First reported 16 Jan 2015•Latest report 18 May 2026
Definition
What this concern includes
Includes appointment, replacement, caseload, absence-cover and required-task failures concerning a designated mental-health Care Co-ordinator or equivalent role.
Not included
Generic multi-agency coordination without a designated care-coordinator role
Referral-pathway failures
Clinical treatment failures unrelated to care-coordinator provision or performance
Reports
21
Distinct published reports
Individual concerns
26
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
54
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 Care3
NHS England3
Norfolk and Suffolk NHS Foundation Trust3
Kent and Medway Mental Health NHS Trust2
Sussex Partnership NHS Foundation Trust2
Brunswick Ward at Lindridge1
Derbyshire County Council1
Derbyshire Healthcare NHS Foundation Trust1
East London NHS Foundation Trust1
Essex Partnership University NHS Foundation Trust1
Gray's Inn Road Medical Practice1
Greater Manchester Health and Social Care Partnership1
Greater Manchester Mental Health NHS Foundation Trust1
Herefordshire and Worcestershire Health and Care NHS Trust1
Lincolnshire County Council1
NHS trust18
Executive non-departmental public body3
Healthcare site3
Ministerial department3
English county council2
Health-system partnership2
Integrated care board2
London borough council1
Registered charity1
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.
Suffolk
Concerns raised3
Failure to identify a dedicated, named care co-ordinator for mental health patients during prolonged planned leave
Lack of a documented system for highlighting and managing planned, prolonged key care co-ordinator absence
Failure to ensure coverage of named key care co-ordinators’ roles and responsibilities during planned leave
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Implement and apply ratified guidance for managing planned prolonged Youth Team care-coordinator absence, including handover, patient review, reallocation decisions, notification and joint transition appointments.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Operate the Trust-wide E-Roster to identify staffing gaps, manage absences, arrange temporary cover and monitor team capacity.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Maintain an accessible Youth Team off-duty chart, updated for absences and changes, with daily huddles confirming staffing and cover requirements.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Conduct monthly Early Warning Trigger Score audits to identify staffing-capacity risks and support escalation for additional staffing support.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Conduct a monthly Associate Director of Nursing Check and Challenge review of the E-Roster to identify factors affecting team capacity and support forward planning.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing rostering, absence-management and risk-monitoring systems are considered sufficient to address staffing vacancies and maintain continuity of care.
Stated by The TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing planned-absence processes and ratified guidance are considered sufficient to document and manage prolonged Youth Team care-coordinator leave.
Stated by Norfolk and Suffolk NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Kent and Medway
Concerns raised1
Lack of care co-ordinators
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Introduce a named worker within the refined community model of care.
Stated by Kent and Medway Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Care coordinators will not be introduced because the national Community Mental Health Framework directs services to move away from care coordination.
Stated by Kent and Medway Mental Health NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West London
Concerns raised1
Lack of cover arrangements for care co-ordinator absence
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Roll out Envoy messaging across all community teams, with monitored patient communication and absence-cover support.
Stated by South West London and St George'S Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025.
Action
Implement an Envoy operating procedure covering planned and unplanned staff leave, out-of-office messages and alternative contact arrangements.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
Action
Revise case-list management when unplanned leave occurs to support continuity of care.
Stated by South West London and St George'S Mental Health NHS TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 17 April 2025.
Worcestershire
Concerns raised1
Delays in initial mental-health care coordinator appointments due to workload pressures
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Embed continuity-of-care arrangements for planned and unplanned staff absence, including guidance, multidisciplinary discussion and joint daily huddles.
Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Action
Require daily meetings to identify absent care-coordinator patients, assign temporary responsibility, and document handovers and rationale in minutes and SystmOne, with induction and attendance requirements.
Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Inner North London
Concerns raised1
Delay in allocation of a replacement mental health care coordinator
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Strengthen staff re-allocation and handover using a standardised handover template and clear successor contact information.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2024.
Action
Recruit to address team vacancies, including targeted recruitment activity and continuing recruitment to remaining posts.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2024.
Action
Increase staffing capacity through experienced agency staff, permanent social workers, a Band 7 supervisory role and a nursing Team Manager.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2024.
Action
Mobilise locality teams to collaborate with Integrated Community Teams and provide flexible staffing from February 2025.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2024.
Action
Train staff and implement the MaST tool for real-time caseload tracking and prioritisation of high-risk service users.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2024.
Action
Use RAG case tracking, weekly allocation meetings and interim manual audits to prioritise and follow up high-risk cases.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2024.
Cornwall and Isles of Scilly
Concerns raised1
Failure to appoint a care coordinator because of staff shortages
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Grow the mental health workforce by an additional 27,000 staff to increase service capacity.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2024.
Manchester West
Concerns raised1
Failure to appoint interim Care Coordinator or Community Psychiatric Nurse cover
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Implement a Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 November 2023.
Action
Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 November 2023.
Action
Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 November 2023.
Action
Audit the absence-cover process after three months to verify that it is embedded and being followed.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 November 2023.
Manchester South
Concerns raised2
Reliance on individual Care Coordinator capacity for comprehensive mental-health information
Unavailability of alternative Care Coordinator cover during staff absence
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement the Living Well model across all ten Greater Manchester localities, including multidisciplinary community mental-health teams.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
Action
Develop and embed multidisciplinary key-worker roles to strengthen community mental-health care and reduce reliance on individual care coordinators.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Responsibility for local mental health staffing, operations and specific Care Coordinator role requirements lies with the relevant NHS trust.
Stated by Maria Caulfield MPRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
GMMH’s existing systems maintain oversight, contact and risk responses when care coordinators are absent, so additional cover arrangements are not identified as necessary.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
PCFT’s existing duty systems, care plans, caseload oversight and risk-based reallocation provide support during planned or unplanned clinician absence.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised2
Excessive caseloads for care co-ordinators
Insufficient number of care co-ordinators for clinical need
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11
Action
Use non-recurrent funding to recruit additional staff for increased referral volume and patient acuity.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Audit care-coordinator caseloads and conduct a further scheduled audit to monitor caseload numbers.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 September 2022.
Action
Introduce the Management and Supervision Tool to support manageable caseloads, supervision and staff support.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Action
Recruit eight additional band 6 community psychiatric nurses to meet increased workload.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Action
Continue reviewing service needs and risks and placing additional staff to manage them.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Action
Recruit temporary staff to maintain continuity while permanent care-coordinator vacancies are filled.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Action
Prioritise mental-health vacancies and use off-framework agencies to retain locum support and consistency during short-term vacancies.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Deliver a training and career-development programme enabling band 5 staff to progress into band 6 care-coordinator roles.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Continue the mental-health transformation programme to enhance service delivery and develop the care model.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Action
Use rolling advertisements and international recruitment to recruit and retain staff, while pursuing a zero-nursing-vacancy objective.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Action
Review resource and staffing levels through Trust executive and North East London system-wide work.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Essex
Concerns raised1
Insufficient attention to the clinical significance of patient disengagement from services
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement the MaST caseload-management tool through agreed pilot sites to support risk, disengagement, caseload, and record-keeping oversight.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.
Action
Review and update the Disengagement Guideline to add Purple RAG identification and regular multidisciplinary discussion of disengaging patients.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2026.
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Includes appointment, replacement, caseload, absence-cover and required-task failures concerning a designated mental-health Care Co-ordinator or equivalent role.
