Recurring concern

Failure to provide indicated psychological interventions in mental health care

First to latest report 22 Apr 2014 — 6 Mar 2025

Reports that mention this concern
19
Times this concern has been raised
20
Stated actions linked to this concern
22

What this concern includes

Includes failures of dedicated psychological or psychosocial intervention provision in mental health care, including absent or inconsistent availability, insufficient clinical psychology capacity and failure to offer interventions when clinically indicated.

What is not included
  • Excludes generic mental-health treatment, staffing or service-capacity deficiencies where psychological or psychosocial intervention provision is not specifically identified.
  • Excludes failures limited to diagnosis, assessment, medication, care planning or risk management unless they directly concern access to or provision of a psychological or psychosocial intervention.
  • Excludes educational, pastoral or general social support that is not a dedicated psychological or psychosocial intervention.
  • Excludes the underlying mental-health condition, self-harm risk or other outcome without an identified failure in psychological-intervention provision.

Reports and published responses 19 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Yorkshire (Western)

    AI-generated summary

    Andrea Denise MANN · 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

    Andrea Denise MANN was discovered hanging at her home on 10 February 2024 and died in hospital the following day after invasive medical care was withdrawn and palliative care was provided. The inquest identified concerns about limited Community Mental Health Trust involvement, the absence of a requested psychiatric appointment, delays in psychological therapy, and the lack of an overarching tool to scrutinise and measure the care provided.

    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 in access to psychological therapy

    Wider context from the report

    “1) That during the period of her involvement with the Community Mental Health Trust between the period 25/04/2023 and 04/12/2023 the care given to the deceased was limited to 2 appointments only within which she was referred back to her GP for medication adjustment which had been seen to be ineffective, and referral to Psychological therapy sessions which had a waiting period of 6 months despite an earlier private consultation having been proved ineffective, That the frequent requests of the deceased and her family for a Psychiatric appointment had not been provided to her, with the result that the deceased had to seek a private consultation. ”

    Source location

    Andrea Denise MANN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Essex

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    KATHARINE ANNE FOX · 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

    Katharine Fox died by hanging in October 2022 after being discharged from hospital, having been unable to access community psychology services during the following months. Concerns related to the lack of handover and continuity between hospital and community psychology services, substantial waiting times, and possible inability of clinicians to access notes held on different computer systems.

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    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 in the provision of psychology sessions

    Wider context from the report

    “(1) I am concerned that the disconnection between the provision of psychology services to patients in hospital and the provision of similar psychology services to patients in the community, including the fact that the community psychology service does not receive any form of handover and that there is a substantial wait for the provision of psychology sessions which may well require continuity to be delivered effectively. ”

    Source location

    KATHARINE ANNE FOX · Prevention of Future Deaths report
    Page 1 · 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

    Embed clinical prioritisation for community psychological treatment, record prioritisation decisions electronically, and monitor waiting-time data.

    Verbatim wording from the response

    “Whilst it is noted that patients do not always require immediate on-going psychological therapy upon discharge from hospital, Psychological Services will, going forward, embed a mechanism for clinical prioritisation in order to ensure that the most urgent cases are appropriately identified and prioritised in the community, ensuring continuity of psychological treatment and minimising waiting times as much as is practicably possible. This will be monitored through the waiting time data that is collected by each service team, and which is reported through our Trust Accountability Framework process.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Undertake regular telephone contact with people waiting for psychological assessment or treatment.

    Verbatim wording from the response

    “With regards to community wait times, the current demand for psychological treatments exceeds capacity, which is unfortunately not unusual within the NHS at this time. However, going forward the system of clinical prioritisation following case-specific discussion/handover will determine if urgency of need and risk warrants prioritisation. In relation to this, the Court is advised that in order to mitigate against any risk for those waiting for treatment in the community, the Psychological Services team implemented a new clinical process in 2023 which involves undertaking regular telephone contact with those waiting for psychological assessment and/or treatment.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Patients do not always require immediate ongoing psychological therapy after discharge; treatment urgency should be determined by clinical need.

    Verbatim wording from the response

    “Whilst it is noted that patients do not always require immediate on-going psychological therapy upon discharge from hospital, Psychological Services will, going forward, embed a mechanism for clinical prioritisation in order to ensure that the most urgent cases are appropriately identified and prioritised in the community, ensuring continuity of psychological treatment and minimising waiting times as much as is practicably possible. This will be monitored through the waiting time data that is collected by each service team, and which is reported through our Trust Accountability Framework process.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 12 December 2023

    Open published response

  3. Surrey

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    Zachary KLEMENT · 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

    Zachary KLEMENT was found suspended in the bedroom of his supported accommodation on 2 March 2021 and was pronounced deceased by attending paramedics. The report raised concerns about the lack of mental health care and therapies tailored to people with neurodiverse conditions, including the absence of suitable inpatient options, limited continuity from Home Treatment Teams, and the limited availability of psychological interventions.

    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 availability of psychological interventions for neurodiverse conditions

    Wider context from the report

    “There is a lack of availability of psychological interventions, being the main treatment for neurodiverse conditions, including art therapy, Dialectical Behaviour Therapy (DBT) and Systems Training for Emotional Predictability and Problem Solving (STEPPS) (Zachary was placed on a waiting list) ”

    Source location

    Zachary KLEMENT · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Gwent

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    Lucy Amanda 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

    Lucy Amanda Jones developed a serious mental illness in 2019 and died by hanging on 12 March 2022. She remained on a waiting list for Cognitive Behavioural Therapy and was not seen in the community after a planned follow-up in January 2022; attempts to contact her were limited to two phone calls, with no cold call made when she could not be contacted.

    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 in access to Cognitive Behavioural Therapy

    Wider context from the report

    “1. Lucy Amanda Jones was admitted to Talygarn Ward at The County Hospital Pontypool in December 2019 under Section 2 of the Mental Health Act. On discharge from hospital, she was placed on the waiting list for Cognitive Behavioural Therapy (CBT). In evidence provided by her General Practitioner, I was informed that Lucy was still waiting for CBT at the time of her death in March 2022. 2. Following Lucy’s death a concise review of the care she had received from the mental health team was undertaken. The review noted that following a consultant review in January 2022, Lucy was due to be followed up in the community within 2 weeks, but that in fact she was not seen again prior to her death. The Community Psychiatric Nurse (CPN) attempted to make contact by phone only 2 occasions and did not speak to Lucy. The CPN was apparently reassured by Lucy’s housemate, who had no concerns for Lucy. No efforts were made to “cold call” when Lucy could not be contacted. ”

    Source location

    Lucy Amanda Jones · Prevention of Future Deaths report
    Page 1 · concerns

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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

    Pilot embedded psychological care with outpatient follow-up and smoother transition pathways.

    Verbatim wording from the response

    “In regard to this particular case, since this time the Health Board has invested further in psychological input to acute treatment areas and is piloting a model of embedded psychological care which gives some provision for outpatient follow-up. This allows for smoother transitions, increased relational consistency (rather than needing to develop a new therapeutic relationship with a different clinician), and more effective care pathways. There is, of course, also the growth in the ‘Open Dialogue’ model of care (a model of mental health care which involves a consistent family and social network approach where all treatment is carried out via a whole system/network meeting, which always include the patient) and this is being provided by multi-disciplinary staff embedded in both acute care environments and community provision.”

    Source location

    Response from Aneurin Bevan University Health Board
    Page 2 · response
    Published 16 January 2023

    Open published response

  5. North East Kent

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    Samuel Alban Stanley · 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

    Samuel Alban Stanley died in hospital on 26 April 2020 from injuries sustained during an episode of high-risk behaviour related to his Prader-Willi syndrome. The report raised concerns about inadequate support for him and his family, limited access to appropriate services, and poor communication between agencies.

    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 offer psychosocial interventions for high-risk behaviour

    Wider context from the report

    “(3) There was evidence given that the mental health team at North East London Foundation Trust were also aware of Sammy’s high-risk behaviours. Support had been provided by a psychology student in the past and he had reportedly responded well to mindfulness therapy and the de-escalation techniques employed by his family. Psychosocial interventions were not offered by the Mental Health Trust and a Care Education and Treatment Review was suggested but not implemented before Sammy’s death. The court heard that such interventions may not have been successful but, in any event, North East London Foundation Trust had not been commissioned to provide anything other than a diagnostic service to children presenting with autism and learning disabilities rather than an overt mental health diagnosis. ”

    Source location

    Samuel Alban Stanley · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Invest £2.1 million in local neurodevelopmental services to improve provision for children and young people.

    Verbatim wording from the response

    “In terms of the commissioning of services, the CCG actively works with partners across the health system to ensure gaps do not exist and that pathways are in place to cater for the presentations and needs of the local communities it serves. NELFT are commissioned to provide more than just diagnostic services including psychological and psychosocial interventions, but the CCG acknowledge that mental health services are under extreme pressure, with increasing referrals that have significantly peaked during and post pandemic. Therefore, the CCG is actively working with NELFT to ensure that services are developed to meet the needs of all children and young people and to identify areas where the service offer can be strengthened and have increased significant levels of investment to help address this.”

    Source location

    Response from Kent and Medway Clinical Commissioning Group
    Page 3 · response
    Published 17 March 2022

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with NELFT to develop children’s mental health services and strengthen the service offer for children and young people.

    Verbatim wording from the response

    “In terms of the commissioning of services, the CCG actively works with partners across the health system to ensure gaps do not exist and that pathways are in place to cater for the presentations and needs of the local communities it serves. NELFT are commissioned to provide more than just diagnostic services including psychological and psychosocial interventions, but the CCG acknowledge that mental health services are under extreme pressure, with increasing referrals that have significantly peaked during and post pandemic. Therefore, the CCG is actively working with NELFT to ensure that services are developed to meet the needs of all children and young people and to identify areas where the service offer can be strengthened and have increased significant levels of investment to help address this.”

    Source location

    Response from Kent and Medway Clinical Commissioning Group
    Page 3 · response
    Published 17 March 2022

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Direct provision of healthcare services is outside the commissioning group’s responsibility.

    Verbatim wording from the response

    “Clinical commissioning groups were established as part of the Health and Social Care Act in 2012 and are responsible for commissioning healthcare services for their local populations. They are also system leaders with a key role to play in improving the quality of care and their role does not sit in isolation. However, they are not directly responsible for the provision of services and nor are they responsible for the commissioning of social care services, which in Kent is the responsibility of Kent County Council.”

    Source location

    Response from Kent and Medway Clinical Commissioning Group
    Page 1 · response
    Published 17 March 2022

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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

    NELFT was commissioned to provide psychological and psychosocial interventions, not solely autism and learning-disability diagnostic services.

    Verbatim wording from the response

    “3. Concern that there was a lack of psychosocial and psychological therapies offered in this case. This was compounded by the information shared that NELFT may not have been commissioned to provide anything other than a diagnostic service for those presenting with autism and learning disabilities rather than an overt mental health issue.”

    Source location

    Response from Kent and Medway Clinical Commissioning Group
    Page 3 · response
    Published 17 March 2022

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Cognitive behavioural therapy was considered inappropriate and ineffective for the individual’s needs; a psychosocial intervention was offered instead.

    Verbatim wording from the response

    “With regard to the psychological treatment offered in this specific case during the episode prior to Sammy’s sad death, the CCG has been assured that NELFT undertook an assessment of need. Sammy’s escalation of need occurred at onset of the pandemic, when statutory services were severely limited in terms of the care they could provide, and the guidance around the management of clinically vulnerable children during the pandemic was in an embryonic stage. Sammy was under the care of a consultant psychiatrist who regularly reviewed and monitored the prescribing of medications. KMCCG understanding of the clinical opinion and expertise of Sammy’s needs was that the psychological intervention of cognitive behavioural therapy would not have been appropriate or effective to meet his needs and hence the more psychosocial intervention of Non Violent Resistance was offered.”

    Source location

    Response from Kent and Medway Clinical Commissioning Group
    Page 4 · response
    Published 17 March 2022

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Commissioners are responsible for ensuring locally appropriate health and social care services, including services for people with complex needs.

    Verbatim wording from the response

    “You may wish to know that under the Equality Act (2010), health and social care organisations must make reasonable adjustments to ensure that disabled people are not disadvantaged. Commissioners are responsible for ensuring the provision of services based on the local needs of their population, including for people with learning disabilities, mental health problems and complex physical needs. Commissioners should take into consideration any relevant guidance, such as those published by the National Institute for Health and Care Excellence in designing their local services.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 17 March 2022

    Open published response

  6. Cambridgeshire and Peterborough

    AI-generated summary

    Daniel France · 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 France was a 17-year-old vulnerable teenager living in a YMCA hostel who died by asphyxiation by hanging; the inquest concluded that his death was suicide. The principal concern was that vulnerable young people known to local authorities and mental health services may not receive adequate support while awaiting substantive treatment, particularly where they are assessed as not requiring urgent intervention but face lengthy waits for psychological therapy.

    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

    Shortage of availability for psychological therapies such as CBT

    Wider context from the report

    “The inquest heard evidence about the considerable delay in obtaining appointments for the Gender Identity Clinic, and about the shortage of availability for psychological therapies such as CBT. ”

    Source location

    Daniel France · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester South

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    Carole Mitchell · 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

    Carole Mitchell died at home on 22 November 2019 after taking a fatal amount of her prescribed medication; the inquest conclusion was suicide. The report identifies concerns about delays in accessing psychological assessment and support-worker services, limited mental health bed capacity, and difficulties gathering information from her family because of concerns about confidentiality.

    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 in access to psychology assessment and therapies

    Wider context from the report

    “1. The inquest heard that psychology assessment and therapies can be very beneficial to those with mental health issues in secondary services as well as primary services. The evidence given was that the delay that Mrs Mitchell experienced in accessing that service was reflective of both the regional and national backlog for appointments. The inquest was told that the position had worsened since 2019 and for example someone in Mrs Mitchell’s position today would be more likely to wait 9 months than the 7 months in 2019. ”

    Source location

    Carole Mitchell · 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

    Commission new annual training places in psychological therapies for community mental health staff through at least 2023/24.

    Verbatim wording from the response

    “However, we know there is regional variation in current provision, in part due to the pressures facing some parts of our community mental health workforce over recent years. To address this, since 2018/19, NHS England has invested in the commissioning of training places for community mental health staff to go on courses in psychological therapies for people with severe mental illness, in partnership with Health Education England. We will continue to commission new training places each year up to at least 2023/24 to increase competency within the workforce.”

    Source location

    2021-0037-Response-from-Dept-of-Health-and-Social-Care-Redacted
    Page 2 · response
    Published 15 February 2021

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop a bespoke mental health workforce strategy to increase recruitment and address service waiting times.

    Verbatim wording from the response

    “There is both local and national (NHSE/I) acknowledgement that this is one of the most significant challenges we face in mental health. The NHS Long Term Plan has identified a number of strategies by which we both upskill the current workforce and increase the size of the workforce. In GM we are in the process of developing a bespoke workforce strategy/plan that will ensure we see a significant surge in new recruits into mental health services which we believe will pointedly reduce the current waiting time for services.”

    Source location

    2021-0037-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
    Page 2 · response
    Published 15 February 2021

    Open published response

  8. Nottinghamshire

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    Patricia Ferguson · 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

    Patricia Ferguson had significant mental ill health and received secondary mental health services before her death by suicide. Clinicians considered that direct work with a clinical psychologist would benefit her, but no clinical psychologist was available; the report identified limited clinical psychology provision in community mental health teams as an ongoing risk of preventable future deaths.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient clinical psychology staffing and access within Community Mental Health Teams

    Wider context from the report

    “(1) The Joint Commissioning Panel for Mental Health’s Guidance for Commissioners of Community Specialist Mental Health Services expresses an expectation there would be more than one clinical psychologist for each Community Mental Health Team, given that clinical psychologists are referred to in the plural within discussions of an appropriate staff team for CMHTs whereas, for example, consultant psychiatrists are referred to in the singular. (2) CMHTs in Nottingham and Nottinghamshire have a commissioned establishment of, at most, one clinical psychologist per team, with some teams having only a part time clinical psychologist post. This inevitably results in some patients, as here, having no access to clinical psychology when this is clinically indicated, creating an ongoing risk of preventable future deaths. ”

    Source location

    Patricia Ferguson · 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

    Fund additional clinical psychology posts and other staff capacity to strengthen community mental health team delivery.

    Verbatim wording from the response

    “The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support testing new delivery models.”

    Source location

    2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
    Page 1 · response
    Published 20 October 2020

    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

    Work with Nottinghamshire Healthcare NHS Trust on a five-year community mental health transformation programme, including monthly transformation meetings.

    Verbatim wording from the response

    “The BCCG is working in partnership with Nottinghamshire Healthcare NHS Trust (NHT) on a programme of transformation to meet the requirements of the NHS Long Term Plan (LTP) over the next 5 years.”

    Source location

    2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
    Page 1 · response
    Published 20 October 2020

    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

    Provide planned annual investment to increase clinical psychology provision across Nottinghamshire Healthcare NHS Trust services.

    Verbatim wording from the response

    “The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence-based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment each year to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the BCCG and the Transformation plan is reviewed by NHS England on a monthly basis. BCCG have planned monthly transformation meetings with NHT commencing which were due to commence in March 2020. However, this has recently been impacted by the COVID-19 pandemic and has commenced week of 1st June 2020.”

    Source location

    2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
    Page 2 · response
    Published 20 October 2020

    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

    Fund additional clinical psychology posts, alongside other posts, to increase community mental health team capacity and test new delivery models.

    Verbatim wording from the response

    “The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support test new delivery models. The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1).”

    Source location

    2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
    Page 2 · response
    Published 20 October 2020

    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

    Invest in increased clinical psychology provision across Nottinghamshire Healthcare NHS Trust services to deliver Long Term Plan ambitions.

    Verbatim wording from the response

    “The LTP has a strong emphasis throughout on ensuring the provision of high quality, evidence-based mental health services which includes increased access to psychological therapies within the community based offer, as well as an increased focus on psychologically formed therapeutic interventions and care plan formulation through multi-disciplinary team approaches. There is planned investment ████████ to deliver the LTP ambitions, which includes increased Clinical Psychology provision across a range of services provided by NHT. The delivery of services is monitored by the CCG and the Transformation plan is reviewed by NHS England on a monthly basis. A Steering Group meets on a monthly basis to oversee the transformation of the Adult and Older Adult Community model. However, this has recently been impacted by the COVID-19 pandemic and will recommence in due course.”

    Source location

    2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
    Page 2 · response
    Published 20 October 2020

    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 healthcare trust determines the exact community mental health team staffing resource required under the agreed service specification.

    Verbatim wording from the response

    “Currently, there is an agreed specification for community mental health teams which Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification.”

    Source location

    2020-0155-Response-from-Bassetlaw-Clinical-Commissioning-Group_Redacted.pdf
    Page 2 · response
    Published 20 October 2020

    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 agreed community mental health team specification and ongoing transformation programme are considered sufficient to address concerns about clinical psychology provision.

    Verbatim wording from the response

    “The national requirement in 2019/20 and 2020/21 is to ‘stabilise and bolster’ core community mental health teams, increasing team capacity and appointment availability. In 2019/20 this included funding for additional Clinical Psychology posts alongside other posts (i.e. pharmacy technicians and administrative support) to support test new delivery models. The LTP is explicit on how community mental health teams need to be developed, with delivery milestones from 2019/20 to 2023/24 (appendix 1).”

    Source location

    2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
    Page 2 · response
    Published 20 October 2020

    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

    Nottinghamshire Healthcare NHS Trust determines the staffing resource required to deliver the community mental health team specification.

    Verbatim wording from the response

    “Currently, there is an agreed specification for community mental health teams which outlines the aims, objectives and outcomes for the service. Nottinghamshire Healthcare NHS Trust use clinical judgement to determine the exact level of staffing resource required to deliver the aims, objectives and outcomes stipulated within the service specification.”

    Source location

    2020-0155-Response-from-Nottingham-and-Nottinghamshire-CCG_Redacted.pdf
    Page 2 · response
    Published 20 October 2020

    Open published response

  9. Manchester South

    AI-generated summary

    Heather Louise Carey · 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

    Heather Louise Carey was admitted to mental health services in July 2017, later took an overdose of paracetamol, and was placed on a 24-week waiting list for Cognitive Analytical Therapy. She hanged herself at home on 20 December 2017. The principal concern was that lengthy waits for psychotherapy and inadequate action to address her high suicide risk may have contributed to her death.

    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 available in-patient psychotherapy

    Wider context from the report

    “The inquest identified a number of issues which likely contributed to Heather's decision to end her life. One of those issues related to the long wait following discharge before psychotherapy would begin. At the time of Heather's admission to TGH there was no psychotherapy available to her as an in-patient because there were insufficient funds available to provide the same. I was told that had been addressed by further funding being made available. At the time of Heather's assessment on 22.11 staffing levels were reduced, through illness and a vacancy, and there was only one psychotherapist available. That was the reason given for the 24 weeks wait. At the inquest I heard evidence that the target waiting list was 18 weeks. Further, that by the time of the inquest that target time was being met. A target waiting time of 18 weeks, I was told, was comparable to ‘cancer waiting times’. However, it transpires that those are the maximum waiting times for non-urgent consultant led treatment for any treatment from the point of referral. Heather was already in receipt of consultant led care. Her need was urgent. Thus such a comparator on waiting times to justify an 18 weeks wait for psychotherapy is not an appropriate measure. By letter dated 3rd January 2019 Pennine Care responded to my concerns about the long waiting list as follows, “The CCG are currently in dialogue with Pennine Care in relation to waiting times for Secondary Care psychological therapies to ensure that existing (emphasis added) resources are effectively utilised and capacity and demand is reviewed to inform commissioning requirements.” It was clear from the evidence heard, not only from Heather's mother and partner but from those involved in her care, that Heather had placed great faith in psychotherapy as the means by which she would bring mental stability back to her life, a release from the increasingly extreme mood swings of her bi-polar disorder. It is not difficult to imagine the despair and distress felt by Heather to be told that it would be almost 6 months before she could even begin the help/treatment she was seeking on voluntary admission some 4 months previously. A target waiting list of 18 weeks is far too long but I was told that this was a funding issue. Unless adequate and sufficient measures are taken to significantly reduce waiting times for acute mental ill-health, comparable to physical life threatening illnesses, NOT simply a redistribution of existing resources, more patients with mental health issues will end their lives while on a waiting list for treatment. ”

    Source location

    Heather Louise Carey · 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

    Invest £600,000 recurrently to improve staffing on Tameside Hospital inpatient mental health wards.

    Verbatim wording from the response

    “The CCG has invested £600,000 recurrently to improve staffing on the inpatient mental health wards at Tameside Hospital with a focus on improving safety, patient experience and outcomes. The Trust has invested this funding in improving the skill mix of the teams, including additional clinical psychology and occupational therapy, as well as nursing and admin. The CCG is formally monitoring the impact of this investment through regular Safer Staffing Reports presented to the Pennine Care Quality Group. Reports from staff on the Tameside wards and the latest CQC report indicate that this is having a positive impact.”

    Source location

    Response from Tameside Metropolitan Borough
    Page 2 · response
    Published 24 May 2019

    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 commissioners and providers are responsible for taking firm action to address the concerns and failings identified.

    Verbatim wording from the response

    “Your report offers significant learning to the local NHS and I expect firm action to be taken by both the local commissioner and provider of services to respond to the concerns raised and the failings identified.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 24 May 2019

    Open published response

  10. Birmingham and Solihull

    AI-generated summary

    Stephen Anthony Kennedy · 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 Anthony Kennedy had a history of emotional unstable personality disorder, depression and frequent self-harm, and his condition deteriorated during 2018. He was found hanging at his home on 08/10/18 and was declared deceased. Concerns included that psychological therapy was unavailable because of service structures and long waiting lists, and that a lack of acute inpatient beds contributed to further episodes of self-harm and suicide attempts.

    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

    Unavailability of timely psychological services due to internal service structures and waiting lists

    Wider context from the report

    “1. The deceased suffered from emotional unstable personality disorder and was in crisis for most of 2018. The recommended treatment for his condition was psychological therapy. He had not had any psychological input since 2010. The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services. He had to be under the community mental health team to be able to access psychological services. There were periods when he was under the care of the community mental health team but at this time he remained on a long waiting list for psychological services. Throughout 2018 he never received any psychological services. I am concerned that the main treatment option for the deceased was not available to him due to internal structures and long waiting lists. ”

    Source location

    Stephen Anthony Kennedy · Prevention of Future Deaths report
    Page 1 · 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

    Formalise distinct community mental-health treatment pathways through the 2019/20 Service Development and Improvement Plan.

    Verbatim wording from the response

    “3.4 Psychological therapy services for people under the care of BSMHFT forms part of the provider’s internal pathway and as such waiting times are not monitored by the CCG. The CCG’s approach is to increasingly commission for outcomes rather than inputs. In line with this, commissioners have set out their intention that community-based mental health services should operate distinct treatment pathways for people with psychotic disorders and those with mood and personality disorders. Pathways will be focused on the delivery of treatment and support that promotes recovery alongside the proportionate management of risk. Providers will be expected to put in place a workforce model that reflects this approach and affords access to treatment options including psychological therapies.”

    Source location

    2019-0039-Response-by-Birmingham-and-Solihull-CCG
    Page 3 · response
    Published 26 May 2019

    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 clinical psychology capacity within every Home Treatment Team.

    Verbatim wording from the response

    “With regard to the matter of Psychological Therapy, I am able to confirm that we now have a plan for investing in clinical psychology capacity within our Home Treatment Team services. From September 2019, subject to recruitment, we anticipate to be in a position whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist within their team. Approval has been given to advertise these posts and this will help us to ensure compliance with NICE guidance and to deliver clinically effective care as per recommended guidelines. The Clinical Psychologist will also contribute to multi disciplinary team assessments, discussions and decisions relating to care planning and treatment options for patients, as well as providing supervision to other members of the team. We are also increasing nursing capacity to ensure that community caseloads are more manageable.”

    Source location

    2019-0039-Response-by-Birmingham-and-Solihull-Mental-Health-NHS-Trust
    Page 2 · response
    Published 26 May 2019

    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

    Develop a community-based Severe Mental Illness offer including psychological therapies, physical healthcare, employment support, personalised care and related support.

    Verbatim wording from the response

    “A new community-based offer for people with Severe Mental Illness will include access to psychological therapies; improved physical health care; employment support; personalised and trauma-informed care; medicines management; and support for self-harm and coexisting substance use. This will give 370,000 adults and older adults greater choice and control over their care, and support them to live well in their communities.”

    Source location

    2019-0039-Response-by-Department-of-Health-and-Social-Care
    Page 3 · response
    Published 26 May 2019

    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 NHS organisations are responsible for providing mental health services, while NHS England commissions specialised services.

    Verbatim wording from the response

    “You will know that the provision of mental health services is a matter for the NHS locally, except where specialised services are required and NHS England is the responsible commissioner. You have issued your report to the Birmingham and Solihull Mental Health NHS Foundation Trust and the Birmingham and Solihull Clinical Commissioning Group (CCG), and I expect the local NHS to take firm action to respond to the concerns and learn from Stephen’s death to ensure the safety of healthcare services.”

    Source location

    2019-0039-Response-by-Department-of-Health-and-Social-Care
    Page 1 · response
    Published 26 May 2019

    Open published response

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