Recurring concern

Excessive waiting times for NHS mental health services

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First reported 31 Jan 2014•Latest report 4 Mar 2026

Definition

What this concern includes

Includes excessive or unsafe waiting times within NHS mental health services, including delays in referral assessment, waiting-list prioritisation, psychological therapy, psychotherapy or other necessary mental health treatment, where the report identifies the delay as a safety concern.

Not included

  • Excludes waiting times for non-mental-health services such as elective surgery, endoscopy, cardiology or emergency-department assessment.
  • Excludes generic staffing, bed-capacity, funding or escalation deficiencies unless they are explicitly tied to excessive waiting times within NHS mental health services.
  • Excludes failures in communication, assessment, referral handling or treatment quality that do not involve excessive access delays.
Reports
33

Distinct published reports

Individual concerns
37

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
77

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 Care18
NHS Greater Manchester Integrated Care Board8
NHS England5
Greater Manchester Mental Health NHS Foundation Trust3
North East London NHS Foundation Trust2
Pennine Care NHS Foundation Trust2
Academy of Medical Royal Colleges1
Aneurin Bevan University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Bradford District Care NHS Foundation Trust1
Bristol NHS Foundation Trust1
Cambridgeshire and Peterborough NHS Foundation Trust1
Cambridgeshire County Council1
Cwm Taf Morgannwg University Local Health Board1
Department for Education1

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 South

    AI-generated summary

    Mark Alan Hughes · 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

    Mark Alan Hughes, who had a history of anxiety and was assessed as at high risk of self-harm and suicide, died after taking codeine and morphine and stabbing himself during the night of 22–23 June 2025. The report raised concerns that urgent referrals from general practice could not be made directly to the Home Based Treatment Team in South Trafford, resulting in a delay over the weekend before assessment or onward referral could occur.

    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 assessment and referral for urgent mental health referrals

    Wider context from the report

    “2. Whilst the usual course is for the South Trafford CMHT to make contact with the service user on the day of referral, the evidence established that on an urgent referral, the South Trafford CMHT have a timeframe of up to 5 days to arrange an assessment. 3. Moreover, with regard to a referral in the circumstances of this matter, the CMHT do not operate over the weekend. This meant that from Friday 20th June 2025 at 17:00, there could be no assessment and no referral to the HBTT, until 09:00 on Monday 23rd June 2025, at the earliest. ”

    Source location

    Mark Alan Hughes · 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

    Hold an urgent-care away day to review and confirm the HBTT SOP and reinforce referral pathways and operational expectations, including direct referrals by primary care networks.

    Verbatim wording from the response

    “In addition, a planned away day is scheduled to take place on 6th May 2026 lead by the clinical service managers for urgent care, during which senior operational leads will meet to review and confirm the HBTT Standard Operating Procedure (SOP). The SOP that went live in February 2026 has a list of services that can refer into HBTT and states that this is not an exhaustive list and that GMMH operate an inclusive referral process to support all GMMH internal teams. This session will be used to clearly outline referral pathways and operational expectations across all GMMH HBTT services.”

    Source location

    Response from GMMH
    Page 2 · response
    Published 9 March 2026

    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 a functioning Referral and Assessment hub in every Trust area by the end of August 2026 to provide a single external referral point.

    Verbatim wording from the response

    “As part of the transformation of community mental health services GMMH are implementing a Referral and Assessment hub who will triage all external referrals and direct to the most appropriate service. These hubs are already in place in some areas of the Trust; the SOP will be finalised by the end of May 2026 and there will be a Referral and Assessment hub functioning in all areas of the Trust by the end of August 2026 enabling GP’s and other professionals to have a single point of referral.”

    Source location

    Response from GMMH
    Page 2 · response
    Published 9 March 2026

    Open published response
  2. Manchester South

    AI-generated summary

    Robert Leighton SMITH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Robert Leighton Smith was found unresponsive at home on 25 October 2024 while prescribed high levels of painkillers; toxicology found above-therapeutic levels of his prescribed medication, and the inquest concluded accidental death. He had been assessed as likely to benefit from Interpersonal Psychotherapy but had not started it because of a significant waiting list, with average waits of 12 months attributed to demand exceeding commissioned capacity.

    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

    Insufficient commissioned capacity for timely mental health therapy support

    Wider context from the report

    “The inquest was told that Mr Leighton –Smith had been assessed as someone who would gain a real benefit from IPT. However he had not started it at the time of his death due to a significant waiting list. This was caused by the demand for the service being far higher than the capacity. The evidence was that at the time of the inquest the waiting time for IPT was on average 12 months. This was due to the ongoing demand against commissioned capacity. The inquest was also told that IPT was not an outlier in relation to its waiting time and that the backlog for all other therapy type services were at a similar level. The consequence of such prolonged waits was that people were having to wait a long time for mental health therapy support that they had been identified as requiring. The Trust GMMH indicated they provided the services they were commissioned to provide but unless the additional services were commissioned they could not increase their provision and waiting lists would remain high. ”

    Source location

    Robert Leighton SMITH · 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

    Use benchmarking to map psychological-therapy provision gaps and inform long-term commissioning plans.

    Verbatim wording from the response

    “In direct response to these challenges, we are actively developing a long-term strategy to improve access to psychological therapies. This includes:”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 16 April 2025

    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

    Explore targeted recruitment, training and retention measures to increase the psychological-therapy workforce.

    Verbatim wording from the response

    “In direct response to these challenges, we are actively developing a long-term strategy to improve access to psychological therapies. This includes:”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 16 April 2025

    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

    Review and evolve commissioning practices to better align psychological-therapy provision with population needs.

    Verbatim wording from the response

    “In direct response to these challenges, we are actively developing a long-term strategy to improve access to psychological therapies. This includes:”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 16 April 2025

    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

    Commission Kooth and Qwell online platforms to provide free, anonymous, clinically supervised mental-health support.

    Verbatim wording from the response

    “• Digital Support commissioned from Kooth and Qwell: We have commissioned online mental health platforms Kooth (for children and young people) and Qwell (for adults), offering free, anonymous, and clinically supervised mental health support. These services expand access to therapeutic support, particularly for those awaiting more intensive interventions.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 16 April 2025

    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

    Commissioned psychological therapy capacity cannot currently meet all identified need because of longstanding underinvestment and financial constraints.

    Verbatim wording from the response

    “Recent benchmarking has demonstrated that our commissioned services currently have the capacity to deliver psychological interventions to approximately 14.6% of individuals who require support outside of early intervention services. This figure reflects longstanding systemic underinvestment and financial challenge resulting in capacity limitations within mental health care.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 16 April 2025

    Open published response
  3. 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
  4. Northamptonshire

    AI-generated summary

    Mr Robin Andrew Ward · 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 Robin Andrew Ward, a 73-year-old man, died by drowning in a bath at the Warren Crisis House on 4 July 2021; the conclusion was that his death was suicide. He had required an acute inpatient mental health bed, but no local bed was available for four days and he was placed at the crisis house as an interim measure. Concerns included pressures on acute and out-of-area mental health bed availability, the lower clinical capacity and lack of ligature safety in crisis houses, and long waiting times for psychological assessment.

    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 psychological assessment

    Wider context from the report

    “a) The Deputy Director for Mental Health at Northamptonshire Healthcare Foundation Trust said in his evidence “there are increasing pressures both locally and nationally with regards to the provision of acute mental health beds”. b) The Deputy Director also said that “we try to avoid supporting those waiting for an acute bed within crisis houses and continue to use out of area provisions as required and where appropriate”. However, it emerged in evidence that there are also pressures locally and nationally on the availability of out of area acute beds and that this particularly so in relation to provision for the elderly. Even if out of area beds are found, they can be a great distance away from the patient’s home address which can present difficulties including in relation to continuity of treatment. In Mr Ward’s case he was having rTMS treatment during each week day and that treatment is not available in all areas of the Country. This increases the likelihood that a crisis house may be utilised. However a crisis house does not offer the same level of clinical capacity and skills mix as a hospital environment and it is also not a ligature safe environment. c) Another particular problem identified was the long waiting times for psychological assessment. ”

    Source location

    Mr Robin Andrew Ward · 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

    Recruit and specially train 8,500 additional mental health workers, including to support people at risk of suicide.

    Verbatim wording from the response

    “Finally, turning to your concerns around long waiting times to access a psychological assessment, it is unacceptable that too many people are not receiving the mental health care they need when they need it and we know that waits for mental health services are far too long. We are determined to change that. As part of our mission to build an NHS that is fit for the future and that is where when people need it, we will make sure that mental health care is delivered in the community where appropriate, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. We will also recruit an additional 8,500 mental health workers to cut waiting times and provide faster treatment which will also help ease pressure on busy mental health services. These new workers will be specially trained to support people at risk of suicide.”

    Source location

    Response from Department of Health and Social care
    Page 2 · response
    Published 28 July 2026

    Open published response
  5. Suffolk

    AI-generated summary

    Gemima CHRISTODOULOU-PEACE · 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

    Gemima Christodoulou-Peace was found suspended by her neck from a ligature and died from suspension hanging, with the inquest noting insufficient evidence that she intended her death at all material times. The report raises concerns about the absence of a single reference point for identifying medications associated with increased suicidal behaviour, limited recording and accessibility of mental-health telephone calls, and delays in access to prescribing mental-health support. Gemima had requested a medication review, but had not seen a prescribing mental-health practitioner before 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

    Delays in access to prescribing mental health practitioners

    Wider context from the report

    “3. Gemima first reported a decline in her mental health in March 2023 and requested to be put back onto her previous medication. Gemima’s GP could not do this without input from a prescribing mental health practitioner, so a referral to secondary Mental Health Services was made. Gemima’s March request did not result in her obtaining an appointment with a prescribing mental health practitioner, at that time. Gemima reported her continuing low mood to her GP again on the 3rd July 2023, but as she had been referred to a Wellbeing Team, was told to contact NHS 111 Option 2 if she was ‘in crisis’. On the 19th July 2023 Gemima told her GP her anxiety was ‘through the roof’ so an urgent referral to the Mental Health Services was made. Gemima was assessed over the telephone six days later on the 25th July 2023, and was offered crisis support which she declined, as Gemima wanted a medication review with the mental health team she had seen previously. On the 25th July 2023 a risk assessment was undertaken with Gemima, and using the RAG (Red, Amber, Green) system, Gemima was deemed to be an ‘Amber’, and therefore ‘moderate’ risk. The court heard that any case risk rated ‘Red’, had a target response time of 4-72 hours (if the patient was in crisis) and 7 days for other ‘Red’ cases. Any case risk rated ‘Amber’ had a target response time of 2 to 4 weeks, and any case rated ‘Green’ had a target response time of 28 days. All treating clinicians who gave evidence in Gemima’s case said ‘in an ideal world’ resources would allow for much more timely interventions than those currently possible, especially those cases rated ‘Red’ or ‘Amber’. Although Gemima herself had recognised the need to be back on her mental health medication, resource pressures meant that at the time of her death, she had still not seen a treating mental health practitioner who could prescribe her previous mental health prescription. Gemima’s treatment assessment was booked for the 8th August 2023, 14 days after her tragic death. ”

    Source location

    Gemima CHRISTODOULOU-PEACE · 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

    Recruit 8,500 additional, specially trained mental health workers to reduce delays and provide faster treatment for people at risk of suicide.

    Verbatim wording from the response

    “More broadly, it is unacceptable that too many people, like Gemima, are not receiving the mental health care they need when they need it and we know that waits for mental health services are far too long. We are determined to change that. As part of our mission to build an NHS that is fit for the future and that is there when people need it, we will modernise the Mental Health Act to give greater choice, autonomy, enhanced rights and support, and ensure everyone is treated with dignity and respect throughout treatment and recruit an additional 8,500 mental health workers to reduce delays and provide faster treatment which will also help ease pressure on busy mental health services. These new workers will be specially trained to support people at risk of suicide.”

    Source location

    Response from DHSC
    Page 3 · response
    Published 31 July 2024

    Open published response
  6. South Wales Central

    AI-generated summary

    Isobel Lilian Stapleton · 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

    Isobel Lilian Stapleton, aged 32, was admitted to hospital for assessment and discharged to her father’s home with home treatment support. On 9 July 2022, she sustained likely self-inflicted injuries at home and died despite paramedic attendance; the inquest concluded that she died from suicide. Concerns included limited access to complete clinical records and a lack of clinical psychologist access for inpatient and home treatment teams, with psychotherapy waiting lists lasting months.

    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 necessary psychotherapy

    Wider context from the report

    “(5) The Home treatment team covering Merthyr Tydfil does not have access to a clinical psychologist to provide direct assessment and treatment of a patient. The waiting list for any necessary psychotherapy is months in length. ”

    Source location

    Isobel Lilian Stapleton · 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

    Invest resources to address the psychological-therapy waiting-list backlog across primary and secondary mental-health services.

    Verbatim wording from the response

    “waiting list in these services, and the Psychologists and Psychological Therapists work closely with the team as soon as a need for input is identified. There has been significant investment of resource to address the backlog of people waiting for psychological therapies in both Primary and Secondary mental health services. This has reduced the number of people waiting over 52 weeks from 221 in May 2023 to 109 in May 2024.”

    Source location

    Response from Cwm Taf Morgannwg University Health Board
    Page 5 · response
    Published 27 June 2024

    Open published response
  7. South London

    AI-generated summary

    Sailor (previously known as Sara) COURT · 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

    Sailor (previously known as Sara) COURT, aged 14, died by suicide on 17 September 2021 after taking an overdose at home while on the CAMHS waiting list for treatment. The principal concerns were unacceptably long waits for assessment and treatment, which had not improved and were attributed to insufficient resources relative to demand.

    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

    Insufficient capacity to safely assess and re-prioritise urgent CAMHS waiting-list patients

    Wider context from the report

    “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long. (2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long. (3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment. This is an unacceptably long delay. (4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment. (5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand. ”

    Source location

    Sailor (previously known as Sara) COURT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in CAMHS treatment

    Wider context from the report

    “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long. (2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long. (3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment. This is an unacceptably long delay. (4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment. (5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand. ”

    Source location

    Sailor (previously known as Sara) COURT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in CAMHS assessment

    Wider context from the report

    “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long. (2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long. (3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment. This is an unacceptably long delay. (4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment. (5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand. ”

    Source location

    Sailor (previously known as Sara) COURT · 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 in the CYPMH workforce and expand NHS mental health support access for children and young people.

    Verbatim wording from the response

    “Improving mental health support for children and young people is a priority for NHS England. The NHS Long Term Plan (LTP) sets an ambitious commitment that access will increase, with 345,000 more children aged 0-25 accessing support in 2023/24 compared to 2019. This commitment came with significant additional funding, rising to over £900 million in 2023/24. We have made significant progress towards this commitment, with 758,000 children and young people receiving support from the NHS in the 12 months to January 2024. This has been achieved through investment in the CYPMH workforce, which has increased by 46% since the start of the LTP in January 2019, and by 70% since 2016.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 9 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

    Recruit 8,500 additional staff across children’s and adult mental health services.

    Verbatim wording from the response

    “As part of our mission to build an NHS that is fit for the future and that serves the patients that need it, this Government will recruit 8,500 additional staff across children’s and adult mental health services, introduce a specialist mental health professional in every school and roll out Young Futures hubs in every community to intervene earlier with more timely mental health support.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 9 August 2024

    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

    NHS England will address concerns about the keeping in touch team in its response to the report.

    Verbatim wording from the response

    “With regards to your concerns about the “keeping in touch team” at South London and Maudsley NHS Foundation Trust. I have been in touch with Stephen Powis at NHS England to discuss the service. I understand that colleagues at NHS England will address these concerns in more detail in its response to your report.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 9 August 2024

    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

    Delivering expanded children’s mental health access ambitions is subject to future funding settlements, with plans to be clarified later.

    Verbatim wording from the response

    “The NHS Long Term Workforce Plan (June 2023) sets out the importance of continued investment in the mental health workforce and, in 2022, NHS England consulted on potential new access and waiting time standards, including for children and young people’s mental health. Delivering these ambitions will be subject to future funding settlements and we will clarify plans in due course.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 9 August 2024

    Open published response
  8. East Sussex

    AI-generated summary

    Jason PULMAN · 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

    Jason Pulman, aged 15, was found dead on 19 April 2022 and the inquest concluded that he died by suicide, by hanging. Evidence indicated that he had not received specialist gender dysphoria treatment while waiting for GIDS and was awaiting further CAMHS assessment. The principal concern was that unclear referral mechanisms and inadequate resources for mental health support during waits for gender services could lead to similar circumstances recurring.

    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

    Insufficient CAMHS resources causing long waits for treatment

    Wider context from the report

    “4. During the inquest, I heard evidence from senior management at the CAMHS run by Sussex Partnership Foundation Trust to the effect that (i) they were unaware that enhanced support was being offered via CAMHS and (ii) due to existing pressures on resources the enhanced support would likely have an impact on the already very long wait times for CAMHS treatment, which in turn would give rise to a risk of patients taking their own lives while waiting for treatment. ”

    Source location

    Jason PULMAN · 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

    Provide additional funding to local mental-health systems to support waiting-list assessments and care.

    Verbatim wording from the response

    “• From April 2024 we have established a process whereby all children and young people who are on the waiting list for CYP gender services are contacted by the NHS and offered an assessment by local NHS mental health services; NHS England has put additional funding into local mental health systems for this purpose. All children and young people who are identified with mental health needs will receive ongoing support by local services while they remain on the waiting list for CYP gender services.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 9 May 2024

    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

    NHS England strongly refutes the suggestion that assessing gender-service waiting-list patients will pose a risk to other patients.

    Verbatim wording from the response

    “NHS England will be contacting senior Trust representatives directly to understand the concerns further, including the suggestion that this initiative will pose a risk to other patients, which we strongly refute. NHS England has put additional funding into local mental health systems for the purpose of seeing children and young people on the waiting list for CYP gender services, and this initiative was established and overseen under the leadership of two senior clinicians: the NHS National Mental Health Director (Claire Murdoch), and the NHS Medical Director for Specialised Services (Professor James Palmer). The initiative was welcomed by the CEOs of the NHS mental health trusts when the proposal was put to them by the NHS National Mental Health Director in January 2024.”

    Source location

    Response from NHS England
    Page 5 · response
    Published 9 May 2024

    Open published response
  9. Manchester South

    AI-generated summary

    Tobias Ryse Mannering-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

    Tobias Mannering-Jones became homeless, isolated and vulnerable, experienced mental health difficulties, drug use and sexual exploitation, and was found dead at Portland Basin Marina on 21 February 2023. The inquest identified concerns about delays in mental health support, inadequate housing and sustained support for vulnerable homeless young people, difficulties contacting people without telephones or addresses, failure to recognise exploitation, and the need for coordinated agency responsibility.

    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 mental health support

    Wider context from the report

    “1. The inquest was told that Tobias had sought and had been referred for mental health support however due to the high demand and long waiting lists he was still on a waiting list at the time of his death. The evidence before the inquest was that long delays were still an issue and were not restricted to Tameside but were part of a national picture of delays and long waiting lists for those seeking help with their mental health. ”

    Source location

    Tobias Ryse Mannering-Jones · 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

    Maintain increased Neighbourhood Mental Health Team capacity through successful recruitment to Senior Mental Health Practitioner posts.

    Verbatim wording from the response

    “Within Tameside there has been improvement with waiting lists in recent months in the Neighbourhood Mental Health Team following successful recruitment to Senior Mental Health Practitioner posts. The Living Well team is now fully staffed for both Coaches and Senior Mental Health Practitioners, however the vacancies remain in the 3.5 therapy pathway with continued efforts in recruitment. To mitigate the risk if any individual is presenting with an increase in risks these are passed through a duty system for a review of the risks and there will be an intervention by a Duty worker that day where identified. The 3.5 pathway waiting times remain on the Pennine Care Foundation Trust (PCFT) Risk Register which is reviewed regularly and has scrutiny by the Senior Leadership Team within that system.”

    Source location

    Response from Greater Mnachester Integrated Care
    Page 2 · response
    Published 20 March 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

    Continue recruiting to fill vacancies in the 3.5 therapy pathway.

    Verbatim wording from the response

    “Within Tameside there has been improvement with waiting lists in recent months in the Neighbourhood Mental Health Team following successful recruitment to Senior Mental Health Practitioner posts. The Living Well team is now fully staffed for both Coaches and Senior Mental Health Practitioners, however the vacancies remain in the 3.5 therapy pathway with continued efforts in recruitment. To mitigate the risk if any individual is presenting with an increase in risks these are passed through a duty system for a review of the risks and there will be an intervention by a Duty worker that day where identified. The 3.5 pathway waiting times remain on the Pennine Care Foundation Trust (PCFT) Risk Register which is reviewed regularly and has scrutiny by the Senior Leadership Team within that system.”

    Source location

    Response from Greater Mnachester Integrated Care
    Page 2 · response
    Published 20 March 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

    Review the Living Well waiting list to assess needs and divert people to other services where appropriate.

    Verbatim wording from the response

    “In addition, The Living Well team are undertaking a review of the Waiting List to assess the current needs and diversion to other services if appropriate.”

    Source location

    Response from Greater Mnachester Integrated Care
    Page 2 · response
    Published 20 March 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

    Implement the Mental Health Workforce Strategy to identify workforce, skill-mix and service-configuration requirements and deliver workforce supply across Greater Manchester.

    Verbatim wording from the response

    “Increasing access to mental health services in the community is a key priority for NHS GM, supported by the Community Mental Health Transformation Workstream. Work to support this includes but is not limited to:”

    Source location

    Response from Greater Mnachester Integrated Care
    Page 2 · response
    Published 20 March 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

    Continue delivering Rough Sleeping Initiative funding to support specialist mental health services in local homelessness plans.

    Verbatim wording from the response

    “DHSC will provide more information on this matter in their response, given their lead on health. I recognise the vital role mental health services play in supporting people experiencing homelessness and rough sleeping, and my Department is supporting provision where it is needed through the Rough Sleeping Initiative (RSI). This is providing over £547 million, between April 2022 to March 2025, to LAs across England to deliver local homelessness and rough sleeping services. Of that, £30 million is funding health interventions, with a significant focus on mental health. Through our expert homelessness and rough sleeping advisers in DLUHC, I will continue to deliver RSI funding this financial year, supporting LAs to deliver specialist mental health support where it is part of their local plans.”

    Source location

    Response from Department for Levelling Up, Housing and Communities
    Page 2 · response
    Published 20 March 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

    Support NICE guidance improving access to coordinated, multidisciplinary health and social care for people experiencing homelessness.

    Verbatim wording from the response

    “The Department recognises the importance of reducing barriers to services for those experiencing rough sleeping. This is why we supported the development of NICE guidance which provides recommendations on ways to improve access to, and engagement with, health and social care services for people experiencing homelessness. It also provides advice on how commissioners, planners, providers and practitioners across disciplines and agencies can work together as part of a multi-disciplinary team to support and improve outcomes for people experiencing homelessness.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 20 March 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

    Work towards implementing new waiting-time standards for people requiring mental healthcare in emergency departments and community settings.

    Verbatim wording from the response

    “Between 2018/19 and 2023/24, NHS spending on mental health has increased by £4.7billion in cash terms as compared to the target of £3.4 billion set out at the time of the NHS Long Term Plan. Almost £16 billion was invested in mental health in 2022/23, enabling 3.6 million people to access mental health services, a 10% increase on the previous year. In addition, the NHS is working towards implementing new waiting time standards for people requiring mental healthcare in emergency departments and in the community, to ensure timely access to the most appropriate, high-quality support.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 20 March 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

    Embed 24/7 urgent mental health helplines across all areas of the country.

    Verbatim wording from the response

    “In terms of crisis care, we have embedded 24/7 urgent mental health helplines in all areas of the country, receiving around 200,000 calls per month, and there are now around 600”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 20 March 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

    Establish or expand crisis alternative services, including crisis cafes, safe havens and crisis houses, as alternatives to emergency or psychiatric admission.

    Verbatim wording from the response

    “In terms of crisis care, we have embedded 24/7 urgent mental health helplines in all areas of the country, receiving around 200,000 calls per month, and there are now around 600”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 20 March 2024

    Open published response
  10. Cornwall and Isles of Scilly

    AI-generated summary

    Nicolas Gerasimidis · 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

    Nicolas Gerasimidis had a history of mental illness manifesting as OCD and anxiety, which deteriorated despite referrals and treatment arrangements. He was found hanged at his home address on 3 June 2023, and the inquest recorded a conclusion of suicide. Concerns included community mental health referrals being rejected, shortages of care coordinators and consultants, a one-year waiting list for psychological treatment, lack of hospital bed availability, and shortcomings in information provided to his family.

    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 with Exposure Response Prevention

    Wider context from the report

    “The Trust’s Patient Safety Review identified the following concerns: - When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues; - No care coordinator was appointed owing to a shortage of staff; - The Trust had and continues to have vacancies at consultant level; - The family was wrongly advised the Trust was not commissioned to treat OCD; - The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP; - Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year; - In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available. The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken. ”

    Source location

    Nicolas Gerasimidis · 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

    Provide increased mental health investment to expand and transform NHS mental health services.

    Verbatim wording from the response

    “You noted that Mr Gerasimidis was on a lengthy waiting-list to access psychological therapy at the time of his death with ensuing concerns that other patients may have to wait significant lengths of time for care. We recognise that the demand on NHS mental health services has risen significantly, and this means that some people may face waiting times that are much longer than we would like. That is why, through the NHS Long Term plan, the Government is providing record levels of investment and increasing the mental health workforce to expand and transform NHS mental health services in England.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 12 February 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

    Grow the mental health workforce by an additional 27,000 staff to increase service capacity.

    Verbatim wording from the response

    “You noted that Mr Gerasimidis was on a lengthy waiting-list to access psychological therapy at the time of his death with ensuing concerns that other patients may have to wait significant lengths of time for care. We recognise that the demand on NHS mental health services has risen significantly, and this means that some people may face waiting times that are much longer than we would like. That is why, through the NHS Long Term plan, the Government is providing record levels of investment and increasing the mental health workforce to expand and transform NHS mental health services in England.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 12 February 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

    Implement new waiting-time measures for people requiring mental healthcare in emergency departments and the community.

    Verbatim wording from the response

    “As part of this expansion, the NHS is also committed to improving access to community mental health services. In 2022/23, 288,000 adults with severe mental health problems were able to access support through transformed models of adult community mental health, and by March 2025, it is expected that that number will have increased to 400,000, compared to 2019. In addition, the NHS is working towards implementing new waiting time measures for people requiring mental healthcare in emergency departments and in the community, to ensure timely access to the most appropriate, high-quality support.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 12 February 2024

    Open published response
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Data last updated 7 September 2026