First reported 15 Apr 2014•Latest report 13 Mar 2025
Definition
What this concern includes
Includes failures of the Mental Health Act assessment process, including suitably qualified first-instance assessment, prompt progression of recommendations, and appropriate action on recommendations to consider detention.
Not included
Excludes generic delays or clinical assessment failures not explicitly connected to Mental Health Act assessment.
Excludes unrelated referral, assessment, staffing, training, or communication deficiencies.
Excludes failures concerning other statutory or specialist assessments unless they are directly part of the Mental Health Act assessment process.
Reports
29
Distinct published reports
Individual concerns
33
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
82
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
Birmingham City Council5
NHS England5
Birmingham and Solihull Mental Health NHS Foundation Trust4
Greater Manchester Mental Health NHS Foundation Trust4
Care Quality Commission3
Birmingham Women'S and Children'S NHS Foundation Trust2
East London NHS Foundation Trust2
Home Office2
Metropolitan Police Service2
Ministry of Justice2
NHS Birmingham and Solihull Integrated Care Board2
North London NHS Foundation Trust2
Oxleas NHS Foundation Trust2
Walsall Borough Council2
NHS trust25
Ministerial department7
English metropolitan district council6
Executive non-departmental public body5
Police force5
Integrated care board4
Type not available4
Health and social care service regulator3
English county council2
Independent healthcare provider2
London borough council2
Clinical commissioning group1
Domiciliary care provider1
English unitary authority1
Healthcare site1
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.
South London
Concerns raised1
Incorrect understanding of Mental Health Act assessment criteria
This report raised 11 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Birmingham and Solihull
Concerns raised1
Barriers to accurate Mental Health Act section assessments
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.5
Action
Recruit and train AMHPs to increase BCC staffing by 35 over five years.
Stated by Birmingham City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2025.
Action
Prepare guidance on using Section 2 versus Section 3 for inclusion in the Mental Health Policy.
Stated by Birmingham City CouncilStated plannedThe respondent said that this action was planned when they made their response on 6 March 2025.
Action
Train doctors and approved mental health professionals through improved mental health assessment training delivered with Birmingham City Council.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2025.
Action
Develop, approve and embed joint guidance for doctors and approved mental health professionals on appropriate Mental Health Act sections.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2025.
Action
Train doctors and approved mental health professionals and incorporate the agreed joint guidance into Trust procedures.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Suggestions that incorrect Mental Health Act detentions are being made are fundamentally inaccurate because AMHPs, not doctors, make detention and section decisions.
Stated by Birmingham City CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
AMHPs are responsible for deciding whether detention occurs and which Mental Health Act section applies, based on medical recommendations.
Stated by Birmingham City CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Lack of an official fast-track procedure for s135(1) warrants
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.6
Action
Review the corporate section 135 warrant process and incorporate matters raised in the report and identified learning.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 25 February 2025.
Action
Prioritise mental health warrant applications as priority-one work when allocating court time.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Maintain an open-door process allowing applicants to obtain immediate access to a courtroom for warrant applications.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Provide out-of-hours access to the Judiciary for urgent mental health warrant applications seven days a week.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Provide a central team and access routes through London magistrates’ courts for urgent warrant applications.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Provide practitioners with guidance describing booking arrangements for non-urgent, urgent and out-of-hours applications.
Stated by HM Courts & Tribunals ServiceStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Responsibility for applying to court for a section 135(1) warrant rests with Approved Mental Health Professionals, who are the only authorised applicants.
Stated by Metropolitan Police ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing booking, open-door, urgent and out-of-hours arrangements provide sufficient access to magistrates’ courts for mental health warrant applications.
Stated by HM Courts & Tribunals ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Arrangements for executing warrants, including any fast-track procedure, do not fall within magistrates’ courts’ responsibilities.
Stated by HM Courts & Tribunals ServiceOutside remitThe respondent said that this matter was outside its role or authority.
Black Country
Concerns raised1
Failure to conduct a full Mental Health Act assessment before release from hospital or custody
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.1
Action
Maintain a procedure for referring Emergency Department patients with concerning behaviour and no identified medical cause to the Mental Health Liaison Service.
Stated by the Royal Wolverhampton NHS TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The Trust does not provide direct mental-health services or mental-health input for people in police custody, so those interventions fall outside its functions.
Stated by the Royal Wolverhampton NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Black Country Healthcare NHS Foundation Trust is responsible for mental-health assessment and intervention following the Trust’s referrals.
Stated by the Royal Wolverhampton NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Mental-health input for people in police custody is provided through the locally organised Liaison and Diversion Service between police and mental-health services.
Stated by the Royal Wolverhampton NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The statutory criteria for continued detention to enable a full mental health assessment were not met.
Stated by West Midlands PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised2
Lack of a joint protocol for working between the two Trusts on Mental Health Act assessment referrals
Failure of Mental Health Liaison to attend acute wards and assess presenting self-harm risks during the assessment waiting period
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.6
Action
Develop a joint EPUT–MSE working protocol defining responsibilities for patients awaiting Mental Health Act assessment.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Action
Develop a joint protocol with EPUT covering assessment sequencing, referral expectations, and staff roles and responsibilities.
Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 June 2024.
Action
Continue delivering training to MSE on available support and Mental Health Liaison Team roles.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Action
Update and ratify the Mental Health Liaison Service Operational Policy and SOP to address risk management and support for patients awaiting assessment.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Action
Share the reviewed Mental Health Liaison SOP with all Liaison Team staff to promote awareness and consistent practice.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Action
Review and update the acute hospital mental health admission policy with practical guidance on accessing and escalating to the Mental Health Liaison Team.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Mental Health Liaison Team provision is commissioned by the ICB under contract with EPUT, requiring those bodies' involvement in service arrangements.
Stated by Mid and South Essex NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Comprehensive mental-health and associated risk assessments are provided by EPUT; acute-trust staff are expected to identify when assessments are needed.
Stated by Mid and South Essex NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Exeter and Greater Devon
Concerns raised1
Lack of understanding of voluntary admission and the least restrictive option in Mental Health Act 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.
Manchester West
Concerns raised1
Failure to refer self-discharge patients to a Consultant or Senior Doctor for Mental Health Act detention consideration
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.3
Action
Complete a Trust-wide review of self-discharge against medical advice policies and procedures.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
Action
Develop, ratify and implement a single Trust-wide self-discharge procedure with a checklist, senior clinical review, capacity and risk assessments, detention consideration, documentation and medication supply requirements.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2023.
Action
Disseminate the ratified procedure to Care Groups and staff through the intranet and junior-doctor induction.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
Birmingham and Solihull
Concerns raised1
Unavailability of approved mental health practitioners within 24 hours
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.11
Action
Recruit, retain and train additional Approved Mental Health Professionals.
Stated by Birmingham City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 18 July 2023.
Action
Use agency workers to maximise Approved Mental Health Professional service capacity.
Stated by Birmingham City CouncilStated completedThe respondent said that this action was complete when they made their response on 18 July 2023.
Action
Require all Approved Mental Health Professionals to contribute to the service daily.
Stated by Birmingham City CouncilStated completedThe respondent said that this action was complete when they made their response on 18 July 2023.
Action
Consult with partner organisations on a Memorandum of Understanding to expand the Approved Mental Health Professional rota.
Stated by Birmingham City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 18 July 2023.
Action
Fund Approved Mental Health Professional training for eligible NHS staff.
Stated by Birmingham City CouncilStated plannedThe respondent said that this action was planned when they made their response on 18 July 2023.
Action
Promote and actively support Approved Mental Health Professional training through the dedicated AMHP Lead.
Stated by Birmingham City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 18 July 2023.
Action
Train eight additional Approved Mental Health Professionals using Skills for Care funding.
Stated by Birmingham City CouncilStated completedThe respondent said that this action was complete when they made their response on 18 July 2023.
Action
Invest at least £2.3 billion annually by March 2024 to expand and transform mental health services.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 18 July 2023.
Action
Provide increased national mental health funding, including a record £15.9 billion investment in 2022/23.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 18 July 2023.
Action
Increase the national mental health workforce by more than 10,000 full-time equivalent staff compared with June 2022.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 18 July 2023.
Action
Grow the mental health workforce by an additional 27,000 staff by March 2024 compared with 2018/19.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 18 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The delay was not caused by insufficient AMHP staffing; sufficient AMHPs were on duty before the statutory deadline.
Stated by Birmingham City CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing arrangements result in attendance at almost all s136 assessment requests within the statutory timeframe.
Stated by Birmingham City CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Police can apply for an extension when they consider that the risk requires additional time.
Stated by Birmingham City CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Many concerns, particularly those relating to the mental health trust, fall outside the respondent’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Relevant trusts are responsible for staffing and operating mental health services.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Lincolnshire
Concerns raised1
Failure to consider Mental Health Act admission criteria
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (Western)
Concerns raised2
Delays in promptly progressing recommendations for section assessment
Failure to protect people with mental illness while awaiting section assessment
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 Health Act assessment process, including suitably qualified first-instance assessment, prompt progression of recommendations, and appropriate action on recommendations to consider detention.
