchy operation of interim psychiatric access arrangements.

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
Unreliable rota-based access to psychiatric advice for the Home Treatment Team
Wider context from the report
“1. Despite the fact the Home Treatment Team purports to offer a genuine alternative to hospital treatment, it is a matter of concern that the Team does not currently have access to a dedicated Consultant Psychiatrist specifically allocated to the service; 2. Whilst the action plan which accompanied the Trust’s internal investigation made reference to plans to recruit to such a post, the manager from the service who gave evidence appeared unaware of any substantive recruitment process currently in train, let alone the timescales within which it might reasonably be anticipated the post will be filled; 3. Although interim measures are in place whereby practitioners in the Home Treatment Team can access a psychiatrist on a rota system, the court heard evidence that the operation and effectiveness of this measure is patchy, with much depending on the individual approach of the particular psychiatrist in dealing with queries from this team alongside their existing workload. ”
Source location
Mr Bromley · Prevention of Future Deaths report
Page 1 · 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
Failure to progress and communicate recruitment arrangements for the dedicated consultant psychiatrist post
Wider context from the report
“1. Despite the fact the Home Treatment Team purports to offer a genuine alternative to hospital treatment, it is a matter of concern that the Team does not currently have access to a dedicated Consultant Psychiatrist specifically allocated to the service; 2. Whilst the action plan which accompanied the Trust’s internal investigation made reference to plans to recruit to such a post, the manager from the service who gave evidence appeared unaware of any substantive recruitment process currently in train, let alone the timescales within which it might reasonably be anticipated the post will be filled; 3. Although interim measures are in place whereby practitioners in the Home Treatment Team can access a psychiatrist on a rota system, the court heard evidence that the operation and effectiveness of this measure is patchy, with much depending on the individual approach of the particular psychiatrist in dealing with queries from this team alongside their existing workload. ”
Source location
Mr Bromley · Prevention of Future Deaths report
Page 1 · 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 dedicated consultant psychiatrist allocated to the Home Treatment Team
Wider context from the report
“1. Despite the fact the Home Treatment Team purports to offer a genuine alternative to hospital treatment, it is a matter of concern that the Team does not currently have access to a dedicated Consultant Psychiatrist specifically allocated to the service; 2. Whilst the action plan which accompanied the Trust’s internal investigation made reference to plans to recruit to such a post, the manager from the service who gave evidence appeared unaware of any substantive recruitment process currently in train, let alone the timescales within which it might reasonably be anticipated the post will be filled; 3. Although interim measures are in place whereby practitioners in the Home Treatment Team can access a psychiatrist on a rota system, the court heard evidence that the operation and effectiveness of this measure is patchy, with much depending on the individual approach of the particular psychiatrist in dealing with queries from this team alongside their existing workload. ”
Source location
Mr Bromley · 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
Acquire additional CCG funding to extend medical cover for the Home Treatment Team.

Verbatim wording from the response
“In addition the Home Treatment Team has acquired additional CCG funding to extend the medical cover to the Home Treatment Team. This was known and already agreed at the point of the inquest. In the short term the Trust Medical Director is providing part-time cover to the team.”

Source location
2019-0307-Response-by-Pennine-Care-NHS-Trust
Page 2 · response
Published 5 November 2019
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
Provide part-time interim medical cover to the Home Treatment Team through the Trust Medical Director.

Verbatim wording from the response
“In addition the Home Treatment Team has acquired additional CCG funding to extend the medical cover to the Home Treatment Team. This was known and already agreed at the point of the inquest. In the short term the Trust Medical Director is providing part-time cover to the team.”

Source location
2019-0307-Response-by-Pennine-Care-NHS-Trust
Page 2 · response
Published 5 November 2019
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 dedicated full-time Consultant Psychiatrist is not required; the existing sector consultant model provides Home Treatment Team medical access.

Verbatim wording from the response
“The Home Treatment Team national core fidelity model does not mandate that teams should have a full time designated Consultant Psychiatrist but that the team should have access to a medic. How this is achieved differs dependant on how local services are commissioned and provided. Some services operate on a model where consultant work will be divided by function i.e. one for inpatient wards, one for CMHT, one for HTT and other areas work on a sector model where the patient is allocated to a consultant dependant on the postcode in which they reside and will have the same consultant no matter where they are in the pathway.”

Source location
2019-0307-Response-by-Pennine-Care-NHS-Trust
Page 1 · response
Published 5 November 2019
Open published response
4 Oct2018
Birmingham and Solihull
Concerns raised1
1. Unavailability of urgent psychiatrist review through home treatment teams
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 1
1. Action
  Work with partners to address recruitment and retention challenges so services are appropriately resourced.
  Stated by NHS Birmingham and Solihull Integrated Care BoardStated planned
AI-generated summary

Michael Paul Wheeler · 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

Michael Paul Wheeler died after jumping from a fourth-floor window at his brother’s home on 26 July 2018, following increasing paranoia and bizarre behaviour. The principal concerns were that he was not reviewed by a psychiatrist, had no treatment plan, and had no planned review on 26 July; broader concerns were raised about pressures on mental health services, including the availability of urgent psychiatric reviews and inpatient beds.

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
Unavailability of urgent psychiatrist review through home treatment teams
Wider context from the report
“3. The fact that at the current time HTT cannot always provide urgent medical review by a psychiatrist creates a risk to life. ”
Source location
Michael Paul Wheeler · 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
Work with partners to address recruitment and retention challenges so services are appropriately resourced.

Verbatim wording from the response
“8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.”

Source location
Birmingham-and-Solihull-CCG-Response
Page 9 · response
Published 4 October 2018
Open published response
25 Apr2017
Inner North London
Concerns raised2
1. Failure to provide timely face-to-face psychiatric assessment after worsened-condition referral
2. Lack of Consultant Psychiatrist assessment for worsened conditions referred to the Home Treatment Team
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 2
1. Action
  Require escalation of Home Treatment referrals not seen within 48 hours to a consultant psychiatrist or team manager for prioritised review.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Provide routine doctor review within 72 hours for Home Treatment referrals without prior professional assessment, with out-of-hours emergency review by on-call psychiatry.
  Stated by East London NHS Foundation TrustStated completed
AI-generated summary

Jamie Neil Elliott · 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

Jamie Neil Elliott died by hanging at his home on 18 November 2016, with an inquest conclusion of suicide. Before his death, he had expressed clear, detailed and escalating suicidal ideation and had declined offered voluntary inpatient admission. Concerns included failures to contact his private therapist and to provide a face-to-face psychiatric assessment after his condition deteriorated.

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 psychiatric assessment after worsened-condition referral
Wider context from the report
“2. There should be a psychiatric assessment, by a Consultant Psychiatrist in circumstances where there is a referral to the Home Treatment Team where a patient’s condition has worsened. Ideally this should be within 48 hours and should be a face to face psychiatric assessment. ”
Source location
Jamie Neil Elliott · Prevention of Future Deaths report
Page 3 · 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 Consultant Psychiatrist assessment for worsened conditions referred to the Home Treatment Team
Wider context from the report
“2. There should be a psychiatric assessment, by a Consultant Psychiatrist in circumstances where there is a referral to the Home Treatment Team where a patient’s condition has worsened. Ideally this should be within 48 hours and should be a face to face psychiatric assessment. ”
Source location
Jamie Neil Elliott · 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
Require escalation of Home Treatment referrals not seen within 48 hours to a consultant psychiatrist or team manager for prioritised review.

Verbatim wording from the response
“In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:”

Source location
2017-0135-Response-by-East-London-NHS-Trust
Page 2 · response
Published 10 July 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
Provide routine doctor review within 72 hours for Home Treatment referrals without prior professional assessment, with out-of-hours emergency review by on-call psychiatry.

Verbatim wording from the response
“In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:”

Source location
2017-0135-Response-by-East-London-NHS-Trust
Page 2 · response
Published 10 July 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Unreliable rota-based access to psychiatric advice for the Home Treatment Team

Failure to progress and communicate recruitment arrangements for the dedicated consultant psychiatrist post

Lack of a dedicated consultant psychiatrist allocated to the Home Treatment Team

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Unavailability of urgent psychiatrist review through home treatment teams

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

Concerns raised2

Failure to provide timely face-to-face psychiatric assessment after worsened-condition referral

Lack of Consultant Psychiatrist assessment for worsened conditions referred to the Home Treatment Team

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

Actions described in response 2

Respondent positions 1

Actions described in response 1

Actions described in response 2