Recurring concern
Failure to provide timely continuing mental health reviews and follow-up
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Request correctionFirst reported 17 Jan 2014•Latest report 25 Jun 2026
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.
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.
- Reports
- 47
- Individual concerns
- 55
- Date range
- 2014–2026
- Stated actions
- 52
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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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Position
Medical review decisions remain risk- and needs-led through multidisciplinary processes rather than being governed by a fixed post-discharge Consultant Psychiatrist review mandate.
Stated by Surrey and Borders Partnership NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Develop a social work checklist guiding risk assessment, escalation, communication, recording and crisis planning for mental health and duty cases.
Stated by Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department -
Action
Disseminate the checklist and safety-huddle procedures to Community Mental Health Team social work staff.
Stated by Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department -
Action
Develop Local Authority mental health, escalation, risk-management, pathway, and reporting and recording policies and procedures, including crisis planning.
Stated by Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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 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.
Responses linked to these concernsEach 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
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Action
Appoint two substantive Consultant Psychiatrists and support them with an Associate Specialist.
Stated by Sussex Partnership NHS Foundation Trust -
Action
Review the medical caseload to ensure patients receive annual medical reviews as required.
Stated by Sussex 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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Position
Whether to discuss a patient at weekly MDT meetings is left to clinical judgment because experienced staff may review care without MDT discussion.
Stated by Sussex Partnership NHS Foundation Trust
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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
Responses linked to these concernsEach 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
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Action
Add an SSRI and suicidality prompt to the first mental health assessment template.
Stated by University of Bristol Students’ Health Service -
Action
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.
Stated by University of Bristol Students’ Health Service -
Action
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.
Stated by University of Bristol Students’ Health Service
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Action
Distribute a Trust-wide alert requiring adherence to NICE antidepressant-prescribing guidance, documented seven-day review responsibility, and auditable team responses.
Stated by Avon and Wiltshire Mental Health Partnership NHS Trust -
Action
Require medical leads to discuss the prescribing alert with all line reports to reinforce effective communication.
Stated by Avon and Wiltshire Mental Health Partnership NHS 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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Position
Changing QOF depression review criteria requires national-level action, with feedback routed through the local CCG.
Stated by University of Bristol Students’ Health Service
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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.
Responses linked to these concernsEach 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
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Action
Use the Bristol Matrix to identify patients requiring psychiatric assessment, supported by established staff training.
Stated by Cardiff & Vale University LHB
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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Position
Existing Bristol Matrix procedures and established training are considered sufficient to identify patients requiring immediate psychiatric assessment.
Stated by Cardiff & Vale University LHB
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Position
Home treatment with frequent specialist input was considered appropriate, balancing admission risks and the patient's unwillingness to be admitted.
Stated by Cardiff & Vale University LHB
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026