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. Birmingham and Solihull

    AI-generated summary

    Daniel Hubert Collins · 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

    Daniel Hubert Collins attempted to take his own life by overdose on 07/04/18 and was discharged from hospital and then from the FTB crisis team, with responsibility placed on him to contact counselling services. He went missing on 26/04/18 and was found deceased in woodland on 28/04/18; the medical cause of death was venlafaxine overdose. The report identified concern that the transfer between mental health services was not communicated or followed up, creating a risk that patients in or recently out of crisis could be lost to mental health services.

    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

    Transfer of necessary mental health care placing responsibility for initiating contact on patients

    Wider context from the report

    “One mental health service, FTB crisis team, transferred necessary mental health care to a second service Living Well consortium (LWC), putting the responsibility of making contact on the patient (aged 22, and only 72 hours post-attempting to take his own life). The rational was “it is part of their recovery, empowers them and gives them choices”. FTB crisis team did not alert LWC to the transfer and did not follow up with LWC or the patient that contact had been made. There was/is no system in place to require FTB crisis team to notify LWC about the transfer or trigger a follow up with LWC/the patient. Therefore, patients are at risk of being lost to the mental health service whilst in crisis/only recently out of crisis. ”

    Source location

    Daniel Hubert Collins · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Dudley Vincent Brown · 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

    Dudley Vincent Brown had multiple health conditions and his care package was withdrawn after incidents involving threats to carers and a social worker. He was found at home in a state of reduced consciousness during a delayed mental health assessment, taken to hospital with multi-organ failure, and died on 11 January 2018. Concerns included the withdrawal of care without welfare checks, misunderstandings about referral responsibilities, and delays involving the mental health assessment and police risk assessment.

    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 arrange welfare checks pending mental health assessment

    Wider context from the report

    “(2) Mr Brown’s care package was withdrawn on 27 December 2017. No arrangements were put into place for Mr Brown’s welfare to be checked in the period pending a mental health assessment. ”

    Source location

    Dudley Vincent Brown · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Birmingham and Solihull

    AI-generated summary

    Leah Abby Ratheram · 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

    Leah Abby Ratheram, who had autism, foetal alcohol syndrome and a history of self-harm, died after being found hanging from a tree on 7 October 2016. The report raised concerns about the lack of coordinated care and unclear responsibility between mental health organisations, ineffective sharing of records and risk information, and uncertainty about the Mental Health Act assessment process.

    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

    Unclear responsibility for patients during transfer between mental health services

    Wider context from the report

    “1. Adults aged between 18 – 25 now have mental health services provided by two organisations – Forward Thinking Birmingham and Birmingham and Solihull Mental Health Trust. If a patient presents in crisis to A&E they will be seen by someone from the RAID team who work for Birmingham and Solihull Mental Health Trust. If they require ongoing treatment they will be referred to forward Thinking Birmingham. There is a concern that patients will have no coordinated approach to their care at a time of crisis. It is also unclear who will ultimately be responsible for the patient, particularly during the period of transfer. ”

    Source location

    Leah Abby Ratheram · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Staffordshire South

    AI-generated summary

    Annabel Mae LEWIS · 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

    Annabel Mae LEWIS, aged 15, died by asphyxia from external airway obstruction after placing a plastic bag over her head at home. The report raised concerns about CAMHS referral handling, including the lack of recorded risk assessment, follow-up arrangements, attempts to engage her parents, and proactive support after she declined an appointment because of difficulty accessing the venue.

    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

    Delays between referral, initial contact and attempted follow-up

    Wider context from the report

    “(1) At the inquest it was evident that Annabel had been referred by her GP to your team in November 2015 but that referral had not been accepted. She was referred again on 20/10/2016 by her school. This time the referral was accepted and your team made contact with her by telephone on 21/10/2016. She declined an appointment because she felt she could not get to the venue. No level of risk was recorded and next of kin details were not available. The date of appointment offered and declined were not recorded. Alternative time for appointment was not recorded. No follow up arrangements were recorded. There was no attempt to contact Annabel thereafter. An unsuccessful attempt to contact the referrer was made on 4/11/2016- the day Annabel took her own life. The time period between referral and initial contact and attempted follow up appears considerable. No attempt appears to have been made to engage with her parents who would have been in a position to assist with transport arrangements. The expectation that young people such as Annabel would 'opt in 'to the system may be unrealistic given the difficulties that she had in engaging. Annabel might well have benefitted had she been offered a more proactive service. ”

    Source location

    Annabel Mae LEWIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner South London

    AI-generated summary

    Dr Debatra Sircar · 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

    Dr Debatra Sircar had longstanding alcohol dependency and depression, and died on 20 February 2016 after a fall associated with alcohol intoxication, causing subdural and intracerebral haemorrhage. He had been assessed as unsuitable for home treatment, but a Mental Health Act assessment was scheduled 11 days later, and he died before it took place. Concerns included the delay in securing hospital care and the absence of a clear interim care plan and responsibility for psychiatric monitoring.

    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 an interim care plan for patients pending Mental Health Act assessment

    Wider context from the report

    “2. In the intervening 11 day period there was an absence of an interim care plan, identified in the SUI investigation. Although there were plans for increased contacts in future interim care for those pending MHA assessment, it was unclear who would take the lead and how a patient would be psychiatrically monitored in that period. ”

    Source location

    Dr Debatra Sircar · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 assign clinical leadership and psychiatric monitoring during interim care pending Mental Health Act assessment

    Wider context from the report

    “2. In the intervening 11 day period there was an absence of an interim care plan, identified in the SUI investigation. Although there were plans for increased contacts in future interim care for those pending MHA assessment, it was unclear who would take the lead and how a patient would be psychiatrically monitored in that period. ”

    Source location

    Dr Debatra Sircar · 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

    Hold thrice-weekly zoning meetings for high-risk individuals and minute agreed risk-mitigation actions.

    Verbatim wording from the response

    “• Zoning meetings to review those individuals considered high risk (i.e. those in the red zone) take place three times per week and agreed actions to mitigate risks are minuted. In addition, regular weekly interface meetings between community and home treatment teams now take place to ensure that the clinical pathway between services is working properly.”

    Source location

    2016-0352.Response-by-Oxlea-NHS-Trust
    Page 2 · response
    Published 19 February 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

    Specify the Home Treatment Team’s expected risk-management role in referrals made while clients await Mental Health Act assessment.

    Verbatim wording from the response

    “Following our review, we have instigated the following change in practice:”

    Source location

    2016-0352.Response-by-Oxlea-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    Open published response

  6. Exeter and Greater Devon

    AI-generated summary

    Louise Turner · 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

    Louise Turner died on 27 June 2014 from inhalation of helium after recently being discharged from a lengthy inpatient stay while receiving treatment for a serious mental health illness. The report raised concerns about inadequate post-discharge care and contact, ineffective duty and buddying arrangements, expectations that patients initiate contact, and the absence of female intensive psychiatric care beds in Devon.

    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 adequate post-discharge mental health care and contact

    Wider context from the report

    “(1) The Devon Partnership trust had no adequate mental health care for Louise after she was discharged. There was inadequate contact and no explanation at Inquest as to why this had not taken place. ”

    Source location

    Louise Turner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Cambridgeshire and Peterborough

    AI-generated summary

    Edward Angus Mallen · 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

    Edward Angus Mallen, who was suffering from depression and had disclosed suicidal thoughts, died after lying across a railway line and being struck by a train on 9 February 2015. The concerns included unclear responsibility for his care, advice from a non-prescriber about medication, lack of information about possible worsening symptoms and increased suicidal feelings, and inadequate awareness of routes to further psychiatric advice.

    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 clear responsibility for care pending further mental health appointments

    Wider context from the report

    “3. Edward received no advice about the contraindications of the medication and critically that he may well feel worse before he felt better and may feel more suicidal. In either event he should have been told who to call to get further assistance. 4. The fact that Edward did not receive this information could be due to there being no clear sense of who would be responsible for his care pending further mental health team appointments. ”

    Source location

    Edward Angus Mallen · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Manchester City

    AI-generated summary

    Nicholas Patrick SULLIVAN · 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

    Nicholas Patrick SULLIVAN, who had a chronic mental illness and was experiencing suicidal ideation and auditory hallucinations, attended an emergency department but was not triaged or referred for a timely mental health assessment. He left after waiting, later reiterated that he was suicidal, ran into a road and was struck by a car, dying from his injuries on 30 November 2014. The principal concerns included failures to record mental health risks at reception, trigger urgent triage and safeguarding, activate escalation procedures, and ensure appropriate coordination and staffing.

    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

    Absence of a clear system to safeguard patients pending mental health assessment

    Wider context from the report

    “5.2 There was no clear system to trigger urgent triage and safeguarding steps prior to that. 5.3 There was no clear system following triage and mental health assessment referral, to safeguard the patient pending that assessment. ”

    Source location

    Nicholas Patrick SULLIVAN · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  9. Cumbria

    AI-generated summary

    Alice Anne McMeekin · 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

    Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

    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 without timely and adequate follow-up care for a person remaining at risk

    Wider context from the report

    “2.The Partnership Trust The Coroner concluded that the evidence at the inquest showed that the perpetrator was suffering from a mental disorder when he tried to kill himself on the 6th June 2013. Whilst the psychiatric nurse that day did not have all the information which was available at the inquest he had information to show that perpetrator had a history of self-harm, unemployment, family stressors, multiple and complex drug misuse, quasi-incestuous sexual feelings, past sex abuse, hopelessness, low mood and serious suicide attempt that day. 3.Not withstanding the above the nurse decided that the perpetrator was of zero risk and was not suffering from a mental disorder. He was discharged with the only potential follow up being talking therapy which would not commence, if it ever did, some weeks hence. The evidence at inquest shows that this was a very disturbed young man having intended to kill himself 6 hours earlier and who remained a risk to himself. Whilst the information known to the nurse at the time the tragic outcome could not have been anticipated, there was an opportunity to render care, which could, as a consequence have made a difference. It is a concern that the two assessments after the killings also concluded the perpetrator was not suffering from a mental disorder. ”

    Source location

    Alice Anne McMeekin · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Manchester West

    AI-generated summary

    Robert Paul Yarnell · 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

    Robert Paul Yarnell died after jumping from Barton Bridge on the M60 Motorway on 8 October 2014, causing multiple injuries. He had been receiving mental health care following a hospital admission, but moving out of the area led to a significant delay in continuing care. Concerns were raised that unclear procedures for transferring care between areas could leave service users without needed support and create risky situations.

    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

    Delays or non-provision of continuing mental health care when service users move outside the Trust area

    Wider context from the report

    “i. Due to Mr Yarnell moving out of the area there was a significant delay in the continuing care that he received following his discharge from hospital after a section 2 admission under the Mental Health Act 1983. Although Mr Yarnell did contact the services of his own volition some time later, I have concerns that in future cases a service user who requires ongoing support and treatment from Lancashire Care NHS Foundation Trust, may not receive it due to residing outside the Trust area. ”

    Source location

    Robert Paul Yarnell · 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