Recurring concern
Failure to provide timely continuing mental health reviews and follow-up
- Reports that mention this concern
- 47
- Times this concern has been raised
- 55
- Stated actions linked to this concern
- 52
What this concern includes
Includes absent or delayed scheduled, early, annual, post-crisis, post-emergency or transfer-of-care mental health reviews and follow-up after a continuing need has been established.
What is not included
- Initial access to mental health assessment before a continuing review or follow-up need is established.
- Routine non-mental-health primary-care follow-up.
- Treatment-quality failures after a timely required review or follow-up occurred.
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
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 47 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Lack of mandated face-to-face consultant psychiatrist review after acute-unit discharge
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Surrey and Borders Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Surrey and Borders Partnership NHS Foundation Trust
Medical review decisions remain risk- and needs-led through multidisciplinary processes rather than being governed by a fixed post-discharge Consultant Psychiatrist review mandate.
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Concerns raised1
Failure to make every possible effort to contact people under mental health care after credible indications of an immediate risk of harm
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Betsi Cadwaladr University LHB
- Wrexham County Borough Council Social Services department
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
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Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department
Develop a social work checklist guiding risk assessment, escalation, communication, recording and crisis planning for mental health and duty cases.
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Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department
Disseminate the checklist and safety-huddle procedures to Community Mental Health Team social work staff.
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Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department
Develop Local Authority mental health, escalation, risk-management, pathway, and reporting and recording policies and procedures, including crisis planning.
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Concerns raised1
Lack of formal mental-health review
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of psychiatric follow-up or support after transfer of care to GP
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Failure of weekly professional team meetings to review mental health deterioration and medication non-compliance
Failure to provide regular Psychiatrist review
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sussex Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Sussex Partnership NHS Foundation Trust
Appoint two substantive Consultant Psychiatrists and support them with an Associate Specialist.
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Sussex Partnership NHS Foundation Trust
Review the medical caseload to ensure patients receive annual medical reviews as required.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Sussex Partnership NHS Foundation Trust
Whether to discuss a patient at weekly MDT meetings is left to clinical judgment because experienced staff may review care without MDT discussion.
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Concerns raised1
Failure to make a follow-up appointment at discharge
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to arrange timely follow-up review after starting antidepressants for people at increased suicide risk or younger than 30 years
Linked responses
- Avon and Wiltshire Mental Health Partnership NHS Trust
- University of Bristol Students’ Health Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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University of Bristol Students’ Health Service
Add an SSRI and suicidality prompt to the first mental health assessment template.
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University of Bristol Students’ Health Service
Schedule routine reviews one week after starting an SSRI, with booked or known follow-up appointments and appropriate follow-up after cancellations or non-attendance.
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University of Bristol Students’ Health Service
Recruit a permanent mental health nurse, define a role reviewing higher-risk or SSRI-starting patients at seven days, and plan use of the new resource with local partners.
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Avon and Wiltshire Mental Health Partnership NHS Trust
Distribute a Trust-wide alert requiring adherence to NICE antidepressant-prescribing guidance, documented seven-day review responsibility, and auditable team responses.
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Avon and Wiltshire Mental Health Partnership NHS Trust
Require medical leads to discuss the prescribing alert with all line reports to reinforce effective communication.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
University of Bristol Students’ Health Service
Changing QOF depression review criteria requires national-level action, with feedback routed through the local CCG.
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Concerns raised1
Failure to arrange psychiatric liaison assessment and professional follow-up after overdose
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cardiff & Vale University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Cardiff & Vale University LHB
Use the Bristol Matrix to identify patients requiring psychiatric assessment, supported by established staff training.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Cardiff & Vale University LHB
Existing Bristol Matrix procedures and established training are considered sufficient to identify patients requiring immediate psychiatric assessment.
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Cardiff & Vale University LHB
Home treatment with frequent specialist input was considered appropriate, balancing admission risks and the patient's unwillingness to be admitted.
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Concerns raised1
Failure to provide needed follow-up review in mental health care
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to provide psychiatrist review and treatment planning for patients with acute paranoid or aggressive presentations
Lack of planned follow-up review for mental health patients
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026