Recurring concern

Unreliable Community Mental Health care access and discharge processes

First to latest report 9 Dec 2015 — 18 Nov 2025

Reports that mention this concern
16
Times this concern has been raised
17
Stated actions linked to this concern
38

What this concern includes

Includes failures in the named Community Mental Health care process involving access, allocation or provision of community mental-health support, appointments from allocated staff, and discharge planning or execution where unclear or inconsistent arrangements can interrupt care or leave risks unmanaged.

What is not included
  • Excludes generic mental-health service capacity, staffing or communication deficiencies unless they directly impair Community Mental Health access or discharge processes.
  • Excludes failures confined to psychiatric appointments, urgent mental-health referrals or other separately named pathways when those processes are the more specific supported concern.
  • Excludes clinical treatment-quality failures after Community Mental Health care has been reliably accessed and discharge arrangements have been completed.
  • Excludes generic discharge failures outside Community Mental Health care.

Reports and published responses 16 reports

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

  1. 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

  2. Staffordshire South

    AI-generated summary

    Dean Mark Rowland · 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

    Dean Mark Rowland, who had a history of two recent self-harm attempts and depression, was found hanging from a bannister on 21 March 2017, and the inquest concluded that his death was suicide. Concerns included his inability to obtain a GP appointment or telephone consultation for nine days when he wished to discuss increasing his antidepressant medication, and his discharge from the community mental health team after one consultation without a follow-up plan beyond returning to primary care.

    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 provide follow-up after community mental health assessment

    Wider context from the report

    “(2) He was referred to a community mental health team having made two serious previous suicide attempts. He was discharged after only one consultation with no follow up plan other than for him to refer back to primary care. The family perceived he would have benefitted from a further appointment. He was very willing to engage with services. ”

    Source location

    Dean Mark Rowland · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 assessment found low suicide risk and sufficiently detailed needs assessment, so discharge after one consultation was considered the right decision.

    Verbatim wording from the response

    “When seen on 19th August 2016, Mr Rowland had moved to Birmingham in order to reside with his mother, and reported improvements in his mental health due to this change of environment and a now amicable relationship with his ex-wife and access to his children. Mr Rowland described his wellbeing “feel like I have my life back and am like my old self” and reported various self-help methods such as exercise and making time for himself. Importantly he expressed no further ideas of suicide. A Patient Health Questionnaire 9 (PHQ-9) was completed as part of the assessment; this is a 9-item questionnaire to explore current symptoms of depression, yielding a score of between 0 and 27. Mr Rowland scored 8, which is indicative of mild depression that would not usually require treatment; scores of 15 and above are usually seen in individuals requiring the input of a CMHT.”

    Source location

    2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
    Page 2 · response
    Published 12 September 2017

    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

    Existing self-help resources, GP referral routes and CMHT re-referral contacts were considered sufficient without ongoing CMHT follow-up.

    Verbatim wording from the response

    “Mr Rowland engaged fully in his assessment and coproduced the plan which was later communicated to him by letter. He felt that the difficulties in his mental health had improved and that he did not require input from the CMHT, but was aware that he could be re-referred at any time should this situation change. The letter validated his efforts to be well and detailed online self-help resources to support these efforts, and also recommended that he register with a GP in Birmingham if he wished to continue to reside there, so that he could be referred quickly to his local mental health services in future should the need arise. If the assessment had highlighted the need for ongoing input from the CMHT, this would have been transferred to the service in Birmingham local to Mr Rowland’s new residence, but as described it was not required.”

    Source location

    2017-0208-Response-by-South-Staffordshire-and-Shropshire-Healthcare
    Page 2 · response
    Published 12 September 2017

    Open published response

  3. Norfolk

    AI-generated summary

    DAVID SEAN READ · 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

    David Sean Read collapsed after injecting heroin on 1 July 2016 and died in hospital on 3 July 2016. Concerns were raised about the handling and timing of his Community Mental Health Team appointments, including that a replacement appointment was scheduled more than 16 weeks after re-referral, during which time he died.

    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 arranging a fresh Community Mental Health Team appointment after cancellation of an initial appointment

    Wider context from the report

    “(3) This appointment was cancelled by Mr Read (no reason is recorded for the cancellation but Mr Read did start alcohol detoxification on this date) and his name was added to the waiting list for a fresh appointment to be arranged. (4) The appointment was treated as a new referral and a new appointment date was sent out on the 18 May 2016 with a new appointment date of 14 July 2016. This is in excess of 16 weeks after the re-referral. Sadly Mr Read died in the meantime. ”

    Source location

    DAVID SEAN READ · 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

    Complete recruitment to vacancies so the community mental health team is fully staffed.

    Verbatim wording from the response

    “Reflecting on this period of time, it is observed there were a number of challenges within the team with respect to vacancies and staff on maternity leave. These had an impact on the team’s ability to offer appointments. Subsequent to this period, recruitment to vacancies means the team is currently fully staffed.”

    Source location

    2017-0031-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 1 · response
    Published 26 February 2017

    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

    Telephone service users who miss appointments to rearrange them instead of sending letters.

    Verbatim wording from the response

    “- If a service user does not attend an appointment they will have a phone call to rearrange an appointment instead of sending a letter. - The service user will no longer get a letter stating that they have been put on a waiting list. - The service user will be given the phone number for the duty worker so if they experience change in their circumstance before attending the appointment they can speak to someone. - Any phone calls to the team or duty worker raising concerns are documented on Lorenzo (the electronic patient record system) and communicated within the team.”

    Source location

    2017-0031-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 1 · response
    Published 26 February 2017

    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

    Have the clinical team leader review pending appointments daily and allocate earlier appointments according to assessed changes in risk.

    Verbatim wording from the response

    “- The clinical team leader monitors cases that have an appointment pending on a daily basis, taking account of any phone calls or concerns and allocates them a sooner appointment based on the assessment of potential change in risk.”

    Source location

    2017-0031-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 2 · response
    Published 26 February 2017

    Open published response

  4. Leicester City and South Leicestershire

    AI-generated summary

    Victoria Georgia Halliday · 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

    Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality disorder.

    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 effective community psychiatric nurse involvement

    Wider context from the report

    “2) There was no, or no effective, community psychiatric nurse involvement and this was a missed opportunity to monitor and assist Victoria when she was in the community. ”

    Source location

    Victoria Georgia Halliday · 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

    Ensure team staff understand the process for allocating a community worker after assessment, including through new-starter induction.

    Verbatim wording from the response

    “In this case, the lack of effective CPN input during the time Victoria was a community patient was an isolated incident, with the assessing CPN failing to follow the standard operating team process, whereby the assessing worker accepts the person onto their case load if they have capacity. If they don’t have capacity the assessing worker should present the outcome of the assessment at the next Multi-Disciplinary team (MDT) meeting in order to allocate to a Community Worker/CPN within the Team.”

    Source location

    Response from Leicestershire Partnership NHS Trust
    Page 2 · response
    Published 20 October 2016

    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

    Implement comprehensive community-based mental health pathways so people access care at the right time and place.

    Verbatim wording from the response

    “We want to eliminate unnecessary out of area placements for adult acute mental health care by 2020/21 and reduce significantly delayed transfers of care so that people can move from hospital to care in the community, ensuring that beds are available for those most in need. We appreciate that this will not happen overnight but we are committed to delivering change. Also, through the Five Year Forward View, we will implement a comprehensive set of community-based mental health pathways of care so that people have access to care at the right time in the right place.”

    Source location

    2016-0370-Response-by-Department-of-Health
    Page 2 · response
    Published 20 October 2016

    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 £400 million of additional investment through 2020/21 to improve community mental health provision.

    Verbatim wording from the response

    “The Government announced an additional £400m investment up to 2020/21 to improve the quality of community mental health provision as an effective and safe alternative to hospital admission. This builds on the successful National Mental Health Crisis Care Concordat which has seen every local area develop a crisis care action plan to ensure that no-one in crisis is turned away.”

    Source location

    2016-0370-Response-by-Department-of-Health
    Page 2 · response
    Published 20 October 2016

    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 lack of effective community psychiatric nurse input was an isolated incident, not evidence that community support generally did not exist.

    Verbatim wording from the response

    “A standard community service exists within LPT for people with personality disorder in the form of community mental health team (CMHT), Crisis Resolution Team (CRT) and Specialist Personality Disorder Service (FDL). Victoria was accessing all these services during the course of her contact with LPT. An identified Community Psychiatric Nurse (CPN) from the CMHT, CRT was present during professional and CPA meetings whilst Victoria was an inpatient. Due to the nature of Victoria’s presentation of presenting in different areas of the country in a crisis covering CPNs and CRT professionals tried to ensure continuity as much as possible.”

    Source location

    Response from Leicestershire Partnership NHS Trust
    Page 2 · response
    Published 20 October 2016

    Open published response

  5. Central Hampshire

    AI-generated summary

    Louise Dawn Locke · 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

    Louise Dawn Locke, a vulnerable adult with undiagnosed mental problems associated with alcohol dependency, died by suicide after hanging herself at her home in Winchester on 27 May 2015. The concerns included her premature discharge from mental health services without a proper risk assessment or adequate support, and inadequate systems for collating information across agencies to identify and support people at high risk.

    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

    Premature discharge from community mental health services

    Wider context from the report

    “(1) The Community Mental Health Service discharged Louise Locke prematurely and without carrying out a proper risk assessment or offering her adequate support ”

    Source location

    Louise Dawn Locke · 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

    Formulate and obtain approval for standard arrangements ensuring patients seeking second opinions are not prematurely discharged and can access suitable appointments.

    Verbatim wording from the response

    “The Adult Mental Health Management Team have discussed this and an action has been assigned to the Clinical Service Directors in each area to formulate a standard plan to ensure that patients requesting second opinions have access to these, and are not prematurely discharged if they advise that they are unable to attend their appointment. There is agreement across all areas that a second opinion offer should be individually negotiated to the needs of the service user, and that if someone alerts us that they cannot attend the appointment then other arrangements will be made to facilitate the appointment either through a different venue or through the consultant travelling to another area. The standard process will depend on the geography of each area and consultants working arrangements.”

    Source location

    2016-0026-Response-by-Southern-Health-NHS-Trust
    Page 1 · response
    Published 29 January 2016

    Open published response

  6. Manchester South

    AI-generated summary

    Jake Robinson · 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

    Jake Robinson died at home on 23 August 2015 after taking his own life; the recorded cause of death was hanging and illicit drug use. Concerns included failures to share information about prescribing diazepam, the failure to identify this issue in the review of his death, fragmented substance-misuse services, and the unexplained rearrangement of a Community Mental Health Team appointment shortly before his 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

    Failure to prioritise Community Mental Health Team appointments for patients at high risk of harm

    Wider context from the report

    “4) There was no explanation in the review as to why the appointment clash between Trafford Aim and the Community Mental Health Team led to the appointment with the CMHT being rearranged. Particularly as Jake had made two recent serious attempts of self-harm in July 2015 and was at the very least recognised as a high risk of accidental harm. Given that Trafford Aim were not prescribing Jake at this time the Court had some difficulties in understanding what their role was given that he was also under Phoenix Futures for his substance misuse. ”

    Source location

    Jake Robinson · 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

    Send all mental health service commissioners NHS England expectations for commissioned arrangements covering urgent correspondence, clinical risk assessment, shared care, incident learning, and vulnerable patients who miss appointments.

    Verbatim wording from the response

    “In order to reduce the risks of recurrence of a similar incident at these and other organisations across Greater Manchester so that referrals are managed and monitored by the responsible commissioning and provider organisations I intend to undertake the following actions by 29 April 2016.”

    Source location

    2015-0474-Response-by-GMCA
    Page 2 · response
    Published 9 December 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

    Reflect further on whether obtaining information about future appointments and clinicians would improve patient care.

    Verbatim wording from the response

    “In conclusion, the RAID Team stated that in their opinion there was no evidence of acute mental illness and that his primary concern currently was illicit drug use. At that time their plan included leaving him under the care of Phoenix Futures as he had a good rapport with his keyworker, he was discharged from RAID with it being stated that he was aware of crisis pathways. In retrospect however we were not aware of when his next appointments were and who they were going to be with. I am not sure whether availing ourselves of this information would have made a major difference but it is certainly something we will reflect on further.”

    Source location

    2015-0474-Response-by-Bodmin-Road-Health-Centre
    Page 2 · response
    Published 9 December 2015

    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