First reported 30 Apr 2014•Latest report 17 Mar 2026
Definition
What this concern includes
Includes failures of the mental-state assessment process, including delayed or missed assessment, failure to undertake an appropriate mental state examination, and materially inconsistent or inadequate assessment of mental state.
Not included
Excludes general mental health risk assessments unless the asserted deficiency specifically concerns assessment of the patient’s mental state.
Excludes failures of treatment, referral, admission, discharge or escalation where mental-state assessment is not itself the unsafe condition.
Excludes generic staffing, training, documentation or communication deficiencies unless they directly impair the mental-state assessment process.
Excludes assessments of physical condition or unrelated clinical states.
Reports
24
Distinct published reports
Individual concerns
25
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
36
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 Care6
NHS England3
East London NHS Foundation Trust2
Essex Partnership University NHS Foundation Trust2
Greater Manchester Police2
HM Prison and Probation Service2
North London NHS Foundation Trust2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Black Country Healthcare NHS Foundation Trust1
BTCM Limited1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Cheshire and Wirral Partnership NHS Foundation Trust1
Cornwall Council1
Crown Prosecution Service1
NHS trust20
Ministerial department6
Police force6
Executive non-departmental public body3
Executive agency2
Healthcare site2
Integrated care board2
Company limited by guarantee1
English county council1
English metropolitan district council1
English unitary authority1
Health and care professional regulator1
Health and social care service regulator1
Mayoral policing body1
National policing body1
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.
Manchester North
Concerns raised1
Failure to share relevant prior mental-health contacts and assessments between GMP and NWAS
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.5
Action
Assess the feasibility of electronic Force-to-Force data exchange between GMP and partner agencies including NWAS.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 8 April 2020.
Action
Consider the effectiveness of current information-sharing arrangements with partners and brief the Greater Manchester Health and Justice Board on the concerns raised.
Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 8 April 2020.
Action
Develop and implement a common, documented GMP-wide procedure with partners for responding to mental-health-related risk to life presented to blue-light services.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 8 April 2020.
Action
Jointly chair a pan-Greater Manchester task and finish group improving risk assessment, management, inter-agency communications and procedures for mental health crisis responses.
Stated by North West Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 April 2020.
Action
Draw together a pan-Greater Manchester protocol defining roles, shared risk assessment, communication and escalation for mental-health-related risk-to-life incidents.
Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 April 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Police and other emergency services are expected to share pertinent information so ambulance clinicians can know about prior contacts and assessments.
Stated by North West Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Failure to provide material arrest information for mental health assessments in custody
This report raised 8 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.7
Action
Implement CONNECT access for Liaison and Diversion staff, including wider custody information and nursing read-write risk recording.
Stated by Black Country Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2019.
Action
Raise the report’s outcome and learning with police through quarterly Joint Operational Group meetings, stressing full handover before every assessment.
Stated by Black Country Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Develop a joint operating protocol with the Sandwell Liaison and Diversion Service for custody-based patient assessment.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Work with police forces to ensure liaison and diversion practitioners receive relevant arrest and presentation information.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Hold a national event to debrief information-sharing issues and share lessons with liaison and diversion practitioners, commissioners and police representatives.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Support development of the Connect police IT system and liaison and diversion functionality to improve custody information access.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2019.
Action
Provide information-sharing training to liaison and diversion teams and offer it to police healthcare providers.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 July 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Other concerns concerned NHS bodies and services not provided by the respondent, so the respondent did not comment on those outcomes.
Stated by Black Country Healthcare NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
The existing custody record and available information access adequately inform Liaison and Diversion assessments, so no future-death risk exists.
Stated by West Midlands PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
An adequate system records arrest circumstances and gives Liaison and Diversion practitioners access to relevant custody information.
Stated by West Midlands PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
No action is required because the existing system addresses the identified risk in this case.
Stated by West Midlands PoliceNo action considered necessaryThe respondent said that no further action was needed.
Position
Local NHS agencies are expected to address the report’s local concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Wiltshire and Swindon
Concerns raised1
Failure to provide healthcare professionals with complete relevant mental-health information for frontline assessments
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.
Liverpool and the Wirral
Concerns raised1
Failure to account for how mental disorders manifest over time during mental health assessments
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.3
Action
Develop and circulate a learning bulletin on recognising diurnal mood variation and considering assessment appointments at different times.
Stated by Cheshire and Wirral Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2019.
Action
Deliver a Trustwide Grand Round for clinicians to share learning and feedback about diurnal mood variation.
Stated by Cheshire and Wirral Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2019.
Action
Adapt Suicide Prevention Training to include diurnal mood variation when teaching about depression and mental state examination.
Stated by Cheshire and Wirral Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Appointments cannot always be offered at different times of day, limiting the ability to respond to diurnal mood variation.
Stated by Cheshire and Wirral Partnership NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to communicate mental health concerns to the forensic medical examiner
This report raised 18 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.
Inner North London
Concerns raised1
Failure to investigate conflicting reports about mental health symptoms
This report raised 10 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.
Inner North London
Concerns raised1
Failure to recognise impaired insight in the context of recurrent unexplained physical symptoms
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
Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 October 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.
Stated by Royal Free London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Delays in arranging immediate mental health assessment
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
Strengthen the direct mental-health referral protocol, including patient-triggered referrals and a disseminated frontline flowchart.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.
Action
Strengthen the direct mental-health referral protocol so patients can promptly trigger referral from emergency-department triage, supported by a disseminated frontline flowchart.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2015.
Plymouth, Torbay and South Devon
Concerns raised1
Delays in determining patients’ mental health state
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.1
Action
Work with health colleagues to obtain mental health input when required in future cases.
Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 22 September 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Robust senior management oversight is considered sufficient to prevent such delays recurring.
Stated by Cornwall CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cumbria
Concerns raised1
Failure of psychiatric assessments to recognise mental disorder and suicide 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.
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Includes failures of the mental-state assessment process, including delayed or missed assessment, failure to undertake an appropriate mental state examination, and materially inconsistent or inadequate assessment of mental state.
