Recurring concern

Failure to ensure experienced mental health professional involvement in care decisions

First to latest report 16 Sep 2016 — 7 Aug 2022

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
12

What this concern includes

Includes failures in mental health assessment, risk evaluation, treatment planning or comparable safety-critical care decisions where an experienced mental health professional was not involved, did not provide direct review or input, or was not available when required to protect the person from avoidable harm.

What is not included
  • Excludes generic mental-health workforce shortages, recruitment, retention or capacity concerns unless they specifically result in absent experienced-professional involvement in a safety-critical care decision.
  • Excludes failures in routine administrative, social-care or non-clinical decisions that do not concern mental health assessment, risk evaluation or treatment planning.
  • Excludes deficiencies limited to the content or application of clinical guidance where experienced-professional involvement was reliable.
  • Excludes specialist input unrelated to mental health care or to a safety-critical assessment, risk or treatment decision.
  • Excludes failures occurring after an appropriately experienced professional has made or reviewed the relevant decision, unless the asserted concern is a separate failure of that professional's decision-making.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Sussex

    AI-generated summary

    Robyn Lily Audrey SKILTON · 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

    On 7 May 2021, 14-year-old Robyn Lily Audrey Skilton was found in Southwater Park with a ligature around her neck, and her death was confirmed by emergency services. The inquest concluded that Robyn took her own life while struggling with her mental health, and that mental health services failed to recognise the deterioration in her mental health or provide the care and treatment she required. The report raised concerns about delayed assessment and treatment, including a lack of timely access to Child Psychiatrist and CAMHS services and insufficient resourcing.

    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 specialist child mental health assessment

    Wider context from the report

    “Robyn was failed by the Mental Health Services quite frankly due to the current lack of resourcing and provision in place to support young people struggling with their mental health. Due to the lack of availability of a Child Psychiatrist there are long waiting times for children to be assessed. Robyn was not seen by a Child Psychiatrist and/or Psychologist, despite there being a need for this to happen, thereby enabling her to be diagnosed and receive a treatment plan. Robyn’s parents did everything they could during this period to support Robyn, including paying for a private counsellor, but sadly Robyn’s mental health continued to deteriorate during this time, and she took her own life. Robyn initial acceptance into tier 3 Children and Mental Health Services (CAMHS) similarly did not happen in a timely manner. I do appreciate that the landscape that the local mental health Trust (Sussex Partnership Foundation Trust) was working under and the fact that Covid heightened the level of complexity across many services but there were many failings in the care provided to Robyn. It became very clear during the Inquest that there is significant under funding of the local mental health Trusts who like many mental health Trusts see an explosion of referrals to their Children and Mental Health services (CAMHS). By way of an example:- Referrals to West Sussex CAMHS have increased by 95.6% from May 2019 (389) to May 2022 (761) West Sussex CAMHS caseload has increased by 85% from May 2019 (2239) to May 2022 (4147) West Sussex CAMHS Duty caseload has increased by 112% from May 2021 (492) to May 2022 (1494) Mental Health A&E presentations, in period April 2021 - March 2022, have increased by 40% on previous year (April 2020 - March 2021). Additionally, across Sussex CAMHS, as a whole, the referrals data shows:- • May 2022 was the highest number of referrals the service has ever received (1350). • Of those 1350 referrals, 80% (1,081) were accepted into the service. • In comparison, in May 2019, 579 were accepted (65% accepted) • So, an additional 502 young people have been accepted in May 2022 compared to May 2019 Despite the increase in numbers accessing CAMHS there has not been any relative increase in resources to meet this demand and therefore the current position is is unsustainable and it is putting many young people’s lives at risk. ”

    Source location

    Robyn Lily Audrey SKILTON · 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

    Expand and strengthen the NHS mental health workforce, including adding 27,000 mental health professionals by 2023/24.

    Verbatim wording from the response

    “Growth of the mental health workforce, as well as retaining and re-skilling our current workforce, is the key strategic priority to ensure we can deliver our commitments to expand services and increase access. This is why, through the Plan we are committed to expanding the NHS workforce, with an aim of having and additional 27,000 mental health professionals by 2023/24, to deliver the expansion and transformation of mental health services, including those for children and young people.”

    Source location

    Response from department of Health and Social Care
    Page 2 · response
    Published 30 September 2022

    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

    Work with NHS England on next steps following consultation on proposed mental health waiting-time standards.

    Verbatim wording from the response

    “More broadly, NHS England consulted on the potential to introduce a range of new waiting time standards as part of its Clinically-led Review of NHS Access Standards⁴. These include:”

    Source location

    Response from department of Health and Social Care
    Page 3 · response
    Published 30 September 2022

    Open published response

  2. Nottinghamshire

    AI-generated summary

    Keith Andrew NOTTLE · 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

    Keith Andrew Nottle died on 5 July 2021 after taking an overdose of two prescribed medications, which the inquest concluded was an accident. Concerns included telephone triage practices that could bypass specialist mental health assessment, the apparent lack of care coordination, and unclear decision-making around his discharge and repeated re-referrals 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

    Failure to ensure specialist mental health assessment of patients triaged by telephone workers

    Wider context from the report

    “Evidence was heard regarding the operation of a triage for patients who may be experiencing a mental health crisis. A practice had developed of bypassing specialist mental health assessment by means of telephone workers making their own judgments about the level of risk a person presents to themselves and others, and a judgment about whether or not they require urgent mental health assessment and / or treatment, based on a very limited criteria. This had the result of only a very small proportion of potentially unwell patients being considered by a person with qualifications to assess and treat mental health. This was a culture and practice which stood in conflict with the procedure the Trust had in writing for the role of the telephone workers. ”

    Source location

    Keith Andrew NOTTLE · 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 refresh helpline workers’ roles, referral escalation, training, supervision, monitoring and audit arrangements.

    Verbatim wording from the response

    “We have reviewed and refreshed the key factors in the role of the helpline (telephone) workers with colleagues in Nottinghamshire Healthcare Trust, including when and how referrals are escalated to the Crisis Team, training, supervision, monitoring and audit.”

    Source location

    Response from Turning Point
    Page 1 · response
    Published 22 September 2022

    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

    Agree a standard operating procedure governing helpline referrals to the Crisis Team.

    Verbatim wording from the response

    “We have met with our colleagues from Nottinghamshire Healthcare Trust on a number of occasions and agreed a Standard Operating Procedure (SOP) for the flow of referrals from the helpline workers to the Crisis Team. This SOP is in line with the service specification and national guidance regarding access to mental health services.”

    Source location

    Response from Turning Point
    Page 1 · response
    Published 22 September 2022

    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

    Ensure helpline workers and their team leader understand the referral standard operating procedure.

    Verbatim wording from the response

    “We have met with the team of helpline workers and their team leader and ensured that they are familiar with the detail of the SOP.”

    Source location

    Response from Turning Point
    Page 1 · response
    Published 22 September 2022

    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

    Introduce additional monitoring and audits to check compliance with the referral procedure and address variance promptly.

    Verbatim wording from the response

    “We have introduced additional monitoring and audits to ensure that all helpline workers are following the SOP and any variance is addressed in a timely way.”

    Source location

    Response from Turning Point
    Page 1 · response
    Published 22 September 2022

    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

    Agree a competency framework covering staff confidence in handling calls and escalating risk.

    Verbatim wording from the response

    “We have also agreed a competency framework to provide assurance that our staff are confident in their ability to handle calls and the escalation process regarding risk, amongst other areas.”

    Source location

    Response from Turning Point
    Page 1 · response
    Published 22 September 2022

    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

    Update the Recovery Worker competency assessment to strengthen competence in call management, systems use, and risk and safety escalation.

    Verbatim wording from the response

    “The Recovery Workers also undertake a competency assessment to ensure they have a high level of competence in managing calls, using correct systems and utilising appropriate escalation protocols in relation to risk and safety management. The competency assessment has been updated in light of this inquest. The updated competency assessment is attached (Appendix 2).”

    Source location

    Response from NHS Nottinghamshire Healthcare
    Page 2 · response
    Published 22 September 2022

    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

    Review local UK Mental Health Triage Scale guidance and establish a more robust process for escalating call-transfer difficulties.

    Verbatim wording from the response

    “We have been assured by Turning Point that in her evidence regarding transfers to CRHT the staff member was referring to June 2021 when the Urgent Access line was first set up, where there were some initial issues with the transfer of calls. The local guidance for the UK Mental Health Triage Scale has been reviewed with a more robust escalation process should there be any difficulty encountered in transfer of a call.”

    Source location

    Response from NHS Nottinghamshire Healthcare
    Page 2 · response
    Published 22 September 2022

    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

    Review and disseminate the Urgent Access line Standard Operating Procedure to relevant staff through email, supervision, and team meetings.

    Verbatim wording from the response

    “The Standard Operating Procedure (SOP) (Appendix 3) for the Urgent Access line has been reviewed and shared with all relevant staff via email and also during supervision and team meetings.”

    Source location

    Response from NHS Nottinghamshire Healthcare
    Page 2 · response
    Published 22 September 2022

    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

    Introduce a digital telephony system that records calls and enables regular audit of call activity.

    Verbatim wording from the response

    “A new digital telephony system is being introduced into the Trust which will provide greater insight into call activity. All calls will be recorded which will enable the roll out of regular audit. It is anticipated that the telephony system will be operational by Mid-August 2022.”

    Source location

    Response from NHS Nottinghamshire Healthcare
    Page 2 · response
    Published 22 September 2022

    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

    Introduce monthly sampling and auditing of telephone recordings to assess SOP compliance and provide training or remedial action where needed.

    Verbatim wording from the response

    “An audit system is being introduced whereby telephone recordings of a sample of telephone calls will be listened to monthly and utilised for audit and training purposes. This will include monitoring if the calls are being handled in accordance with the SOP and taking remedial action if needed.”

    Source location

    Response from NHS Nottinghamshire Healthcare
    Page 2 · response
    Published 22 September 2022

    Open published response

  3. Swansea and Neath Port Talbot

    AI-generated summary

    David Nigel Phillips · 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 Nigel Phillips, who had a history of mental illness, previous suicide attempts, alcohol-related issues and type 2 diabetes, was found drowned in a rock pool near Mumbles Pier on 4 January 2015. He had been arrested the previous day after being found intoxicated in his parked car and had told police he had been attempting to take his own life. The principal concerns were that an experienced mental health professional should have assessed him and that the healthcare professional lacked access to his medical records, including mental health records, to review his medication and risks accurately.

    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 ensure experienced mental health professional assessment of older people who self-harm

    Wider context from the report

    “My concerns are that:- (1) An experienced mental health doctor or nurse should have been called to carry out the assessment rather than a nurse. The quality of the assessment is critical rather than a box ticking exercise. (2) The Health Care Professional did not have access to detainee’s medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred. An ability to review medication and if necessary prescribe medication would be helpful and access to medical records is critical. Access to electronic Individual Health Records to include mental health records ”

    Source location

    David Nigel Phillips · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026