Recurring concern

Unreliable interim mental health support during care transitions

First to latest report 15 Apr 2014 — 5 Sep 2025

Reports that mention this concern
21
Times this concern has been raised
24
Stated actions linked to this concern
13

What this concern includes

Includes failures of the mental health care transition or interim-support process that leave patients without appropriate support while awaiting, moving between or remaining pending mental health services, including absent monitoring, unclear responsibility, delayed referral, discharge-dependent access and reliance on patient-led contact.

What is not included
  • Excludes generic staffing, documentation or communication deficiencies unless they are directly tied to an identified gap in interim mental health support during a care transition.
  • Excludes failures concerning non-mental-health services, hazards or clinical processes without an interim mental-health-support component.
  • Excludes deficiencies occurring within established ongoing treatment that do not concern a delay or transition between mental health services.

Reports and published responses 21 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner West London

    AI-generated summary

    Mr Philip Anthony Dean · 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 Philip Anthony Dean, who had chronic depressive illness and had become suicidal, jumped from Battersea Bridge into the River Thames on 13 August 2013 and died after being recovered and resuscitated. The principal concerns included inadequate continuity of care, discharge from the Home Treatment Team before psychology referral could be made, failure to record and communicate the GP’s concerns, insufficient assessment by medically qualified personnel, apparent under-resourcing, and an inadequate serious untoward incident investigation.

    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

    Discharge-dependent referral to psychology leaving patients without ongoing support

    Wider context from the report

    “(2)That discharge from the HTT is required before referral to psychology can be made, leaving patients without ongoing support in the interim. ”

    Source location

    Mr Philip Anthony Dean · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026