Recurring concern

Failure to provide timely continuing mental health reviews and follow-up

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First reported 17 Jan 2014•Latest report 25 Jun 2026

Definition

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

Distinct published reports

Individual concerns
55

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
52

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.

Department of Health and Social Care7
NHS England6
NHS Birmingham and Solihull Integrated Care Board4
Pennine Care NHS Foundation Trust3
Sussex Partnership NHS Foundation Trust3
Betsi Cadwaladr University LHB2
Central and North West London NHS Foundation Trust2
East London NHS Foundation Trust2
Greater Manchester Mental Health NHS Foundation Trust2
Leicestershire Partnership NHS Trust2
Midlands Partnership University NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
North London NHS Foundation Trust2
Recipient name withheld2
South West London and St George'S Mental Health NHS Trust2

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.

  1. Birmingham and Solihull

    AI-generated summary

    Stephen Peter Jackson · 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

    Stephen Peter Jackson was found deceased at home on 11 August 2018 after sending his mother a text message saying “sorry”; drugs paraphernalia and a suicide note were present, and the provisional cause of death was a diamorphine overdose. The report raised concerns that he was not seen by mental health clinicians after his GP requested an urgent appointment, despite reported low mood and negative thoughts, and that delays and possible under-funding of mental health services posed a risk of future deaths.

    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 mental health follow-up after hospital discharge

    Wider context from the report

    “1. On the 1st August 2018 Mr. Jackson attended his GP and expressed frustration that following his discharge from hospital on the 23rd July 2018. He had not been contacted by the home treatment team and his GP wrote to the Kingstanding and Erdington Home Treatment Team that same day asking them to expedite his appointment, reporting that Mr. Jackson continued to have low mood and negative thoughts and merited an urgent appointment. 2. Mr. Jackson was not seen by mental health clinicians following the GP request. ”

    Source location

    Stephen Peter Jackson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Birmingham and Solihull

    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

    Transfer of necessary mental health care placing responsibility for initiating contact on patients

    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

    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

  3. Gloucestershire

    AI-generated summary

    MARTIN LEE TILLEY · 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

    Martin Lee Tilley had a long history of substance misuse and significant mental health problems, including self-harm discussions, suicidal thoughts, and apparent visual and auditory hallucinations before his last appointment with the Homeless Healthcare Team in July 2017. He was found deceased on 17 October 2017 from the combined toxic effects of prescribed and non-prescribed medication; concerns were raised that there was no evidence of follow-up by the team after July and no answer explaining whether his presentation should have led to an emergency psychiatric assessment or referral to tertiary 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 patients after missed mental health appointments

    Wider context from the report

    “Prior to Mr Tilley's last appointment with the psychiatric nurse (CPN) attached to the Homeless Healthcare Team in July 2017 he was talking of self-harm, had suicidal thoughts and was apparently experiencing visual and auditory hallucinations. It appears that after not attending an appointment with the CPN in July Mr Tilley was no longer seen by the team. Prior to the inquest the Homeless Healthcare Team were asked to explain the circumstances in which such a presentation would result in a referral for an emergency assessment by a psychiatrist or the tertiary mental health services. No answer to this question was forthcoming. Furthermore there was no evidence that Mr Tilley was followed up by the Homeless Healthcare Team after July 2017. ”

    Source location

    MARTIN LEE TILLEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Inner North London

    AI-generated summary

    Siân Louise WITHERIDGE · 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

    Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis team.

    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 crisis team follow-up meetings

    Wider context from the report

    “5. There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan. False reassurance appeared to have been drawn from the latter. No arrangement was made for the crisis team to meet Ms Witheridge on 30 May. ”

    Source location

    Siân Louise WITHERIDGE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Janet WILLIAMS · 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

    Janet Williams became ill in early 2016 and received mental health care, including admission and home treatment. She died by suicide at home on 8 March 2017 while suffering late onset paranoid schizophrenia. Concerns included failures to record and monitor her care plan, insufficient reviews and medical follow-up, inadequate response to family concerns, and retrospective entries in her medical records.

    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

    Delays in arranging required medical reviews

    Wider context from the report

    “4. A meeting was then scheduled three months’ away, for 9 August 2016, despite the need for medical review and the lack of any alternative arrangement in the meantime. ”

    Source location

    Janet WILLIAMS · Prevention of Future Deaths report
    Page 2 · 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 arrange psychiatrist medical reviews

    Wider context from the report

    “6. Between 11 October 2016 when Ms Williams was discharged by the home treatment team, and her death on 8 March 2017, Ms Williams’ care co-ordinator did not arrange for a medical review by the psychiatrist. ”

    Source location

    Janet WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. South Wales Central

    AI-generated summary

    David Michael Sewell · 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

    David Michael Sewell was found in the bath at his home in the early hours of 5 June 2017 with injuries to his arms and holding a razor. He had a history of mental health difficulties, including previous self-harm and an overdose, and the inquest concluded that the cause of death was transection of the left brachial artery and recorded a conclusion of suicide. The principal concern was the apparent lack of a robust system to ensure that people with mental health problems were seen and appropriately cared for, including further efforts to re-engage Mr Sewell after he did not respond to a letter.

    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

    Lack of a robust system to ensure people with mental health problems are seen and receive appropriate care

    Wider context from the report

    “1) When Mr Sewell attended for the appointment with the Psychiatrist he was told by the main reception that they were unaware of a Health Worker of that name and he left the building. He was contacted by telephone on 3 occasions on the 16th and 17th August but displayed hostility towards members of the team. His case was discussed by the Multi-Disciplinary Team on the 18th August 2016 who decided to write a letter him which was sent on the 26th August inviting him to make contact or otherwise he would be discharged from the Team as care. He did not respond to that letter and no further follow up was made. The concern the evidence revealed relates to the apparent lack of a robust system to ensure that individuals with mental health problems, who may have experienced psychotic episodes as Mr Sewell had, are seen and appropriate care delivered. It was apparent from the evidence that after the letter was sent inviting him to make contact he was simply discharged from the case load with no further efforts or steps being made to try and re-engage him. There was clearly a need to do so. ”

    Source location

    David Michael Sewell · 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

    Notify main reception staff to identify Mental Health appointments and direct or assist confused attendees appropriately.

    Verbatim wording from the response

    “To reduce this potential for confusion in the future the Adult Mental Health Directorate management teams have written to colleagues who are responsible for staffing the main reception (and their managers). Within this letter it reminds staff that people arriving for appointments that are not on the main system should be asked if the appointment is with the Mental Health Team and if so direct accordingly. Also to be alert to the fact that people may be confused on the matter and require more attention. (letter attached).”

    Source location

    2017-0229-Response-by-University-Health-Board
    Page 2 · response
    Published 5 October 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

    Mental Health Act detention was not considered available, and community services were judged appropriate based on the presenting condition.

    Verbatim wording from the response

    “The Mental Health Directorate Management Team have reviewed the case and the circumstances of Mr Sewell’s engagement. As you state a referral was received at the Community Mental Health Team (CMHT) following assessment by the Psychiatric Liaison Service. The referral was sent to the CMHT following a detailed assessment on the 4th August 2017 that included consideration for detention under the Mental Health Act (MHA, 1983) which stated that Mr Sewell would not be detainable. It was therefore the professional view of the CMHT that this was not an option at the time of the presenting condition and that community services were deemed the appropriate course of action.”

    Source location

    2017-0229-Response-by-University-Health-Board
    Page 1 · response
    Published 5 October 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

    The disengagement policy was followed and discharge was reasonable, so no further engagement action was considered available.

    Verbatim wording from the response

    “A review of the Disengagement Policy for Mental Health has been conducted, and it concluded that all stages of the policy were followed and it was reasonable at this time to discharge Mr Sewell as he clearly had no intention to meaningfully engage with the service. As consideration for Mental Health Act detention had been undertaken, the team wrote to Mr Sewell at the time as telephone contact was clearly antagonising the situation, to further offer a service.”

    Source location

    2017-0229-Response-by-University-Health-Board
    Page 2 · response
    Published 5 October 2017

    Open published response

  7. Staffordshire South

    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. Staffordshire South

    AI-generated summary

    Annabel Mae LEWIS · 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

    Annabel Mae LEWIS, aged 15, died by asphyxia from external airway obstruction after placing a plastic bag over her head at home. The report raised concerns about CAMHS referral handling, including the lack of recorded risk assessment, follow-up arrangements, attempts to engage her parents, and proactive support after she declined an appointment because of difficulty accessing the venue.

    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 proactive follow-up after a declined appointment

    Wider context from the report

    “(1) At the inquest it was evident that Annabel had been referred by her GP to your team in November 2015 but that referral had not been accepted. She was referred again on 20/10/2016 by her school. This time the referral was accepted and your team made contact with her by telephone on 21/10/2016. She declined an appointment because she felt she could not get to the venue. No level of risk was recorded and next of kin details were not available. The date of appointment offered and declined were not recorded. Alternative time for appointment was not recorded. No follow up arrangements were recorded. There was no attempt to contact Annabel thereafter. An unsuccessful attempt to contact the referrer was made on 4/11/2016- the day Annabel took her own life. The time period between referral and initial contact and attempted follow up appears considerable. No attempt appears to have been made to engage with her parents who would have been in a position to assist with transport arrangements. The expectation that young people such as Annabel would 'opt in 'to the system may be unrealistic given the difficulties that she had in engaging. Annabel might well have benefitted had she been offered a more proactive service. ”

    Source location

    Annabel Mae LEWIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Manchester South

    AI-generated summary

    Thomas Josef Green · 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

    Thomas Josef Green died at home on 10 June 2016; the medical cause of death was asphyxiation secondary to hanging, and the inquest concluded that he had taken his own life. The principal concerns related to unclear or unactioned psychiatric referral, lack of psychiatric follow-up and treatment for complex PTSD after discharge, referral to an unsuitable service, and a commissioning gap for complex PTSD 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

    Lack of psychiatric follow-up after hospital discharge

    Wider context from the report

    “2. Hence when Mr Green was discharged from hospital there was no psychiatric follow-up and no treatment plan in place to address the diagnosis of complex PTSD. ”

    Source location

    Thomas Josef Green · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Leicester City and South Leicestershire

    AI-generated summary

    Victoria Georgia Halliday · 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

    Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality 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

    Failure to review patients after 2 admissions within 6 months

    Wider context from the report

    “4) The care programme approach (CPA) was not adhered to and NICE guidelines were not followed, specifically in ensuring there was a review after 2 admissions within 6 months, and to ensure the roles and responsibilities of all health and social care professionals involved were identified. ”

    Source location

    Victoria Georgia Halliday · 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

    Develop a Standard Operating Procedure clarifying CPA roles, care-coordinator allocation, transfers, community allocation and required reviews.

    Verbatim wording from the response

    “In order to ensure roles and responsibilities of health and social care professionals involved in the CPA process are clear, understood and adhered to, a Standard Operating Procedure (SOP) is under development. Included in this SOP it will confirm and clarify the process to identify a Care Co-ordinator for patients in in-patient services, and will confirm and clarify the transfer and allocation process for the identification of the Care Co-ordinator in the community team, and associated reviews required.”

    Source location

    Response from Leicestershire Partnership NHS Trust
    Page 3 · response
    Published 20 October 2016

    Open published response
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Data last updated 7 September 2026