Recurring concern

Failure to provide continuous access to appropriate mental health care

First to latest report 3 Feb 2015 — 12 Dec 2019

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
6

What this concern includes

Includes failures in mental health service access, assessment or acceptance arrangements that exclude or leave people without care because their presentation does not fit a psychiatric label, service remit or boundary between mental health organisations, including gaps between OSW and CMHT thresholds.

What is not included
  • Excludes generic mental health waiting-time, staffing or treatment-quality concerns where no service-boundary or diagnostic-acceptance gap is identified.
  • Excludes failures within a specific mental health referral, crisis, home-treatment or discharge pathway when that named pathway is the material unsafe condition.
  • Excludes cases where a person was appropriately assessed and offered suitable mental health care, but later treatment or follow-up was inadequate.
  • Excludes generic gaps in services for overlapping mental-health and complex needs unless the assertion specifically identifies exclusion or lack of access caused by diagnostic or organisational thresholds.

Reports and published responses 3 reports

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

  1. Norfolk

    AI-generated summary

    Peter Frosdick · 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

    Peter Frosdick, who had cirrhosis and was experiencing paranoid thinking, extreme anxiety and irrational behaviour, died by hanging in his garage. The concerns raised included that his mental health was not adequately assessed beyond his alcohol dependence, that home treatment or hospital admission was not offered or explored, and that teams appeared unfamiliar with each other’s referral criteria and dismissed his GP’s concerns.

    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 accept patients whose mental state does not fit a psychiatric label

    Wider context from the report

    “(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team, home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't. ”

    Source location

    Peter Frosdick · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. South Yorkshire (Western)

    AI-generated summary

    Aryan Akhgar · 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

    Aryan Akhgar, aged 17, died on 6 March 2018 after hanging himself with the intent to take his own life. The report identified a gap in urgent mental health services for 16- and 17-year-olds in Sheffield: although an urgent response was recommended on 9 January 2018, the first visit by mental health professionals did not occur until 15 January 2018. The report also raised concern that funding for additional CAMHS resources was not guaranteed.

    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

    Lack of urgent mental health service provision for 16- and 17-year-olds

    Wider context from the report

    “5.1 A gap in services was identified for 16 and 17 years old’s with urgent mental health issues, such as Aryan had. On 9th January 2018, Aryan was assessed as requiring urgent mental health input, commencing the next day. This was not available as a service for under 18’s in Sheffield and so a referral to Adult Mental Health Services was made in order to obtain this. The adult service refused to take the referral because Aryan was still a child. This gap in the provision between the two services meant that Aryan did not receive the urgent mental health input which he required and there is a risk that other under 18’s in his situation might also suffer the same problem. ”

    Source location

    Aryan Akhgar · 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

    Complete and approve the business case for the CAMHS Home Intensive Treatment Team.

    Verbatim wording from the response

    “At the time of writing, the business case for the HITT team has been completed and was approved by the CCG on 7th May 2019, with a plan to begin a phased implementation from the autumn 2019. The service will be evaluated to ensure that it meets the needs of the young people who are its service users.”

    Source location

    2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
    Page 2 · response
    Published 9 June 2019

    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

    Reconfigure the existing Sheffield Treatment and Recovery Service into a CAMHS Home Intensive Treatment Team for young people up to age 18.

    Verbatim wording from the response

    “Sheffield Children’s NHS Foundation Trust and NHS Sheffield Clinical Commissioning Group have been working collaboratively to develop a robust long term solution to the issues you have highlighted. The two organisations have considered the potential models and have agreed the most appropriate way forward to be through the reconfiguration of the existing Sheffield Treatment and Recovery (STAR) Service into a CAMHS Home Intensive Treatment Team (HITT).”

    Source location

    2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
    Page 1 · response
    Published 9 June 2019

    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

    Recruit nursing staff for the new CAMHS Home Intensive Treatment Team.

    Verbatim wording from the response

    “The CCG and the Trust recognise that there is urgency to the situation and are working closely to ensure that there is no delay to its implementation noting also the temporary change in pathway agreed between Sheffield Children’s NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has already begun to recruit nursing staff to the new service in anticipation of its formal commissioning.”

    Source location

    2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
    Page 2 · response
    Published 9 June 2019

    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

    Establish a Mental Health Liaison Team supporting 0–18-year-olds attending designated emergency departments, with out-of-hours cover.

    Verbatim wording from the response

    “This new team will be responsible for children and young people up to the age of 18 years and will be aligned with, and where appropriate, undertake, joint working with the Home Intensive Treatment Services provided by Sheffield Health and Social Care NHS Foundation Trust. In addition the Mental Health Liaison Team will support 0-18 year olds attending either Sheffield Children’s or the Northern General Hospital’s Emergency Departments. Access to the HITT will be within 24 hours when required whilst the Liaison Team will operate to meet the demands through the Emergency Departments with an on call rota in place for out of hours.”

    Source location

    2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
    Page 2 · response
    Published 9 June 2019

    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 the temporary care pathway change agreed with Sheffield Health and Social Care NHS Foundation Trust.

    Verbatim wording from the response

    “The CCG and the Trust recognise that there is urgency to the situation and are working closely to ensure that there is no delay to its implementation noting also the temporary change in pathway agreed between Sheffield Children’s NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has already begun to recruit nursing staff to the new service in anticipation of its formal commissioning.”

    Source location

    2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
    Page 2 · response
    Published 9 June 2019

    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 jointly approved policy arrangements providing out-of-hours emergency home treatment to eligible 16- and 17-year-olds requiring crisis intervention.

    Verbatim wording from the response

    “1. An addendum to the Transitions Policy has been jointly approved by both Trusts that ensures that emergency home treatment will be provided to 16/17 year olds by Sheffield Health and Social Care’s adult services, should they require crisis intervention out of hours and where they are not known to Child and Adolescent Mental Health Services which mirrors that already present for those known to the Services. This was implemented with effect from January 2019.”

    Source location

    2019-0115-Response-by-Sheffield-Childrens-NHS-Trust
    Page 2 · response
    Published 9 June 2019

    Open published response

  3. Cornwall

    AI-generated summary

    Shannon Kimberley Gee · 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

    Shannon Kimberley Gee, aged 16, died as the result of an Accident. The report raised concerns about gaps between mental health services, delays of weeks in resolving disputes over responsibility for treatment, and difficulties transferring medical notes and records.

    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 of OSW and CMHT treatment thresholds to provide continuous service coverage

    Wider context from the report

    “The situation now is improved from when ████████ encountered the delay in treatment to her but, on the evidence should ████████ a delay of ‘weeks’ in resolving clinical disputes as to which organisation should treat a patient is still worrying. Ideally, there should be a seamless union between the two organisations. The fact that there is not appears to be a consequence of the maximum threshold for treatment by OSW being lower than the minimum threshold for acceptance on to the CMHT workload. Put another way, it is entirely conceivable that both OSW and CMHT may be correct in applying their respective rules as to whether a patient needs to be taken on where that patient’s presenting complaints falls between the two organisations’ rules. That may require formal guidance to resolve hence directing this letter to the Secretary in addition to the Commissioners. The difficulties set out concerning the transfer of medical notes and records appear more difficult to justify. ”

    Source location

    Shannon Kimberley Gee · 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.

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Data last updated 7 September 2026