Recurring concern

Unreliable multidisciplinary and interagency care planning for mental-health relapse

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First reported 1 Jul 2019•Latest report 25 Feb 2022

Definition

What this concern includes

Includes failures in multidisciplinary or interagency mental-health care-planning arrangements that are specifically intended to identify relapse indicators, agree preventive or responsive actions, assign responsibilities, share relevant risk information and coordinate follow-up, including joint plans and pre-discharge multidisciplinary discussions.

Not included

  • Excludes generic interagency communication, care coordination or role-clarity failures where mental-health relapse planning is not the shared unsafe condition.
  • Excludes general care-planning failures unrelated to mental-health relapse indicators or relapse prevention.
  • Excludes failures limited to discharge-letter content, family communication or medication management unless they directly constitute the coordinated relapse-planning process.
  • Excludes failures to implement an otherwise complete relapse plan where the planning process itself was reliable.
  • Excludes the existing broader concerns concerning generic multidisciplinary meetings, mental-health care coordination or interagency information sharing when no specific relapse-planning condition is identified.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2019–2022

First to latest report issue date

Stated actions
1

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.

Black Country Healthcare NHS Foundation Trust1
Care Quality Commission1
Essex Partnership University NHS Foundation Trust1
Walsall Borough Council1

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.

  1. Essex

    AI-generated summary

    Stephanie Moyce · 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

    Stephanie Moyce, who had a history of mental health issues and repeated suicide attempts, took her own life on 30 July 2021 and was discovered by her partner. The report identified concerns about unclear responsibility for care and oversight after psychotherapy discharge, inadequate discharge planning and safety-netting, the lack of routine multidisciplinary discussion, and insufficient involvement of her carer in Section 117 after-care reviews.

    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 routinely discuss psychotherapy patients in locality multidisciplinary team meetings before discharge to share progress, vulnerability and relapse-risk information

    Wider context from the report

    “3. Evidence confirmed that patients under psychotherapy are not presently routinely discussed in the locality multi-disciplinary team meetings prior to their discharge leading to a missed opportunity: (a) to share information about the specific progress, vulnerabilities and risks of relapse of the patient (and measures to mitigate or deal with the same); as well as (b) to organise and follow up the overall discharge planning. ”

    Source location

    Stephanie Moyce · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Black Country

    AI-generated summary

    Mr Peter Lawrence (PL) · 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

    Mr Peter Lawrence, a 48-year-old man with paranoid schizophrenia and a history of disengagement from mental health services, was found outside his flat on 8 February 2019 after falling from the balcony and died from traumatic injuries. Concerns included the lack of a joint multi-disciplinary/agency care plan, inconsistent care coordination, and the absence of a coordinated mental health assessment and possible admission when concerns about self-care and disengagement arose.

    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 a joint multidisciplinary and interagency care plan for responding to relapse indicators

    Wider context from the report

    “2. There was a lack of a joint multi-disciplinary/agency care plan (between Local authority and Mental Health Trust) which could have resulted in delays in a timely response to known relapse indicators. ”

    Source location

    Mr Peter Lawrence (PL) · 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

    Formulate a joint action plan to improve multidisciplinary and multi-agency care plans and risk assessments for community patients with complex needs.

    Verbatim wording from the response

    “The Trust has in conjunction with Walsall Council formulated a further joint action plan to ensure that policies and procedures relating to multidisciplinary/agency care plans and risk assessments meet the needs of community patients with complex needs and that a multi-agency working approach is reinforced going forward.”

    Source location

    2019-0245-Response-by-Dudley-and-Walsall-Mental-Health-NHS-Trust
    Page 1 · response
    Published 9 September 2019

    Open published response
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Data last updated 7 September 2026