First reported 16 Sep 2016•Latest report 7 Aug 2022
Definition
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.
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
3
Distinct published reports
Individual concerns
3
A report can raise multiple concerns
Date range
2016–2022
First to latest report issue date
Stated actions
12
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 Care1
Mitie1
NHS Wales1
Nottinghamshire Healthcare NHS Foundation Trust1
South Wales Police1
Turning Point1
Health-system partnership1
Ministerial department1
NHS trust1
Police force1
Prison operator1
Registered provider of social housing1
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.
West Sussex
Concerns raised1
Delays in specialist child mental health assessment
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.
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
Expand and strengthen the NHS mental health workforce, including adding 27,000 mental health professionals by 2023/24.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Work with NHS England on next steps following consultation on proposed mental health waiting-time standards.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Nottinghamshire
Concerns raised1
Failure to ensure specialist mental health assessment of patients triaged by telephone workers
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.
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.10
Action
Review and refresh helpline workers’ roles, referral escalation, training, supervision, monitoring and audit arrangements.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Agree a standard operating procedure governing helpline referrals to the Crisis Team.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Ensure helpline workers and their team leader understand the referral standard operating procedure.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Introduce additional monitoring and audits to check compliance with the referral procedure and address variance promptly.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Agree a competency framework covering staff confidence in handling calls and escalating risk.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Update the Recovery Worker competency assessment to strengthen competence in call management, systems use, and risk and safety escalation.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Review local UK Mental Health Triage Scale guidance and establish a more robust process for escalating call-transfer difficulties.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Review and disseminate the Urgent Access line Standard Operating Procedure to relevant staff through email, supervision, and team meetings.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Introduce a digital telephony system that records calls and enables regular audit of call activity.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Introduce monthly sampling and auditing of telephone recordings to assess SOP compliance and provide training or remedial action where needed.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Swansea and Neath Port Talbot
Concerns raised1
Failure to ensure experienced mental health professional assessment of older people who self-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 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 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.
