First reported 17 Dec 2013•Latest report 11 Oct 2025
Definition
What this concern includes
Includes failures within mental health assessment pathways to provide an in-person assessment, including where a face-to-face assessment is needed after deterioration, psychotic or suicidal symptoms, or where voluntary agreement is absent and compulsory assessment should be considered.
Not included
Excludes failures concerning face-to-face consultation or assessment outside mental health care, such as drug dispensing, neurology, general medical diagnosis or unrelated clinical procedures.
Excludes generic failures of referral, admission, documentation, staffing or training unless they directly concern whether a clinically indicated face-to-face mental health assessment was provided.
Excludes the general use of telephone consultations where the report does not identify a clinically indicated need for face-to-face mental health assessment.
Reports
11
Distinct published reports
Individual concerns
11
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
9
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 Care2
NHS Greater Manchester Integrated Care Board2
Pennine Care NHS Foundation Trust2
East London NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
Greater Manchester Police1
Herefordshire and Worcestershire Health and Care NHS Trust1
Lancashire & South Cumbria NHS Foundation Trust1
LPFT Legal Services1
Metropolitan Police Service1
NAViGO Health and Social Care CIC1
NHS England1
North West Ambulance Service NHS Trust1
Recipient name withheld1
Tees, Esk and Wear Valleys NHS Foundation Trust1
NHS trust6
Integrated care board2
Ministerial department2
Police force2
Executive non-departmental public body1
Health-system partnership1
Independent healthcare provider1
Sub-organisation1
Type not available1
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.
West Sussex, Brighton and Hove
Concerns raised1
Failure to ensure in-person mental health assessments where remote appointments are unsuitable
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Local services determine the availability of in-person mental health appointments, and no national policy is currently planned.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to provide face-to-face CMHT assessment in line with Trust Policy
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Face-to-face CMHT review was not necessarily required because the patient had not yet been allocated a care coordinator.
Stated by Pennine Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Lincolnshire
Concerns raised1
Failure to undertake face-to-face assessment after recent suicide attempts
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
No systems or process changes are needed because the assessment followed recognised practice and decisions depend on individual circumstances.
Stated by NAViGO Health and Social Care CICNo action considered necessaryThe respondent said that no further action was needed.
Position
Follow-up after hospital assessment was assigned to local LPFT services, with NAViGO recommending face-to-face contact.
Stated by NAViGO Health and Social Care CICRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to provide face-to-face mental health assessment when clinically needed
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.5
Action
Produce and iteratively update standard operating procedures for safe remote general-practice services during changing pandemic requirements.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
Action
Develop joint guidance with the Royal College of General Practitioners on choosing remote or face-to-face consultations, including patient safety and safety-netting.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
Action
Provide patients with access to face-to-face GP consultations where clinically appropriate or directly requested.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
Action
Reintroduce advance booking of face-to-face GP appointments across Stockport practices.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
Action
Operate telephone triage with safety netting and same-day face-to-face appointments for patients reporting mental health concerns.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing remote-consultation procedures require safety-focused triage and clinician selection of consultation method according to each patient’s circumstances.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing appointment systems provide face-to-face consultations where clinically appropriate or directly requested, so further access changes are unnecessary.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing triage and safety-netting processes adequately manage telephone mental-health presentations, including same-day assessment and referral information.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Telephone-only GP assessments of mental health risk and need
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.
Manchester North
Concerns raised1
Unavailability of an out-of-hours mental-health community response service for face-to-face assessment
This report raised 13 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
CRT cannot respond to all mental-health incidents because demand exceeds its commissioned capacity and requires triage.
Stated by Greater Manchester PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to obtain direct or supported assessment of a person when access is challenged by concerns about police uniforms
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Suggested scene-assessment actions will not be made mandatory because they may be impracticable or inappropriate in some circumstances.
Stated by Metropolitan Police ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to provide timely face-to-face psychiatric assessment after worsened-condition referral
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.2
Action
Require escalation of Home Treatment referrals not seen within 48 hours to a consultant psychiatrist or team manager for prioritised review.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2017.
Action
Provide routine doctor review within 72 hours for Home Treatment referrals without prior professional assessment, with out-of-hours emergency review by on-call psychiatry.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2017.
Preston and West Lancashire
Concerns raised1
Cancellation of planned face-to-face mental health assessments
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised1
Failure to obtain or require face-to-face assessment when clinically indicated
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.2
Action
Remind staff to explore and use alternative venues for appointments.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 August 2014.
Action
Share recommendations with the crisis team and reinforce consultation with colleagues and medical staff for complex assessments.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 August 2014.
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Includes failures within mental health assessment pathways to provide an in-person assessment, including where a face-to-face assessment is needed after deterioration, psychotic or suicidal symptoms, or where voluntary agreement is absent and compulsory assessment should be considered.
