Recurring concern

Failure to reliably send required mental health service communications to service users

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First reported 16 Jan 2015•Latest report 10 Aug 2022

Definition

What this concern includes

Includes failures by mental health services to prepare, send or reliably deliver required patient-facing communications, including opt-in information, appointment communications and comparable notices necessary for access, engagement or continuity of mental health care.

Not included

  • Excludes clinician-to-clinician, GP-facing or other professional correspondence unless the assertion also concerns required communication directly to the mental health service user.
  • Excludes general mental health service access, appointment availability or treatment failures where the patient-facing communication process is not itself deficient.
  • Excludes generic communication, documentation or staffing deficiencies without a specific required mental health service communication to a service user.
  • Excludes discharge correspondence and other separately named communication processes where an existing narrower concern provides the more faithful boundary.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2015–2022

First to latest report issue date

Stated actions
3

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.

Brighton and Hove City Council1
East London NHS Foundation Trust1
NHS Birmingham and Solihull Integrated Care Board1
NHS England1
Norfolk and Suffolk NHS Foundation Trust1
Sussex Partnership NHS Foundation Trust1
Tees, Esk and Wear Valleys NHS Foundation Trust1

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. North Northumberland

    AI-generated summary

    Allan Michael WADDUP · 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

    Allan Michael WADDUP died in prison on 13 December 2019 after seeking mental health support. He had been referred and later self-referred, but was discharged without an assessment, was not assessed before his death, and concerns were raised about appointment notification, the Did Not Attend process, delays in triage, and the absence of weekend triage or urgent-assistance guidance on the prison kiosk.

    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 provide inmates with appointment letters notifying them of planned mental health appointments

    Wider context from the report

    “(1) Mr Waddup was referred to mental health on 29th October 2019 on triaged within 24 hours on 30th October 2019. Attempts were made to assess him by telephone on 14, 19 and 21 November 2019. It is not clear if Mr Waddup personally knew of the appointments. Appointment letters are currently not sent to inmates at HMP Northumberland to notify them of planned appointments. Prisoners could be notified on the day via the appointment scheduling process within the prison whereby the wing is notified of who has appointments with various departments. I heard that TEWV provide mental health services across the North East cluster of prisons including four prisons in the North West. In some custodial facilities an appointment letter is sent. This system is not replicated in HMP Northumberland ”

    Source location

    Allan Michael WADDUP · Prevention of Future Deaths report
    Page 3 · 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

    Introduce reviewed and updated appointment letter templates across prison establishments, including HMP Northumberland.

    Verbatim wording from the response

    “Appointment letter templates have been reviewed and updated and have now been introduced across all prison establishments, including HMP Northumberland where TEWV provide Mental Health care delivery. As part of this process of review, the letter content has been reviewed to ensure its content is succinct and clear, dated and provides the relevant information.”

    Source location

    Response from NHS Tees, Esk and Wear Valleys
    Page 1 · response
    Published 3 November 2022

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Elena WELLS · 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

    Elena Wells, who had a history of mental health issues, died after placing a ligature around her neck while alone at home awaiting an urgent mental health admission. The report identified unclear responsibility and communication between the Local Authority and Mental Health Trust, and insufficient out-of-hours support and supervision while she waited for a bed.

    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 provide advice about the available place of safety

    Wider context from the report

    “2. In this case a clinical decision was made to leave Miss Wells at home until a bed was found with Miss Wells, who was already ill enough to need urgent admission, having to inform the services if she declined further. No provision was made for Miss Wells to be reviewed out of hours, overnight and into the early morning by, for example, the Crisis Team, and no advice offered on the existence of a place of safety at the local Mental Health Hospital. Evidence showed that professionals can contact the Crisis Team in these circumstances but that is not done as a routine and patients appear to be left to make important decisions for themselves in circumstances where their declining mental health may prohibit them from doing so. It is requested that the Trust consider ways of providing extra support and supervision to those patients who are waiting for an urgent admission, particularly those who may be left alone at home for any period until a bed is found. ”

    Source location

    Elena WELLS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Birmingham and Solihull

    AI-generated summary

    Stephen Peter Jackson · 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

    Stephen Peter Jackson was found deceased at home on 11 August 2018 after sending his mother a text message saying “sorry”; drugs paraphernalia and a suicide note were present, and the provisional cause of death was a diamorphine overdose. The report raised concerns that he was not seen by mental health clinicians after his GP requested an urgent appointment, despite reported low mood and negative thoughts, and that delays and possible under-funding of mental health services posed a risk of future deaths.

    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 send mental health appointments

    Wider context from the report

    “3. Mr. Jackson wrote a very detailed suicide note within which he refers to feeling unsupported by professionals who did not send him appointments or answers his calls, the context would support this being a reference to mental health professionals. ”

    Source location

    Stephen Peter Jackson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Bedfordshire and Luton

    AI-generated summary

    LUKE ALF EDWARD MOULDING · 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

    On 25 November 2016, Luke Alf Edward Moulding entered a railway line near his home after consuming alcohol and drugs, collided with a train, and died from severe traumatic injuries. The report raised concerns that an “opt in” letter following a mental-health consultation was not sent, and that the process for sending such letters could be made more effective.

    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 send required opt-in letters

    Wider context from the report

    “(1) The Deceased saw ████████, Speciality Doctor in Psychiatry, at Beacon House Community Mental Health Team on 11th November 2016. The deceased left part way through the consultation. ████████ decided an “opt in” letter was required. It was not sent. (2) The evidence is that “opt in” letters are “normally typed and sent by 10 working days. (3) There seems to be no reason why a typed letter is required. A pre-printed letter/brochure/card would suffice and give the service users sufficient information, should they require it. ”

    Source location

    LUKE ALF EDWARD MOULDING · 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

    Update the CMHT Operational Policy to require opt-in letters to be sent within five working days.

    Verbatim wording from the response

    “The reviewer’s identified that the Operational Policy for the CMHT did not provide guidelines on the service timescales for providing opt-in letters and were concerned to find that the lead time in November 2016 was up to 30 days. It was therefore recommended that the Operational Policy be updated to provide appropriate timescales.”

    Source location

    2017-0121-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 5 April 2017

    Open published response

    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

    Audit local compliance with the five-working-day opt-in letter timescale.

    Verbatim wording from the response

    “Action was subsequently undertaken to the Operational Policy which now requires that opt-in letters should be sent within 5 working days. Compliance against this timescale will be the subject of local audit to ensure compliance.”

    Source location

    2017-0121-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 5 April 2017

    Open published response

  5. Norfolk

    AI-generated summary

    Mark Robert Anstice · 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

    Mark Robert Anstice, who had a history of mental health and social problems and previous self-harm, was found hanged on 27 September 2014. Concerns included that recommended support-worker or care-coordinator provision was not actioned, uncertainty about a carer’s assessment referral, gaps in team awareness of appointments, and difficulties supporting his attendance at group sessions due to lack of transport or means.

    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 inform the service user about proposed help with practical barriers to group attendance

    Wider context from the report

    “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem; (2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team (3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care. (4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups. (5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered. (6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014. (7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014. ”

    Source location

    Mark Robert Anstice · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026