Recurring concern

Unreliable Care Programme Approach care coordination

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First reported 24 Jun 2015•Latest report 12 Jan 2026

Definition

What this concern includes

Includes failures of the named Care Programme Approach and its dedicated care-coordination controls, including allocation of a care coordinator, structured reviews, medication review, care planning, role definition, risk management, inter-professional coordination and required follow-up.

Not included

  • Excludes medication-review failures that are not part of the Care Programme Approach.
  • Excludes generic care coordination, communication or governance deficiencies where the Care Programme Approach is not explicitly involved.
  • Excludes failures of unrelated discharge, treatment or referral processes unless they are specifically identified as CPA controls.
  • Excludes final membership conclusions; the cited assertions support consideration of this parent only.
Reports
21

Distinct published reports

Individual concerns
25

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
27

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.

HM Prison and Probation Service3
NHS England3
Sussex Partnership NHS Foundation Trust3
Central and North West London NHS Foundation Trust2
East London NHS Foundation Trust2
Essex Partnership University NHS Foundation Trust2
Ministry of Justice2
Brunswick Ward at Lindridge1
Department of Health and Social Care1
Derbyshire County Council1
Derbyshire Healthcare NHS Foundation Trust1
Dorset Healthcare University NHS Foundation Trust1
Elmbridge Borough Council1
Greater Manchester Mental Health NHS Foundation Trust1
HCRG Care Services Ltd1

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. Brighton and Hove

    AI-generated summary

    Alice MEAD · 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

    Alice Mead was known to mental health services and was receiving care under the Care Programme Approach. The inquest concluded that she took her own life on 20 January 2015. Concerns included the failure to replace her care co-ordinator, inadequate response to her requests for a medication review, delayed action following urgent concerns, and a lack of documented review of her risk assessment.

    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 document risk assessment reviews

    Wider context from the report

    “(4) There was no evidence that Alice’s risk assessment was reviewed and updated during December 2014 or January 2015. If it was, such reviews should have been documented in accordance with the Care Programme Approach. They were not ”

    Source location

    Alice MEAD · 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 replace and appoint a Care Co-ordinator

    Wider context from the report

    “(1) When her Care Co-ordinator left the Trust she was not replaced so Alice was left without one of the corner stones of the Care Programme Approach. Although later a Multi-Disciplinary Team meeting decided she should have a Care Co-ordinator, no action was taken to appoint one. ”

    Source location

    Alice MEAD · 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

    Review and redesign Trust-wide Care Programme Approach processes, including developing the new policy and preparing for electronic-record rollout.

    Verbatim wording from the response

    “The Care Programme Approach (CPA) is in the process of being reviewed across the Trust. This work is being led by ████████, Director of Occupational Therapy and Recovery Practice. We have a newly constituted CPA steering group, with cross care group representation and we are agreeing the new processes in preparation for the roll out of Carenotes (the new electronic records system). A new CPA policy has been drafted and we hope to launch it in September 2015. When the new CPA policy is launched there will be full staff training in place. Information leaflets and short films will be available and all information will be available on the Trust’s intranet. The training will be co-produced with service users and peer trainers to ensure a holistic approach.”

    Source location

    2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
    Page 1 · response
    Published 24 June 2015

    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

    Track risk-assessment dates in the East ATS caseload spreadsheet and monitor and audit compliance, escalating required action.

    Verbatim wording from the response

    “Staff in the East ATS and MHRRS, responsible for assessing service users’ risk, have undergone bespoke Applied Suicide Intervention Skills Training (ASIST). This internationally renowned training was delivered in June 2015 by Grassroots, Suicide Prevention charity. To ensure risk assessments are up to date we have developed a new East ATS caseload spread sheet to capture risk assessment dates; supervisors will monitor this frequently, audit compliance, and escalate to the Team Leaders if action is required.”

    Source location

    2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    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

    Implement multidisciplinary caseload reviews, prioritising reviews when care coordinators leave and documenting decisions in electronic records.

    Verbatim wording from the response

    “As you say, a care coordinator was not allocated to Ms Mead when her previous care coordinator left the Trust. At that time Ms Mead’s case was reviewed, and the decision was made not to allocate a new care coordinator. ████████ General Manager, Community Services Brighton & Hove, has confirmed the introduction of an improved system; where all care coordinators’ caseloads are reviewed with a Consultant Psychiatrist and Team Leader. Particular focus is applied to caseload reviews when a care coordinator is leaving and the decisions and outcomes are documented by the reviewing team on the electronic health record clinical information system. Service users will be allocated a lead practitioner or care coordinator, based on their clinical need and are not reliant on calling the duty team.”

    Source location

    2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
    Page 1 · response
    Published 24 June 2015

    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

    Allocate service users a lead practitioner or care coordinator according to clinical need.

    Verbatim wording from the response

    “As you say, a care coordinator was not allocated to Ms Mead when her previous care coordinator left the Trust. At that time Ms Mead’s case was reviewed, and the decision was made not to allocate a new care coordinator. ████████ General Manager, Community Services Brighton & Hove, has confirmed the introduction of an improved system; where all care coordinators’ caseloads are reviewed with a Consultant Psychiatrist and Team Leader. Particular focus is applied to caseload reviews when a care coordinator is leaving and the decisions and outcomes are documented by the reviewing team on the electronic health record clinical information system. Service users will be allocated a lead practitioner or care coordinator, based on their clinical need and are not reliant on calling the duty team.”

    Source location

    2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
    Page 1 · response
    Published 24 June 2015

    Open published response
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Data last updated 7 September 2026