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
NHS trust32
Healthcare site10
Ministerial department8
Integrated care board7
Executive non-departmental public body6
Local health board6
Type not available4
Police force3
English unitary authority2
English county council1
English district council1
English metropolitan district council1
Executive agency1
Health-system partnership1
Justice inspectorate1
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.
North Wales (East and Central)
Concerns raised1
Infrequent consultant psychiatrist review of recently sectioned and treated inpatients
This report raised 2 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to prioritise Community Mental Health Team appointments for patients at high risk of harm
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 concerns
Each 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
Action
Send all mental health service commissioners NHS England expectations for commissioned arrangements covering urgent correspondence, clinical risk assessment, shared care, incident learning, and vulnerable patients who miss appointments.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 9 December 2015.
Action
Reflect further on whether obtaining information about future appointments and clinicians would improve patient care.
Stated by Bodmin Road Health CentreStated plannedThe respondent said that this action was planned when they made their response on 9 December 2015.
Leicester City and South Leicestershire
Concerns raised2
Delays in offering psychiatric follow-up appointments
Failure to respond to non-attendance with clinical risk consideration
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 concerns
Each 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.9
Action
Increase outpatient appointment capacity through a programme maximizing use of clinical appointment slots.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2015.
Action
Develop a partial-booking system for outpatient appointments.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2015.
Action
Monitor open patient contacts weekly and refer them to medical staff for clinical decisions.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2015.
Action
Remind community mental health staff to follow the Did Not Attend policy for missed appointments.
Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2015.
Action
Conduct regular spot checks of compliance with the Did Not Attend policy.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2015.
Action
Review the Did Not Attend policy and introduce a flow chart for responding to missed appointments.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2015.
Action
Circulate an interim missed-appointment flow chart to community mental health teams.
Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2015.
Action
Contact new patients and recent non-attenders with appointment reminders, and alert clinicians to missed appointments for risk assessment.
Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2015.
Action
Audit compliance with the Did Not Attend policy during quarter two of 2016/17.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The concern about psychiatric follow-up falls to Leicestershire Partnership Trust, which will respond separately.
Stated by Leicester City CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cumbria
Concerns raised1
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to initiate youth offending and mental health monitoring after case transfer
This report raised 27 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised1
Lack of a referral follow-up system
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.
Cornwall
Concerns raised1
Failure to act on a care plan received from the Community Mental Health Team
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
