Recurring concern

Unsafe coordination and continuity during mental health service transfers

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First reported 17 Dec 2013•Latest report 6 May 2026

Definition

What this concern includes

Includes transfers between Trusts, areas or mental-health teams where planning, ownership, information exchange or continuity is deficient.

Not included

Ordinary clinical handover with no transfer of mental-health service responsibility
Discharge from mental-health care with no receiving service
Referral failures before a transfer is accepted

Reports: 26
Individual concerns: 33
Date range: 2013–2026
Stated actions: 39

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care4

Greater Manchester Mental Health NHS Foundation Trust3

Lancashire & South Cumbria NHS Foundation Trust3

NHS England3

Herefordshire and Worcestershire Health and Care NHS Trust2

North East London NHS Foundation Trust2

Pennine Care NHS Foundation Trust2

Arts University Bournemouth1

Avon and Wiltshire Mental Health Partnership NHS Trust1

Betsi Cadwaladr University LHB1

Birmingham Women'S and Children'S NHS Foundation Trust1

Blackpool Teaching Hospitals NHS Foundation Trust1

Cheshire and Wirral Partnership NHS Foundation Trust1

Countess of Chester Hospital NHS Foundation Trust1

Coventry and Warwickshire 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.

20 Feb2015
Carmarthenshire & Pembrokeshire
Concerns raised1
1. Breakdown in information transition and passing between Child/Adolescent and Adult Mental Health Teams
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Circulate transition guidelines between child and adult mental health services.
  Stated by Hywel Dda University LHBStated completed
AI-generated summary

Laura Hill · 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

Laura Hill, aged 21, was admitted to a psychiatric ward after a serious overdose and later absconded twice before being found hanging from a tree in a wooded area. The concerns identified included information-sharing failures, stretched staffing, training needs around police handovers, absconding, personality disorders and detention powers, and the ward door policy.

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
Breakdown in information transition and passing between Child/Adolescent and Adult Mental Health Teams
Wider context from the report
“(1) That there appears to be a breakdown in the transition and passing of information between the Child/Adolescent and the Adult Mental Health Teams. ”
Source location
Laura Hill · 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
Circulate transition guidelines between child and adult mental health services.

Verbatim wording from the response
“In January 2013, the Health Board provided transition guidelines in relation to Specialist Child and Adolescent Mental Health Services to Adult Mental Health and Learning Disability Services. The document was circulated across all the relevant teams and provides clear transition guidelines in line with best practice and government guidelines with regards to transitions between services. It is recognised that times of transition can pose potential risks if they are not robustly managed and the guidance enhances the safety of the transition process with clear steps for professionals to follow.”

Source location
2015-0092-Response-by-University-Health-Board
Page 1 · response
Published 20 February 2015
Open published response
20 Feb2015
Wiltshire and Swindon
Concerns raised1
1. Failure to record primary responsibility for patient care during transfers of care
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Implement a mental health referral proforma to record risk, assessment timeframe, accepting practitioner and agreed actions for out-of-hours referrals.
  Stated by Salisbury NHS Foundation TrustStated planned
2. Action
  Incorporate the mental health referral proforma into the upgraded ED electronic system for electronic transfer and storage by the end of 2015.
  Stated by Salisbury NHS Foundation TrustStated planned
3. Action
  Update JSP 950 Leaflet 2-7-2 with guidance on care transfers, responsibility, NHS coordination, information sharing and access to Defence Medical Services advice.
  Stated by Ministry of DefenceStated in progress
1. Action
  Continue discussions with the Ministry of Defence and NHS England to address concerns about information sharing and care responsibility for armed forces personnel.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Conduct a joint root cause analysis with Salisbury District Hospital and the Armed Forces, including review of relevant policies and procedures.
  Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated planned
Respondent positions 5
1. Position
  Further advice on the specific concerns cannot be provided because Public Health England is not in a position to advise further.
  Stated by Public Health EnglandUnable to act
1. Position
  The Department of Health, Ministry of Defence and NHS England will address the specific concerns through their ongoing discussions.
  Stated by Public Health EnglandRedirects responsibility
2. Position
  The mental health providers named in the report are expected to comment on the particular case and address concerns locally.
  Stated by Public Health EnglandRedirects responsibility
3. Position
  The out-of-hours Service Liaison Officer service is non-clinical and does not assess or assume responsibility for people in mental health crisis.
  Stated by Ministry of DefenceOutside remit
4. Position
  Local mental health providers are expected to address the specific case and concerns from their local perspective.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Richard Jeffrey Jones · 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

Richard Jeffrey Jones was at home alone and, during 14 to 15 October 2012, voluntarily ingested a quantity of tramadol that led to loss of consciousness, respiratory depression and aspiration of gastric contents, causing his death. The report raised concerns about recording and sharing information on risk and urgency, and about identifying primary responsibility when care was transferred between 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
Failure to record primary responsibility for patient care during transfers of care
Wider context from the report
“I am concerned in particular as to the following matters : a) As to the way in which information obtained from such a patient is recorded , with especial reference to the perceived level of risk and the degree of urgency in carrying out an assessment. b) As to how that information is shared with other agencies involved in the care of that patient to ensure that it is accurately passed on, particularly as to the level of risk and degree of urgency. c) As to who has primary responsibility for the care of that patient and how that is recorded by all those involved, particularly where there is a transfer of care. ”
Source location
Richard Jeffrey Jones · 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
Implement a mental health referral proforma to record risk, assessment timeframe, accepting practitioner and agreed actions for out-of-hours referrals.

Verbatim wording from the response
“To ensure robust recording of information to the out-of-hours AWP service a proforma will be generated for clinician use. This will include information such as the assessed level of risk as per the mental health risk assessment tool, the agreed timeframe for assessment, the name of the accepting mental health practitioner, and any other agreed actions from the telephone referral conversation. The proforma will safeguard against any misunderstandings between an ED clinician to an AWP”

Source location
2015-0068-Response-by-Salisbury-NHS-Trust
Page 2 · response
Published 20 February 2015
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
Incorporate the mental health referral proforma into the upgraded ED electronic system for electronic transfer and storage by the end of 2015.

Verbatim wording from the response
“mental health worker and vice versa. Once completed, the information will then be faxed or emailed to an agreed secure number or address for AWP to place with the AWP patient record, and the original will be held within the ED patient record at SFT. This will be incorporated within the ED upgraded electronic system by the end of the year so that it can be transferred and stored electronically.”

Source location
2015-0068-Response-by-Salisbury-NHS-Trust
Page 3 · response
Published 20 February 2015
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
Update JSP 950 Leaflet 2-7-2 with guidance on care transfers, responsibility, NHS coordination, information sharing and access to Defence Medical Services advice.

Verbatim wording from the response
“I can confirm that we are now updating leaflet 2-7-2 of the Department’s medical policy document (Joint Service Publication (JSP) 950) which covers the provision and management of Defence mental health services. This will include new guidance and policy on the principles of transfer, which will include addressing both internal transfers of care between different Defence Medical Services (DMS) care providers and the transfers between DMS providers and external agencies.”

Source location
2015-0068-Response-by-Ministry-of-Defence
Page 2 · response
Published 20 February 2015
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
Continue discussions with the Ministry of Defence and NHS England to address concerns about information sharing and care responsibility for armed forces personnel.

Verbatim wording from the response
“At a national level, the Department of Health (DH) works closely with the MoD and with NHS England to ensure that service personnel receive the right health services. Medical notes relating to an individual patient must pass readily from the MoD to the NHS and back again as appropriate. This will become increasingly important as the number of Armed Forces reservists is increased, as these personnel will access health services from the MoD when mobilised, and from the NHS at other times.”

Source location
2015-0068-Response-by-Department-of-Health2
Page 2 · response
Published 20 February 2015
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
Conduct a joint root cause analysis with Salisbury District Hospital and the Armed Forces, including review of relevant policies and procedures.

Verbatim wording from the response
“Your report was considered by our Critical Incident Review Group, which is chaired by my Medical Director, ████████ on 2 March 2015. It was decided that to best explore the issues you have raised, we should conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces. This will enable staff from the different agencies to collaborate and identify the best solutions to the problems you have raised concerns about, to include a review of any relevant policies and procedures.”

Source location
2015-0068-Response-by-Avon-Wiltshire-Mental-Health-NHS-Trust
Page 1 · response
Published 20 February 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Further advice on the specific concerns cannot be provided because Public Health England is not in a position to advise further.

Verbatim wording from the response
“DH will continue their discussions with MoD and NHSE on this issue and these discussions will address the specific concerns you have raised in your report. Unfortunately, PHE are not in a position to advise on this matter further.”

Source location
2015-0068-Response-by-Public-Health-England
Page 1 · response
Published 20 February 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Department of Health, Ministry of Defence and NHS England will address the specific concerns through their ongoing discussions.

Verbatim wording from the response
“I am aware you have also written to the Department of Health (DH), and I understand that DH, the Ministry of Defence (MoD) and NHS England (NHSE) work closely together to ensure that service personnel receive the right health services. These organisations are also aware of the need for effective patient note transfer between the MoD and the NHS.”

Source location
2015-0068-Response-by-Public-Health-England
Page 1 · response
Published 20 February 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The mental health providers named in the report are expected to comment on the particular case and address concerns locally.

Verbatim wording from the response
“Finally, I have been advised that the mental health providers named in your report are expected to provide comment on the detail of this particular case and to address your concerns from their local perspective.”

Source location
2015-0068-Response-by-Public-Health-England
Page 2 · response
Published 20 February 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The out-of-hours Service Liaison Officer service is non-clinical and does not assess or assume responsibility for people in mental health crisis.

Verbatim wording from the response
“It should be noted that the Service Liaison Officer Service is not a clinical one. The on duty SLO is not expected to carry out an assessment or take responsibility for someone in crisis or discharged from hospital.”

Source location
2015-0068-Response-by-Ministry-of-Defence
Page 3 · response
Published 20 February 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Local mental health providers are expected to address the specific case and concerns from their local perspective.

Verbatim wording from the response
“Firstly, I would expect the mental health providers named in your report to provide comment on the detail of this particular case and to address your concerns from their local perspective.”

Source location
2015-0068-Response-by-Department-of-Health2
Page 1 · response
Published 20 February 2015
Open published response
13 Feb2015
Manchester West
Concerns raised2
1. Unclear procedures and protocols for continuing care when service users move outside the Trust area
2. Delays or non-provision of continuing mental health care when service users move outside the Trust area
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
Unclear procedures and protocols for continuing care when service users move outside the Trust area
Wider context from the report
“ii. The procedures and protocols currently in place within Lancashire Care NHS Foundation Trust for the continuing care of a service user, when that service user moves out of the area, are not clear and give rise to risky and potentially fatal situations. ”
Source location
Robert Paul Yarnell · 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
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
29 Aug2014
Blackpool and the Fylde
Concerns raised1
1. Failure to exchange sufficient relevant mental health information during cross-area transitions
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Stephen James Morris · 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 James Morris, who had previously been diagnosed with bipolar affective disorder, was found deceased in the bath at his flat on the morning after 16 June 2013. A post-mortem found high levels of mood-stabilising and antidepressant medication, whose combined effects proved fatal; the inquest concluded that he took his own life. The principal concerns were that Mirtazapine was prescribed despite awareness of his diagnosis and its suitability concerns, based on the patient's verbal account rather than confirmation from the mental health team.

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 exchange sufficient relevant mental health information during cross-area transitions
Wider context from the report
“Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because: • I am concerned that there was a limited exchange of information as regards Stephen and his mental health between the mental health professionals in Cheshire and their counterparts in Blackpool. • By the time that Stephen came to Blackpool for what turned out to be the final time the professionals in Blackpool did not have a detailed picture of how Stephen had presented during recent weeks in relation to his mental health. • When individuals with a similar mental health history as Stephen do move from one area of the country to another there is the potential for a mental health team to find themselves with less detailed relevant information than may be the case for a similar individual who has recently been residing within the immediate area. I am concerned that the quality of exchange of information needs to be such that when mental health professionals find themselves dealing with such an individual that they have as much relevant information as possible to be able to assess the risk such a patient poses and to respond accordingly. ”
Source location
Stephen James Morris · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Jun2014
Norfolk
Concerns raised1
1. Failure to make direct written Trust-to-Trust referrals when transferring patients to another Trust
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · 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

Sol Hadhasseh had a complex mental health history and was found unresponsive at her flat on 28 November 2013 after concerns were raised for her welfare. The inquest concluded that she had killed herself, with the medical cause of death recorded as tramadol toxicity; concern was raised that her transfer between mental health trusts had not been arranged through a direct Trust-to-Trust referral.

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 make direct written Trust-to-Trust referrals when transferring patients to another Trust
Wider context from the report
“I heard at the Inquest from the Acting Deputy Service Manager of Norfolk & Suffolk NHS Foundation Trust’s Access & Assessment Team. In her evidence she stated that in her experience she would have expected the Warwickshire & Coventry Partnership Trust to have made a direct written referral Trust to Trust rather then via the GP, given the complex needs and history of Sol and that this should have been planned in advance. Whilst it can not be known whether had such referral been made the outcome for Sol would have been different, I am nevertheless concerned that a similar circumstance to arise in the future an preventable death might occur and there is a continuing risk that other deaths could occur which could be avoided. I was therefore concerned that procedures for transferring a patient to another Trust should be reviewed by the Warwickshire & Coventry Partnership Trust. ”
Source location
SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report
Page 1 · concerns
Open source report
17 Dec2013
Worcestershire
Concerns raised1
1. Failure to define and communicate mental health teams' roles and responsibilities for onward care
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sean Christopher Seabourne · 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

Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.

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 define and communicate mental health teams' roles and responsibilities for onward care
Wider context from the report
“(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests. (2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient. (3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team. It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself. It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself. Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case. ”
Source location
Sean Christopher Seabourne · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Breakdown in information transition and passing between Child/Adolescent and Adult Mental Health Teams

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to record primary responsibility for patient care during transfers of care

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised2

Unclear procedures and protocols for continuing care when service users move outside the Trust area

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

Concerns raised1

Failure to exchange sufficient relevant mental health information during cross-area transitions

Concerns raised1

Failure to make direct written Trust-to-Trust referrals when transferring patients to another Trust

Concerns raised1

Failure to define and communicate mental health teams' roles and responsibilities for onward care

Actions described in response 1

Actions described in response 5

Respondent positions 5