Recurring concern

Unreliable care-coordinator provision and cover for mental health service users

First to latest report 16 Jan 2015 — 18 May 2026

Reports that mention this concern
21
Times this concern has been raised
26
Stated actions linked to this concern
54

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.

What is 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 and published responses 21 reports

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

  1. Norfolk

    AI-generated summary

    Mark Robert Anstice · 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 Robert Anstice, who had a history of mental health and social problems and previous self-harm, was found hanged on 27 September 2014. Concerns included that recommended support-worker or care-coordinator provision was not actioned, uncertainty about a carer’s assessment referral, gaps in team awareness of appointments, and difficulties supporting his attendance at group sessions due to lack of transport or means.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to action recommendations for support worker or care coordinator provision

    Wider context from the report

    “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem; (2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team (3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care. (4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups. (5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered. (6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014. (7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014. ”

    Source location

    Mark Robert Anstice · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026