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. Mid Kent and Medway

    AI-generated summary

    Roger Adrian Stevenson · 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

    Roger Adrian Stevenson was found deceased in supported accommodation on 2 May 2022, having last been known to be alive on 30 April 2022; the medical cause of death was fatal toxic morphine intoxication. The report identified concerns that Roger had become lost to mental health services, including a lack of follow-up, delays in care-coordinator allocation, insufficient continuity between services, and limited long-term support for cyclical mental ill health.

    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 accessing mental health services and treatment

    Wider context from the report

    “1. That Roger, as a vulnerable adult who had been recognised to be in need of care and support, had been lost in the system (e.g. with a lack of 72 hour follow up in 2021) and may have been inappropriately housed. 2. There was a need for recognition of service users with cyclical chronic mental ill health issues – in this case being that help Roger received tended to be only at the time of crisis thus doing nothing to address long-term underlying chronic conditions. 3. That there was a lack steps taken to address isolation felt by service users suffering ill health where there were likely to be substantial delays in accessing services (such as being allocated a care co-ordinator) and receiving treatment which could lead to further feelings of desperation leading to thoughts of suicide and self-harm. 4. KMPT needed to ensure service users do receive a 72 hour follow up after presenting to an Emergency Department, ”

    Source location

    Roger Adrian Stevenson · 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

    Make emergency mental health support available through NHS111 across England.

    Verbatim wording from the response

    “The Government is committed to improving urgent mental health services. We have now made emergency mental health support through NHS111 available everywhere in England. For those with severe needs or in crisis, 24/7 urgent mental health helplines are already available in all areas of the country. These crisis lines currently take around 200,000 calls a month. Linking these through to NHS111 will provide a consistent route for people to access support across the country. Delivering this commitment will enable anyone experiencing a mental health crisis to access assessment and, if appropriate, onward referral and treatment at any time of the day by calling NHS111.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 21 November 2023

    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 NHS mental health workforce by an additional 27,000 staff between 2019/20 and 2023/24.

    Verbatim wording from the response

    “With regard to your concerns around staffing shortages, the government is not able to comment on staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we do recognise the wider need to increase capacity in NHS mental health services. Nationally, we are making positive progress on our ambition to grow the mental health workforce by an extra 27,000 staff between 2019/20 and 2023/24. We delivered three quarters of this (around 20,800) by December 2023 with further growth expected to have been achieved once the full year figures for 2023/24 are available.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 21 November 2023

    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

    Expand and transform community mental health services for adults with severe mental illness through the NHS Long Term Plan.

    Verbatim wording from the response

    “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. Through the NHS Long Term Plan, we are committed to expanding and transforming mental health services in England so that more people can get the help and support that they need. As part of this, we are set to reach nearly £1 billion additional funding invested by 2023/24 (compared to 2018/19) to transform community mental health services for adults with severe mental illness.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 2023

    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 is responsible for addressing the report’s concerns about local mental health service issues.

    Verbatim wording from the response

    “I note that you have also addressed matters of concern to the Chief Executive of NHS England, and I would expect her response to address the concerns raised around local issues.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 2023

    Open published response
  2. South Yorkshire (Western)

    AI-generated summary

    Alex Dews · 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

    Alex Dews went to a bridge at Dearne Valley Country Park on 14 July 2022, fell into shallow water, and died at Sheffield Children’s Hospital on 18 July 2022. The report raises concerns about school documentation and assessment processes, barriers to referral to NHS mental health services, unclear allocation of school-procured psychology support, and inadequate communication with the support provider.

    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

    Excessive waiting times for NHS mental health services

    Wider context from the report

    “1. Alex was not referred by school to NHS mental health services as a result of their experience that if Alex was in receipt of any other support he would not be accepted onto the waiting list (which would be in excess of 10 months to be seen). ”

    Source location

    Alex Dews · Prevention of Future Deaths report
    Page 4 · 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

    Continue expanding and transforming NHS mental health care for children and young people.

    Verbatim wording from the response

    “More generally, we are aware that some children and young people are not able to access support they need in a timely manner. Through the NHS Long Term Plan, we are continuing to expand and transform NHS mental health care and spend on children and young people’s mental health services has increased from £841 million in 2019/20 to just over £1 billion in 2022/23.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 30 October 2023

    Open published response
  3. Gwent

    AI-generated summary

    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

    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

    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
  4. North and South Northumberland

    AI-generated summary

    Charley Ann Patterson · 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

    Charley Ann Patterson had experienced low mood, anxiety, bullying and previous self-harm. She attended hospital for support in May 2020, but the planned referral to the Northumberland (Early Help) Hub was not made and there was an absence of communication with other services and professionals. She later died by suicide on 1 October 2020. The concerns included increased demand for children’s mental health support following the Coronavirus pandemic and delays in receiving treatment and early support.

    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 children and young people's access to mental health treatment and support

    Wider context from the report

    “(1) During the course of the inquest, it was a concern to me the increase in the number of children and young people who are now being seen with regard to their emotional well-being, psychological distress and mental health difficulties which have impacted on them requiring support and assessment since the Coronavirus pandemic and the delays that now exist before they receive treatment and support. (2) I heard that in 2020 if the criteria for referral had been met for referral to Children's Adolescent Mental Health Services there would have been a triage of the child or young person within 8 weeks, treatment within up to 19 weeks with the number of referrals at that time being 1,595. In 2022, subject to meeting the criteria for referral, there would be a triage of the child or young person within 3 weeks but that waiting time for treatment has increased from up to 19 weeks up to 63 weeks with the number of referrals being 2,275. ”

    Source location

    Charley Ann Patterson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. West Sussex

    AI-generated summary

    Robyn Lily Audrey SKILTON · 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

    On 7 May 2021, 14-year-old Robyn Lily Audrey Skilton was found in Southwater Park with a ligature around her neck, and her death was confirmed by emergency services. The inquest concluded that Robyn took her own life while struggling with her mental health, and that mental health services failed to recognise the deterioration in her mental health or provide the care and treatment she required. The report raised concerns about delayed assessment and treatment, including a lack of timely access to Child Psychiatrist and CAMHS services and insufficient resourcing.

    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 tier 3 CAMHS acceptance

    Wider context from the report

    “Robyn was failed by the Mental Health Services quite frankly due to the current lack of resourcing and provision in place to support young people struggling with their mental health. Due to the lack of availability of a Child Psychiatrist there are long waiting times for children to be assessed. Robyn was not seen by a Child Psychiatrist and/or Psychologist, despite there being a need for this to happen, thereby enabling her to be diagnosed and receive a treatment plan. Robyn’s parents did everything they could during this period to support Robyn, including paying for a private counsellor, but sadly Robyn’s mental health continued to deteriorate during this time, and she took her own life. Robyn initial acceptance into tier 3 Children and Mental Health Services (CAMHS) similarly did not happen in a timely manner. I do appreciate that the landscape that the local mental health Trust (Sussex Partnership Foundation Trust) was working under and the fact that Covid heightened the level of complexity across many services but there were many failings in the care provided to Robyn. It became very clear during the Inquest that there is significant under funding of the local mental health Trusts who like many mental health Trusts see an explosion of referrals to their Children and Mental Health services (CAMHS). By way of an example:- Referrals to West Sussex CAMHS have increased by 95.6% from May 2019 (389) to May 2022 (761) West Sussex CAMHS caseload has increased by 85% from May 2019 (2239) to May 2022 (4147) West Sussex CAMHS Duty caseload has increased by 112% from May 2021 (492) to May 2022 (1494) Mental Health A&E presentations, in period April 2021 - March 2022, have increased by 40% on previous year (April 2020 - March 2021). Additionally, across Sussex CAMHS, as a whole, the referrals data shows:- • May 2022 was the highest number of referrals the service has ever received (1350). • Of those 1350 referrals, 80% (1,081) were accepted into the service. • In comparison, in May 2019, 579 were accepted (65% accepted) • So, an additional 502 young people have been accepted in May 2022 compared to May 2019 Despite the increase in numbers accessing CAMHS there has not been any relative increase in resources to meet this demand and therefore the current position is is unsustainable and it is putting many young people’s lives at risk. ”

    Source location

    Robyn Lily Audrey SKILTON · 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

    Work with NHS England on next steps following consultation on proposed mental health waiting-time standards.

    Verbatim wording from the response

    “More broadly, NHS England consulted on the potential to introduce a range of new waiting time standards as part of its Clinically-led Review of NHS Access Standards⁴. These include:”

    Source location

    Response from department of Health and Social Care
    Page 3 · response
    Published 30 September 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

    Delays and gaps in psychological therapy support pending substantive treatment

    Wider context from the report

    “My concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment. Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation. That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act. I understand that there is a long term plan to extend young people’s services to age 25, but I remain concerned about the ongoing situation, and that a young person today could be faced with the same challenges in finding support pending substantive treatment. ”

    Source location

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

    Open source report
  7. Manchester South

    AI-generated summary

    Joy Burgess · 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

    Joy Burgess died by suicide on 9 June 2021 as a consequence of multiple injuries. She had complex mental health difficulties, was experiencing deteriorating mental health and thoughts of self-harm, and had left hospital because she found the ward environment busy and extremely noisy. The concerns identified were that mental health wards could be unsuitable for recovery and that patients experienced lengthy waits for psychological therapies.

    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

    Lengthy waits for access to psychological therapies

    Wider context from the report

    “2. The Court heard that patients continue to experience lengthy waits if referred for psychological therapies, both locally and nationally. In the Tameside area, the current average wait was thought to be around one year from referral. ”

    Source location

    Joy Burgess · 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 £500 million to expand mental health services, address waiting times, invest in the workforce, and support talking therapies, crisis services and suicide prevention.

    Verbatim wording from the response

    “The pandemic has had an impact on the mental health and wellbeing of many people, which has caused increased demand for mental health services. In order to help address this, we provided an extra £500 million in 2021/22 to accelerate our expansion plans and address waiting times for mental health services, which will provide more people with the mental health support they need and invest in the NHS workforce. This funding included £110 million to expand adult mental health services - including talking and psychological therapies, implementing the community mental health framework, investment in crisis services and maintaining the delivery of the 24/7 urgent mental health helplines stood up earlier in the pandemic, as well as additional investment in suicide prevention programmes.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 7 February 2022

    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 NHS England on next steps following its consultation on proposed mental health access standards.

    Verbatim wording from the response

    “With regards to those people with more complex mental health needs, who are waiting for treatment, NHS England consulted in 2021 on the potential to introduce five new waiting time standards as part of its clinically-led review of NHS access standards. The proposals included:”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 7 February 2022

    Open published response
  8. Manchester North

    AI-generated summary

    Nichola Jane Lomax · 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

    Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.

    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

    Failures and delays in maintaining and re-referring patients on the Priory waiting list

    Wider context from the report

    “7) Delay in Re-Referral For GMMH/PRIORY Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list. This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS. ”

    Source location

    Nichola Jane Lomax · 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

    Review the Greater Manchester adult eating disorder pathway and revise protocols and collaboration arrangements.

    Verbatim wording from the response

    “The traffic light system in MEED has been endorsed by NHSE/I and is being rolled out across the system in Greater Manchester and nationally now so that, like NEWS 2, we can see significant improvement in risk assessment and triage. There will also be a requirement for all ICSs to have a formally established whole-system MEED group, which we have started for young people and are now starting for adults, with a link across the two to ensure the transitions are also addressed. Greater Manchester have also accelerated the review of the whole adult eating disorders pathway, including revised protocols with our independent sector providers and greater collaboration with the voluntary, community and social enterprise sector providing both prevention and recovery support as well as carer support.”

    Source location

    2021-0433 - Response regarding Nichola Lomax
    Page 3 · response
    Published 31 December 2021

    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

    Broaden the children and young people’s eating disorder working group into an all-age group addressing transitions and consistent referral pathways.

    Verbatim wording from the response

    “In advance of this, GMHSCP MH Programme Team are working with partners to ensure the Children and Young Person’s Eating Disorders working group that is already in place is broadened to become an all-age group. This will address wider transition issues between Children’s and Adult Eating Disorder services - an area of particular concern for this patient group. Actions to ensure connectivity of evidence-based pathways that apply consistent referral criteria will be a key part of the work of this group. It will involve clinicians, commissioners, service providers and service users. This is something that has already been encouraged over the past year in the”

    Source location

    2021-0433 - Response regarding Nichola Lomax
    Page 38 · response
    Published 31 December 2021

    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 expanded adult eating disorder service to provide medical monitoring, specialist treatment, consultation and coordinated pathways.

    Verbatim wording from the response

    “GMHSCP also acknowledges that the commissioned adult eating disorders service in Bury (like many areas of the country) was insufficient to meet local need. Since then, funding has now also been confirmed between Bury CCG and GMHSCP to implement the GMMH Adult Eating Disorders Business Case.”

    Source location

    2021-0433 - Response regarding Nichola Lomax
    Page 39 · response
    Published 31 December 2021

    Open published response
  9. Norfolk

    AI-generated summary

    Mary Jane BUSH · 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

    Mary Jane BUSH, who had a diagnosis of anxiety disorder, post-traumatic stress syndrome and suicidal ideation, was found at her home on 6 August 2020; the inquest conclusion was suicide. The principal concerns were delays in her mental health assessment and psychological therapy, ongoing delays in providing therapy, and difficulties with recruitment and retention of suitably skilled staff.

    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 mental health assessment following referral

    Wider context from the report

    “1. Mary was referred to the mental health team in November 2019 and was assessed in January 2020, some three weeks later than should have been. ”

    Source location

    Mary Jane BUSH · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  10. Manchester South

    AI-generated summary

    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

    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 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
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Data last updated 7 September 2026