Failure to provide face-to-face mental health assessment when clinically indicated
First to latest report 17 Dec 2013 — 11 Oct 2025
Reports that mention this concern
11
Times this concern has been raised
11
Stated actions linked to this concern
9
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 11 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
Local services determine the availability of in-person mental health appointments, and no national policy is currently planned.
Redirects 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.
Linked response
Pennine Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Pennine Care NHS Foundation Trust
Face-to-face CMHT review was not necessarily required because the patient had not yet been allocated a care coordinator.
Disputes 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.
Linked response
NAViGO Health and Social Care CIC
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
NAViGO Health and Social Care CIC
No systems or process changes are needed because the assessment followed recognised practice and decisions depend on individual circumstances.
No action considered necessaryThe respondent said that no further action was needed.
NAViGO Health and Social Care CIC
Follow-up after hospital assessment was assigned to local LPFT services, with NAViGO recommending face-to-face contact.
Redirects 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.
Linked responses
NHS England
NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
NHS England
Produce and iteratively update standard operating procedures for safe remote general-practice services during changing pandemic requirements.
NHS England
Develop joint guidance with the Royal College of General Practitioners on choosing remote or face-to-face consultations, including patient safety and safety-netting.
NHS Greater Manchester Integrated Care Board
Provide patients with access to face-to-face GP consultations where clinically appropriate or directly requested.
NHS Greater Manchester Integrated Care Board
Reintroduce advance booking of face-to-face GP appointments across Stockport practices.
NHS Greater Manchester Integrated Care Board
Operate telephone triage with safety netting and same-day face-to-face appointments for patients reporting mental health concerns.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
NHS England
Existing remote-consultation procedures require safety-focused triage and clinician selection of consultation method according to each patient’s circumstances.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
NHS Greater Manchester Integrated Care Board
Existing appointment systems provide face-to-face consultations where clinically appropriate or directly requested, so further access changes are unnecessary.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
NHS Greater Manchester Integrated Care Board
Existing triage and safety-netting processes adequately manage telephone mental-health presentations, including same-day assessment and referral information.
Existing 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.
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.
Linked response
Greater Manchester Police
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Greater Manchester Police
CRT cannot respond to all mental-health incidents because demand exceeds its commissioned capacity and requires triage.
Unable 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.
Linked response
Metropolitan Police Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Metropolitan Police Service
Suggested scene-assessment actions will not be made mandatory because they may be impracticable or inappropriate in some circumstances.
Unable 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.
Linked response
East London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
East London NHS Foundation Trust
Require escalation of Home Treatment referrals not seen within 48 hours to a consultant psychiatrist or team manager for prioritised review.
East London NHS Foundation Trust
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.
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.
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.
Linked response
Tees, Esk and Wear Valleys NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Tees, Esk and Wear Valleys NHS Foundation Trust
Remind staff to explore and use alternative venues for appointments.
Tees, Esk and Wear Valleys NHS Foundation Trust
Share recommendations with the crisis team and reinforce consultation with colleagues and medical staff for complex assessments.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.