Recurring concern

Unreliable interim mental health support during care transitions

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First reported 15 Apr 2014•Latest report 5 Sep 2025

Definition

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.

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
21

Distinct published reports

Individual concerns
24

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
13

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.

NHS England3
Birmingham Women'S and Children'S NHS Foundation Trust2
NHS Birmingham and Solihull Integrated Care Board2
South West London and St George'S Mental Health NHS Trust2
Betsi Cadwaladr University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Brighton and Hove City Council1
Cambridgeshire and Peterborough NHS Foundation Trust1
CAMHS East – Cross Street Clinic1
Cheshire and Wirral Partnership NHS Foundation Trust1
College of Policing1
Cumbria Constabulary1
Department of Health and Social Care1
Devon Partnership NHS 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. 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
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Data last updated 7 September 2026