First reported 25 Jun 2014•Latest report 8 Apr 2026
Definition
What this concern includes
Includes failures in dedicated processes for circulating, receiving, reading or making available safety-critical mental health information to staff responsible for assessment, triage, response or ongoing care, including ambulance-control communications, mental-health-team messages and internal team communications.
Not included
Excludes generic communication, staffing, documentation or information-system deficiencies where safety-critical mental health information is not the material object of the failure.
Excludes failures in clinical assessment, treatment or escalation after the relevant mental health information was reliably received and available.
Excludes routine administrative or non-safety-related mental health communications.
Excludes failures confined to a separately named mental health referral, crisis, appointment or information system when that named process supplies the more specific supported boundary.
Reports
14
Distinct published reports
Individual concerns
17
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
35
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.
Essex Partnership University NHS Foundation Trust2
Metropolitan Police Service2
Achieve Together Limited1
Betsi Cadwaladr University LHB1
Cheshire and Wirral Partnership NHS Foundation Trust1
College of Policing1
Department of Health and Social Care1
East London NHS Foundation Trust1
Essex County Council1
Greater Manchester Mental Health NHS Foundation Trust1
Greater Manchester Police1
Home Office1
Manchester University NHS Foundation Trust1
Ministry of Justice1
Nestor Primecare Services Limited1
NHS trust7
Police force4
Ministerial department3
English county council2
Healthcare site2
Company1
Independent healthcare provider1
Integrated care board1
Local health board1
National policing body1
Prison operator1
Prison or young offender institution1
Registered provider of social housing1
Supported living provider1
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.
Nottinghamshire
Concerns raised1
Lack of a formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff
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.11
Action
Establish regular information-sharing through daily briefings, SIM meetings, drug-strategy discussions, and communication across prison operational and healthcare teams.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Implement a formal information-sharing procedure requiring prompt, secure, documented handover of clinical and risk information, standard documents, and escalation when contact fails.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Share and agree the information-sharing guidance with CFT staff, Prison Healthcare providers, and HMP Lincoln to establish consistent cross-organisational expectations.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Embed the information-sharing guidance through team briefings, clinical supervision, and induction for new staff.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.
Action
Maintain a dedicated CFT Link Worker as a consistent Prison Healthcare contact with oversight of information sharing, timely responses, continuity, and service liaison.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Establish bimonthly interface meetings with HMP Nottingham Prison Healthcare teams to review cases, address communication issues, monitor guidance adherence, and escalate risks.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2026.
Action
Work jointly with Northamptonshire Healthcare NHS Foundation Trust to clarify responsibilities, availability expectations, responsiveness, and escalation pathways.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.
Action
Conduct quarterly audits of information-sharing timeliness, documentation completeness, and escalation, and report findings to relevant quality and accountability groups.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2026.
Action
Issue and disseminate information-sharing guidance to prisons through booklet, wallet-sized and intranet formats.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham PrisonStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Ask the Information Sharing Advisory Group to examine the circumstances of Mr Thornton’s death, identify learning and assess whether updated guidance is needed.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham PrisonStated plannedThe respondent said that this action was planned when they made their response on 13 April 2026.
Action
Ensure findings from the NOMIS/DPS alerts review inform future enhancements addressing the identified concerns.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham PrisonStated plannedThe respondent said that this action was planned when they made their response on 13 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Healthcare information-sharing concerns have been referred to the relevant NHS trusts for separate consideration and response.
Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham PrisonRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised1
Lack of a mechanism for police to communicate consented mental-health risk information to medical or mental health care providers
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
Require the Contact and Control Room to confirm NHS 111 Option 2 was signposted or contacted before closing a CAD incident.
Stated by Suffolk ConstabularyStated plannedThe respondent said that this action was planned when they made their response on 12 February 2026.
Action
Continue consulting partner agencies to evaluate NHS 111 Option 2’s operability, reliability, staff knowledge, and training needs.
Stated by Suffolk ConstabularyStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Action
Continue cooperating with partner agencies and sharing relevant information under applicable arrangements to support timely clinically led crisis assessment when suicide risk is identified.
Stated by Suffolk County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Existing NHS 111 Option 2 clinical pathways provide an adequate mechanism for raising adult mental health concerns below statutory thresholds.
Stated by Suffolk ConstabularyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NSFT holds statutory and operational responsibility for adult mental health care across Suffolk, rather than MASH or the police.
Stated by Suffolk ConstabularyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A new MASH pathway is not viable because projected referrals would impose substantial operational impact and require structural redesign.
Stated by Suffolk ConstabularyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Adult mental health provision and clinical pathways are the responsibility of NHS commissioners and mental health providers.
Stated by Suffolk County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
SCC will not create a new MASH pathway for adult mental health-only referrals outside safeguarding or adult social care functions.
Stated by Suffolk County CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Essex
Concerns raised1
Failure to inform the ongoing ECT consultant of mental health deterioration
This report raised 12 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
Review information-sharing protocols for collaboration with professionals in other organisations.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Introduce structured handovers and shared care plans accessible to involved health, care-home and social-care professionals.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Inner North London
Concerns raised1
Failure to communicate concerning behaviour and environmental damage to mental health staff
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.3
Action
Review and update the national Support Planning Procedure to record hospital contacts, required clinical escalation and post-hospital support-plan reviews.
Stated by RiversideStated completedThe respondent said that this action was complete when they made their response on 21 May 2025.
Action
Train and remind staff to communicate behavioural changes, environmental damage, deterioration and other welfare concerns promptly through appropriate clinical escalation channels.
Stated by RiversideStated completedThe respondent said that this action was complete when they made their response on 21 May 2025.
Action
Add welfare-escalation and relevant legal-status requirements to the organisation-wide Quality Audit Tool for auditors to check.
Stated by RiversideStated plannedThe respondent said that this action was planned when they made their response on 21 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Support Officers are not authorised or trained to restrain residents because their remit is supportive and non-clinical.
Stated by RiversideOutside remitThe respondent said that this matter was outside its role or authority.
Inner West London
Concerns raised3
Failure to circulate mental health information promptly during I grade calls
Lack of dispatcher training on passing possible mental health concerns over the airwaves
Dispatcher pod failures causing mental health concerns to be missed under work pressure
This report raised 9 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.3
Action
Update Despatch Course lesson plans to train dispatchers to relay possible mental-health concerns over the airwaves promptly.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
Action
Enhance dispatcher training and lesson plans on communicating CAD-assigned units to responding officers.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
Action
Update dispatcher training and lesson plans to relay key information, including mental-health concerns and the number of units en route.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
Cheshire
Concerns raised2
Lack of access by café71 staff to mental health team information about patients’ backgrounds and risk factors
Delays in GP review of correspondence relevant to mental health team action
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.
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
Audit referrals sent to Café 71 every six months and report findings through Acute Care and First Response governance meetings.
Stated by Cheshire and Wirral Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2024.
Action
Work with CWP and GP colleagues to improve the timeliness and content of correspondence about Crisis Line contacts.
Stated by NHS Cheshire and Merseyside Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Café 71 does not operate in isolation; staff can obtain relevant mental-health information from Trust crisis-line staff with the individual’s consent.
Stated by Cheshire and Wirral Partnership NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Norfolk
Concerns raised1
Failure to circulate important emails to relevant CRHTT personnel
This report raised 7 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.3
Action
Operate one generic CRHTT email address with a defined process for qualified practitioners to check and action messages.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
Action
Provide administrative and senior support-worker capacity to monitor the CRHTT inbox during weekday and weekend periods.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
Action
Audit implementation of the CRHTT email-management and night-handover processes over six months.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
Manchester South
Concerns raised1
Poor-quality documentation and information sharing between officers and supervision
This report raised 6 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 communicate identified mental health concerns to custody staff
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.
East London
Concerns raised1
Failure to obtain and communicate relevant police and family information during admission
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.
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
Review and update s136 questionnaires, handover forms, policies, guidance and weekly internal audit tools to strengthen information gathering, assessment and record-keeping.
Stated by NELFT NHS NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Action
Create a generic secure NHS.net account for the s136 suite to receive confidential collateral patient information.
Stated by NELFT NHS NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Action
Submit proposed Form 434 amendments to the policy, mental health and legal departments for consideration and approval.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Design a bespoke handover form with NELFT for use at the 136 suite.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Action
Hold a progress-review meeting on the bespoke handover form.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
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Includes failures in dedicated processes for circulating, receiving, reading or making available safety-critical mental health information to staff responsible for assessment, triage, response or ongoing care, including ambulance-control communications, mental-health-team messages and internal team communications.
