Recurring concern
Unreliable crisis-team access and communication
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Request correctionFirst reported 19 May 2014•Latest report 28 May 2025
What this concern includes
Includes failures of the dedicated crisis-team access and communication process, including unreliable telephone access, ineffective routes for sending information directly to the crisis team, and failures to provide or receive relevant information from referring parties when these impair access to timely crisis support.
Not included
- Excludes general mental-health service access, treatment or staffing deficiencies that are not specifically tied to reaching or communicating with the crisis team.
- Excludes failures of crisis-team clinical assessment, care continuity or referral disposition after communication has been successfully established, unless the communication-access failure is also identified.
- Excludes generic telephone, communication or information-sharing deficiencies without an explicit crisis-team context.
- Excludes failures belonging to a distinct named pathway, such as emergency call handling or Crisis Team referral triage, where the crisis-team access and communication process is not the unsafe condition.
- Reports
- 10
- Individual concerns
- 13
- Date range
- 2014–2025
- Stated actions
- 12
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised2
Failure to communicate accurate assessment and appointment information
Failure of effective communication within and across mental health services
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.3
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Action
Provide reflective supervision to the staff member involved in the missed communication.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Send patient contact details and highlighted actions to GPs through administrative support.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Route crisis-team communications and psychiatrist review requests to multidisciplinary team mailboxes.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to re-contact the crisis team after a concerning change in a resident’s condition
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
DePaul disputes that it failed to identify behavioural deterioration or raise concerns, citing referrals to mental-health services and safeguarding teams.
Stated by Depaul UK
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Concerns raised1
Lack of clarity about neighbourhood team referral back to the crisis team
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.2
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Action
Resume regular Neighbourhood Team and Crisis Pathway meetings and produce an action plan to communicate shared referral processes and criteria.
Stated by East London NHS Foundation Trust -
Action
Implement a six-month rolling training programme for Neighbourhood Teams on clinical risk, referral processes, and risk indicators.
Stated by East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing procedures are considered sufficient for neighbourhood team clinicians to refer service users back to the crisis team when necessary.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure to communicate that a review was not a formal mental health assessment
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Improve communication between crisis and other Trust teams by requiring further discussion of concerning decisions.
Stated by North London NHS Foundation Trust
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Concerns raised1
Ineffectiveness of the pathway for communicating information directly to the crisis team
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing signposting and consent-based referral during the 999 call provide the available pathway to crisis services.
Stated by Yorkshire Ambulance Service NHS Trust
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Concerns raised2
Delays in notifying GPs of Crisis Team discharge
Lack of clear Crisis Team training, structural or protocol provision for discharge communication
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide immediate written discharge and high-risk notification to the crisis team
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of communication within the crisis team and with crisis houses
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.
Stated by North London NHS Foundation Trust
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Concerns raised1
Insufficient information captured by the crisis team pager messaging service
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Confusion and lack of clarity in terminology for out-of-hours CRISIS team calls
Failure of the CRISIS team to provide relevant information or advice to referring parties
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Use and monitor a referral flow chart clarifying whether urgent referrals require advice or assessment.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Review and update the Liaison Psychiatry out-of-hours roles and responsibilities protocol to improve staff guidance.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Implement the SMART Tool in the Emergency Department, finalise its design, incorporate it into the Junior Doctor Handbook, and use it with the Mental Health Trust.
Stated by Maidstone and Tunbridge Wells NHS Trust
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Action
Reinforce requirements for staff to provide complete, accurate information to carers and referring agencies.
Stated by Kent and Medway Mental Health NHS Trust -
Action
Monitor compliance with relevant policies through supervision and audit, managing performance concerns under the Trust’s performance framework.
Stated by Kent and Medway Mental Health NHS Trust
Data last updated 7 September 2026