Recurring concern

Unclear roles and pathways for community mental-health services

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First reported 12 Sep 2013•Latest report 8 Aug 2025

Definition

What this concern includes

Includes failures within community mental-health services and their referring or receiving teams to define, communicate and maintain a shared understanding of service scope, limitations, referral routes and appropriate use, including understanding what Home Treatment Teams and other community services can provide on discharge.

Not included

  • Excludes generic staff-training or communication deficiencies where community mental-health service roles or pathways are not the material unsafe condition.
  • Excludes failures of community mental-health service capacity, appointment access, treatment quality or discharge execution when staff understanding of service roles and pathways is not itself deficient.
  • Excludes referral failures caused solely by missing information, staffing shortages or patient disengagement where the scope and pathway requirements were clearly understood.
  • Excludes non-mental-health community services and generic multi-agency coordination concerns without a specific community mental-health service-role or pathway component.
Reports
8

Distinct published reports

Individual concerns
9

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
10

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.

Department of Health and Social Care3
NHS England2
NHS Greater Manchester Integrated Care Board2
College of Policing1
Devon Local Medical Committee1
Durham Constabulary1
Herefordshire and Worcestershire Health and Care NHS Trust1
Killick Street Health Centre1
Livewell Southwest1
Norfolk and Suffolk NHS Foundation Trust1
North London NHS Foundation Trust1
Priory Group1

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. Manchester North

    AI-generated summary

    Jessica Lynda Smithson · 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

    Jessica Lynda Smithson, aged 27, died by suicide after contacting a crisis text mental health service following an alleged serious sexual assault. The service did not contact the Metropolitan Police despite messages indicating an immediate risk to her life. The report identified concerns about inconsistent procedures among charity crisis text services and the absence of a commissioned crisis text mental health service in Greater Manchester.

    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 of crisis text services to use Greater Manchester mental health pathways for early referral

    Wider context from the report

    “2. Within the Greater Manchester Area there is no commissioned crisis text mental health support service. Whilst GM residents can message national services, often the location of an individual texter will not be known. The court heard from Greater Manchester Police that they receive a significant number of referrals which have been sent by this crisis service to the Metropolitan Police, almost one a day where there has been a real and immediate risk to a person’s life identified. All of these referrals require an immediate police response (they are outside of Right Care Right Person). If there was a GM commissioned service, it is likely that any search for the location of the individual would be done by GMP and would shorten the timeframe in which they could respond to the risk. In addition, a GM commissioned service would have a greater understanding of local pathways in order to refer people who may have a deteriorating mental health before they reached the point of crisis. ”

    Source location

    Jessica Lynda Smithson · 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 phased, locally delivered crisis-text service integrated with the Greater Manchester 111 mental-health crisis line.

    Verbatim wording from the response

    “NHS GM alongside the mental health trusts have considered options for the provision of crisis text services and are currently considering our preferred model through our Greater Manchester Mental Health Clinical Effectiveness Group (CEG) as our established clinical governance route. Our preferred model is for a text service to be incorporated into the Greater Manchester 111 Mental Health crisis line service so that texts are handled by Greater Manchester Mental Health First Responders based within the team.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 13 August 2025

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    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 non-NHS charity’s service delivery and clinical governance arrangements fall outside the respondent’s ability to comment on.

    Verbatim wording from the response

    “We would suggest the Coroner’s Office approaches the charity directly for further information about the support provided, if required. As this is a non-NHS provider, we are unable to comment on their service delivery arrangements or clinical governance processes.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 13 August 2025

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    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

    Independent charitable organisations providing crisis text services are outside Government and NHS control.

    Verbatim wording from the response

    “I hope you will understand that charitable organisations providing crisis text services are independent of both Government and the NHS.”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 13 August 2025

    Open published response
  2. County Durham and Darlington

    AI-generated summary

    Sophie Ann Louise Cotton · 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

    Sophie Ann Louise Cotton had a long history of mental health problems and previous suicide attempts. On 6 January 2025, after she failed to attend important family contact and could not be contacted, four calls were made to the police requesting a welfare check; shortly afterwards, her family found her hanging by a ligature at home. The principal concerns were refusals or delays in police attendance under the “Right Care, Right Person” procedure, including where callers expressed a real and immediate risk to life and where mental health services could not enter locked premises.

    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 account for mental health crisis team inability to enter locked premises when directing callers to mental health services

    Wider context from the report

    “(2) During the 16:44 call the “Right Care, Right Person” advice to contact mental health services appears to have disregarded the fact that the mental health crisis team do not have the power to enter locked premises and so would require police attendance to facilitate entry to the premises. ”

    Source location

    Sophie Ann Louise Cotton · 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

    Monitor and work with partners on powers of entry so agencies understand legal parameters and available options.

    Verbatim wording from the response

    “Ongoing monitoring and work is being undertaken with partners with regards to powers of entry to ensure all partners are aware of the legal parameters in which all agencies operate, including for all agencies to understand the specific legal powers available to them, and to ensure all options are being considered.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 29 May 2025

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    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

    Collate concerns raised, review them against the toolkit and guidance, and amend the toolkit where necessary.

    Verbatim wording from the response

    “The College collates all information in respect of concerns that are raised, and reviews these against the toolkit and guidance provided to forces. The toolkit is subject to ongoing review and where necessary amendments will be made. The College continues to encourage forces to follow the guidance within their development of RCRP and provides ongoing support and advice to forces.”

    Source location

    Response from College of Policing
    Page 3 · response
    Published 29 May 2025

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    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 reviewing toolkit content and provide forces with tools, training and support to implement and deliver Right Care, Right Person.

    Verbatim wording from the response

    “The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. The College continually reviews the content of the toolkit guidance to ensure forces are provided with the tools, training, and support to effectively implement and deliver RCRP.”

    Source location

    Response from College of Policing
    Page 3 · response
    Published 29 May 2025

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    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

    A review found no significant failings in the use or implementation of the Right Care Right Person policy.

    Verbatim wording from the response

    “A thorough review has since taken place and although it has not highlighted any significant failings in the use of, and implementation of the ‘Right Care Right Person’ (RCRP) policy, the review of the incident(s) has resulted in two specific points of organisational learning and recommendations to be implemented and progressed. Durham Constabulary has also consulted with the national mental health co-ordinator to ensure the response is aligned to national practice.”

    Source location

    Response from Durham Police and Crime Commissioner
    Page 1 · response
    Published 29 May 2025

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    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

    Operational decisions and responses under Right Care, Right Person are the responsibility of individual police forces, including Durham Constabulary.

    Verbatim wording from the response

    “In relation to the operational elements and decision-making processes, we have been in contact with Durham Constabulary and understand that a full response to these points is being provided.”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 29 May 2025

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    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

    Police cannot enter a person’s home for a welfare check where assessed risk does not reach the threshold of risk to life and limb.

    Verbatim wording from the response

    “The College RCRP guidance reaffirms the position as set out within the case of Syed v DPP [2010] EWHC 81 (Admin) in relation to the powers of entry available to the police. The toolkit states ‘There is no specific power of entry to carry out a concern for welfare check…’”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 29 May 2025

    Open published response
  3. Manchester North

    AI-generated summary

    Mr Benjamin Sulzbacher · 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 Benjamin Sulzbacher had experienced deteriorating mental health and was admitted to a private hospital after attempting to tie a ligature at home. After discharge, no referral was made to the NHS Home Based Treatment Team, and he died after tying a ligature on 27 September 2023. Concerns included uncertainty among services about NHS discharge support for private inpatients and a lack of understanding at the Priory about the community services available.

    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 understanding of NHS community discharge services

    Wider context from the report

    “1. There was a lack of understanding from the Priory witnesses as to what the NHS community services could offer on discharge. The court heard that the Home Based Treatment Team was understood to simply be a “Crisis team” which was incorrect. ”

    Source location

    Mr Benjamin Sulzbacher · Prevention of Future Deaths report
    Page 3 · 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

    Raise the case during quality assurance visits to providers, highlighting NHS referral access for privately funded patients and robust discharge planning.

    Verbatim wording from the response

    “We will be raising this case at our quality assurance visits to providers over the coming weeks, highlighting how private providers can refer all patients (both NHS and privately funded) into NHS services and the importance of robust discharge planning. We will also be sharing this learning at the Greater Manchester System Quality Group in July and at the Greater Manchester Mental Health Programme Board.”

    Source location

    Benjamin Sulzbacher - Prevention of Future Deaths Report and Responses Bundle
    Page 4 · response
    Published 12 August 2024

    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

    Share guidance with consultant psychiatrists explaining the importance and professional requirement of maintaining current knowledge of local NHS community mental health services.

    Verbatim wording from the response

    “Following the inquest, e-mail communications have been shared with all Priory consultant psychiatrists by the Clinical Director of the Private and Wellbeing service network, ████████ to explain the importance and professional requirement for them to maintain up-to-date knowledge and understanding of the services local NHS mental health community teams are able to offer.”

    Source location

    Benjamin Sulzbacher - Prevention of Future Deaths Report and Responses Bundle
    Page 5 · response
    Published 12 August 2024

    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

    Create local NHS mental health services directories at all hospitals and update and disseminate them through induction and annual professional communications.

    Verbatim wording from the response

    “Additionally, in order to facilitate contact and communication with NHS mental health services, all Priory hospitals have been asked to create a local NHS Mental Health Services Directory. This will focus on (and clearly distinguish between) Crisis Teams, Home Treatment Teams, Community Mental Health Teams, specialist mental health services and any other relevant mental health services in the region/local area. This directory will be updated annually and shared with all relevant healthcare professionals at the hospital, including Visiting Consultants at the point of their induction and annually thereafter.”

    Source location

    Benjamin Sulzbacher - Prevention of Future Deaths Report and Responses Bundle
    Page 5 · response
    Published 12 August 2024

    Open published response
  4. Manchester South

    AI-generated summary

    Shahzadi Khan · 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

    Shahzadi Khan was detained under the Mental Health Act after a manic episode with psychotic symptoms and was discharged from an out-of-area private hospital to her family home. Following inadequate discharge planning, communication problems and a failure to arrange the appropriate community care pathway, she deteriorated and took a fatal overdose of prescribed zopiclone at home. The concerns included the effects of out-of-area placements, poor coordination of local care pathways, and insufficient awareness of menopause as a possible factor in mental health deterioration.

    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 understanding of local mental health care pathways by coordinating teams

    Wider context from the report

    “3. The inquest heard that due to its size the mental health trust covers a number of areas. Each area has its own systems and pathways. Lack of understanding of these pathways by coordinating teams meant that patients were not being moved onto the correct pathway for care. The inquest heard that this was compounded by a lack of awareness by the Trafford HBT of the local pathway for a patient such as Ms Khan and the need for a clear discharge plan to be in place that was understood by all those involved in a patient’s care including her family and mental health care workers. ”

    Source location

    Shahzadi Khan · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  5. Plymouth, Torbay and South Devon

    AI-generated summary

    Graeme Robert Mathieson · 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

    Graeme Robert Mathieson died following an intentional overdose of prescribed medication. The inquest concluded suicide and identified gross failures to provide basic medical attention while he was in a dependent position, which caused or contributed to the outcome. Concerns included time constraints affecting recognition of his serious psychiatric condition, confusion about mental-health care pathways, and weaknesses in transfer processes.

    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 mental health care pathways for professionals after discharge

    Wider context from the report

    “It became apparent during the course of the inquest that a number of professionals (both GPs and care coordinators) were confused or unclear about the correct pathway for ████████ to follow once he had been wrongly discharged from the local CM HT. I indicated that I felt it may be beneficial for Livewell Southwest to add a ‘Professionals’ tab or page to its website so that doctors and other professionals could refer to it in the event of uncertainty. I suggested that it may be sensible for a doctor representing GPs locally to sit down with an individual from Livewell Southwest to ensure that any areas of ongoing confusion were recognised and appropriately addressed. ”

    Source location

    Graeme Robert Mathieson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  6. Inner North London

    AI-generated summary

    Andrew Elliot FROST · 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

    Andrew Elliot Frost, aged 34, took his own life after jumping in front of an underground train on 25 September 2014. The report identified concerns about a lack of shared understanding between the crisis team and general practitioner, incomplete recording of information, and an inadequate pager messaging service.

    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 shared understanding between referrers and crisis teams about crisis team capabilities and limitations

    Wider context from the report

    “During the second encounter on 24 September 2014, whilst police and paramedics were at Mr Frost’s home, you and he spoke on the telephone. You were worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. You were told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him. However, there was no shared understanding between you and the crisis team about what the crisis team could and could not do. You thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day. You regarded the crisis team as an emergency service, which the team leader told me in court is not the case. It seems that you, your partners, and other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis teams about their service, including its limitations. I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else. ”

    Source location

    Andrew Elliot FROST · 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

    Lack of specific training and education for general practitioners about crisis team services and limitations

    Wider context from the report

    “During the second encounter on 24 September 2014, whilst police and paramedics were at Mr Frost’s home, you and he spoke on the telephone. You were worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. You were told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him. However, there was no shared understanding between you and the crisis team about what the crisis team could and could not do. You thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day. You regarded the crisis team as an emergency service, which the team leader told me in court is not the case. It seems that you, your partners, and other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis teams about their service, including its limitations. I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else. ”

    Source location

    Andrew Elliot FROST · 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

    Meet with Crisis Team managers to discuss service provision.

    Verbatim wording from the response

    “Following your requirement for our service to meet with the Crisis Team, I can confirm that we have now met with them on the 19th March and discussed the service provision with the Crisis Team. I met up with ████████ both senior Managers at the Crisis team. Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP’s at the practice and also to enable us to discuss individual clients.”

    Source location

    2015-0119-Response-by-Killick-Street-Health-Centre
    Page 1 · response
    Published 12 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

    Establish regular meetings between practice GPs and the Crisis Team to discuss service provision and individual clients.

    Verbatim wording from the response

    “Following your requirement for our service to meet with the Crisis Team, I can confirm that we have now met with them on the 19th March and discussed the service provision with the Crisis Team. I met up with ████████ both senior Managers at the Crisis team. Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP’s at the practice and also to enable us to discuss individual clients.”

    Source location

    2015-0119-Response-by-Killick-Street-Health-Centre
    Page 1 · response
    Published 12 February 2015

    Open published response
  7. Worcestershire

    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
  8. Norfolk

    AI-generated summary

    Matthew Christopher Dunham · 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

    Matthew Christopher Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.

    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 shared understanding of team referral roles and interfaces

    Wider context from the report

    “b) There appears not to have been a clear shared understanding between professionals as to which team it was appropriate to refer Mr Dunham too. There was some lack of understanding revealed as to whether a referral to the assessment team or the crisis resolution and home treatment team was appropriate. This highlights the need for there to be a clear understanding about the roles of each team and the interface between them. ”

    Source location

    Matthew Christopher Dunham · 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

    Base a Crisis Resolution and Home Treatment team member within the Access and Assessment Team to support prompt joint working and care transitions.

    Verbatim wording from the response

    “To enhance the interface between the two clinical teams, Access and Assessment Team (AAT) and CRHT, a member of the CRHT is now based within the AAT. This enables joint working without any delay, supporting transition of care between the two teams. The Trust is monitoring its effectiveness in identifying people in need of this crisis support.”

    Source location

    Response
    Page 2 · response
    Published 26 January 2014

    Open published response
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Data last updated 7 September 2026