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. Avon

    AI-generated summary

    Sian Leigh ARMSTRONG · 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

    Sian Leigh ARMSTRONG had a history of depression and had previously attempted suicide by overdose. She was assessed as needing CBT after this attempt, but had not received it by her death in June 2014. The principal concern was the delay in providing CBT, with a request for reassurance that it would be made available to children requiring it in a timely manner.

    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 providing CBT to children assessed as needing it

    Wider context from the report

    “1. There was a delay in Sian receiving CBT which she was assessed as requiring. ”

    Source location

    Sian Leigh ARMSTRONG · 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

    Involve Off the Record staff in CAMHS intake meetings and finalise governance arrangements for cross-organisational working.

    Verbatim wording from the response

    “• Bristol and South Gloucestershire Clinical Commissioning Groups (CCG) directly commission Tier 2 services from Off the Record. We are working with our two CCG’s, to involve Off the Record in our CAMHS intake meetings”

    Source location

    2015-0019-North-Bristol-NHS-Trust
    Page 1 · response
    Published 21 January 2015

    Open published response
  2. Manchester South

    AI-generated summary

    Rowena Kathryn Golton · 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

    Rowena Kathryn Golton had a history of recurring depression, suicidal thinking and deteriorating mental illness. On 6 April 2014, after being assessed as low risk of suicide and discharged from A&E with a plan for later crisis-team review, she jumped from a fire escape and died from multiple traumatic injuries. Concerns included limited access to psychologists within crisis teams and significant waiting times 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

    Significant waiting times for access to psychological therapy

    Wider context from the report

    “- Evidence was given as to the lack of availability of psychological services within the crisis teams. Following her admission as an inpatient she was then under the care of the crisis team. Not all crisis teams have access to a psychologist and the internal admissions recognised that there needed to be a review of the availability of psychological services to ensure adequate provision and access. - In addition there was recognition that the waiting times for access to psychological therapy are significant and there is a greater need for the service to prioritise cases. ”

    Source location

    Rowena Kathryn Golton · 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

    Commission a diagnostic review of Citywide IAPT services.

    Verbatim wording from the response

    “With regards to Manchester Mental Health and Social Care Trust response indicating that they have reviewed access to clinical psychology services I can confirm that the Citywide Team commissioned a review of psychological therapies (IAPT) with the two providers of this service in Manchester; Manchester Mental Health and Social Care Trust being one of the providers reviewed. I assume that this review is what the Trust response relates to as I am not aware of any separate review of IAPT being undertaken.”

    Source location

    2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
    Page 1 · response
    Published 11 November 2014

    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 providers to implement recommendations from the IAPT diagnostic review.

    Verbatim wording from the response

    “The National IAPT Intensive Support Team was asked to undertake a diagnostic review of the Citywide IAPT services. The review was requested by Commissioners in response to our low performance for the national indictors and the need to achieve 15% access to psychological therapies in line with the IAPT programme and the long waiting lists. An external and expert review was required to help understand why performance is low. The subsequent report offered a number of options to consider to more effectively offer NICE recommended therapies for mild to moderate-severe anxiety and depression, Step 2 and Step 3 psychological therapies (IAPT). As a result both commissioners and providers are working together to implement the recommendations of the report.”

    Source location

    2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
    Page 1 · response
    Published 11 November 2014

    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

    Further examine waiting-list information to verify patient numbers and actions taken to manage waits.

    Verbatim wording from the response

    “Following the National IAPT team review and the examination of the Psychological Therapies CQIN that is in place relating to waiting times, Commissioners now have a better understanding of how the Trust manages waiting lists. We need to further examine the current waiting list information to verify the actual number of patients waiting to be assured that all possible actions are being taken by the Trust to regularly cleanse and review the number of patients waiting. We are working with the Trust to improve their data cleansing and waiting list management processes as we have concerns regarding the accuracy of the data.”

    Source location

    2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
    Page 2 · response
    Published 11 November 2014

    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 the Trust to improve data-cleansing and waiting-list management processes.

    Verbatim wording from the response

    “Following the National IAPT team review and the examination of the Psychological Therapies CQIN that is in place relating to waiting times, Commissioners now have a better understanding of how the Trust manages waiting lists. We need to further examine the current waiting list information to verify the actual number of patients waiting to be assured that all possible actions are being taken by the Trust to regularly cleanse and review the number of patients waiting. We are working with the Trust to improve their data cleansing and waiting list management processes as we have concerns regarding the accuracy of the data.”

    Source location

    2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
    Page 2 · response
    Published 11 November 2014

    Open published response
  3. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Lee Jay Bonsall · 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

    Lee Jay Bonsall was found hanging from a bannister rail at his home on 3 March 2012, and the inquest recorded the medical cause of death as asphyxia by hanging, with intent unclear. Concerns related to citalopram being prescribed on repeat and the ten-month waiting time for psychotherapy.

    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 psychotherapy making it an unavailable alternative to anti-depressant medication

    Wider context from the report

    “(2) The ten month waiting times for psychotherapy effectively means that this is not a viable alternative to anti-depressant medication and it might well be that a review of these waiting times is appropriate. ”

    Source location

    Lee Jay Bonsall · 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

    Develop revised mental-health access and waiting-time standards to improve parity with physical-health services.

    Verbatim wording from the response

    “The Department and NHS England are committed to ending this imbalance. We believe that it is vital to develop and implement new access and waiting time standards to have true parity of esteem. We are committed to providing access to services and waiting times on a par with physical health.”

    Source location

    2014-0044-Response-by-Department-of-Health-1
    Page 3 · response
    Published 31 January 2014

    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 revised mental-health access and waiting-time standards through a phased programme beginning in April 2015.

    Verbatim wording from the response

    “The Department and NHS England are committed to ending this imbalance. We believe that it is vital to develop and implement new access and waiting time standards to have true parity of esteem. We are committed to providing access to services and waiting times on a par with physical health.”

    Source location

    2014-0044-Response-by-Department-of-Health-1
    Page 3 · response
    Published 31 January 2014

    Open published response
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Data last updated 7 September 2026