Recurring concern

Unreliable community mental-health response to urgent GP concerns

First to latest report 17 Feb 2016 — 14 May 2024

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
11

What this concern includes

Includes failures in the process by which community mental-health services receive, distinguish, prioritise, clinically review, respond to and follow up urgent GP concerns or requests for advice, including misclassification as referrals, unsafe discharge after non-response, unclear urgency procedures and delays caused by inadequate response capacity.

What is not included
  • Excludes general community mental-health staffing or capacity shortages unless they directly impair the response to an urgent GP concern or request for advice.
  • Excludes routine mental-health referrals, appointments and follow-up where no GP-raised concern or request for advice is involved.
  • Excludes failures in GP clinical assessment or treatment before a concern is sent to community mental-health services.
  • Excludes failures after a community mental-health service has reliably responded to the GP concern, including downstream treatment or discharge decisions unrelated to the response process.
  • Excludes the broader existing concern concerning unreliable mental-health referral pathways when the assertion is not specifically about responding to an urgent GP concern or request for advice.

Reports and published responses 5 reports

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

  1. Cornwall and Isles of Scilly

    AI-generated summary

    Sally Poynton · 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

    Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental 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

    Failure to distinguish GP requests for advice from referrals

    Wider context from the report

    “2) Community Mental Health Team i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain. I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly. ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice. iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances. iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge. I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above. ”

    Source location

    Sally Poynton · Prevention of Future Deaths report
    Page 4 · 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 responding to GP requests for mental health advice due to staffing shortages

    Wider context from the report

    “2) Community Mental Health Team i) There was a delay of one month in responding to a letter requesting advice from a GP. This was said to be due to staff shortages. At inquest it was noted that, 3.5 years later, staff shortages remain. I am aware the ICB has made concerted efforts to recruit. This is a concern that appears to require attention from central government and so this point needs addressing by the Secretary of State. I note this is not the first occasion I have written to the Minister to make her aware of the persisting difficulties in recruiting mental health staff in Cornwall and the Isles of Scilly. ii) A letter requesting advice was treated as a referral (twice.) It was accepted in evidence that there appeared to be confusion on the part of CMHT staff about how to treat a letter from a GP notwithstanding it set out clearly it was a request for advice. iii) Once the letter from the GP was taken as a request for a referral, attempting to contact the patient by telephone. It was known Jacob was selectively mute and so it should have been readily apparent he was not going to respond. Policy appears to have been followed without consideration of the clinical circumstances. iv) Discharging a patient’s referral without any clinical judgment. ████████ referral was discharged after he did not answer his phone twice (as he wouldn’t, being mute) or respond to an opt-in letter (that was sent to the wrong address.) The evidence was clear that ████████ lacked insight into his condition and steadfastly refused all offers of support. He was not going to ‘opt-in’ voluntarily. What appeared from the evidence to be a blanket policy of discharging patients who fail to respond (because they are unwell and lack insight) will result in those patients most in need of care being wrongly discharged. In my view, there needs to be some form of triage or clinical attention given to why a patient has not responded and whether it is appropriate to discharge. I recognise that this consideration, in addition to informing Nearest Relatives of their right to request a MHA, will result in additional burdens for what is an already over-stretched workforce. This may be a matter for the Minister to reflect upon in considering the staffing issue highlighted above. ”

    Source location

    Sally Poynton · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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

    No further difficulties need to be overcome in the referral pathway into secondary mental health services.

    Verbatim wording from the response

    “• In terms of its function as a referral pathway I do not believe that there are any difficulties which need to be overcome.”

    Source location

    Response from Cornwall Council
    Page 2 · response
    Published 20 May 2024

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    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

    The Integrated Care Board is expected to respond to concerns about the specific care provided.

    Verbatim wording from the response

    “I would expect the Cornwall and Isles of Scilly Integrated Care Board to respond in detail to the concerns you have raised about the specifics of the care that Sally’s son received.”

    Source location

    2024-0267 Response from Department of Health and Social Care
    Page 1 · response
    Published 20 May 2024

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    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

    Responsibility for local mental health service staffing and operations lies with the relevant trust.

    Verbatim wording from the response

    “Turning to your concerns around the impact of staffing shortages on service delivery, 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 recognise the need to increase workforce capacity in NHS mental health services overall. Nationally, positive progress has been made on growing the mental health workforce which, as at December 2023, had increased by around 20,800 compared to 2019/20. In addition, the NHS Long Term Workforce Plan sets out an ambition to grow the mental health, primary and community care workforce by 73% by 2036–37.”

    Source location

    2024-0267 Response from Department of Health and Social Care
    Page 2 · response
    Published 20 May 2024

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Carl Robert ELLSON · 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

    Carl Robert ELLSON was found deceased in a wooded area on 16 July 2022 after sustaining a fatal self-inflicted wound. He had been experiencing anxiety and insomnia and had presented with suicidal ideation shortly before his death. The concerns identified were that GP access to urgent mental health reviews was unclear and unsafe, that patients in crisis were expected to initiate contact with mental health practitioners, and that GPs were not fully aware of how to request an urgent psychiatric review.

    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

    Lack of a clear and safe system for GPs to contact mental health teams for urgent reviews

    Wider context from the report

    “1. On 13/07/22 Dr Ellson's GP needed to arrange an urgent mental health review as Dr Ellson had presented with suicidal ideation. The GP had significant difficulties trying to contact the Mental health team with messages giving incorrect numbers. My concern is that the system for GPs to contact mental health teams for urgent reviews is not clear nor safe. ”

    Source location

    Carl Robert ELLSON · 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

    Continue issuing all GP surgeries reminders of mental health referral contact numbers through Teamnet.

    Verbatim wording from the response

    “same numbers available to the public. Both email address and contact telephone number are prominent on the GP Referral Form. Whilst we believe GPs are aware of the correct numbers, going forward, we will continue to issue reminders to all GP surgeries of the contact numbers through Teamnet, which is the service used for all referral and service information. Between our two organisations we are refreshing all of the information on Teamnet, to ensure that the information is both relevant and prominent.”

    Source location

    Response from NHS Herefordshire and Worcestershire
    Page 2 · response
    Published 20 December 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

    Refresh Teamnet referral information to ensure it is relevant and prominent.

    Verbatim wording from the response

    “same numbers available to the public. Both email address and contact telephone number are prominent on the GP Referral Form. Whilst we believe GPs are aware of the correct numbers, going forward, we will continue to issue reminders to all GP surgeries of the contact numbers through Teamnet, which is the service used for all referral and service information. Between our two organisations we are refreshing all of the information on Teamnet, to ensure that the information is both relevant and prominent.”

    Source location

    Response from NHS Herefordshire and Worcestershire
    Page 2 · response
    Published 20 December 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

    Use the Medical Leadership Forum to reiterate the urgent referral process and address concerns.

    Verbatim wording from the response

    “As part of striving for continuous improvement our Medical Leadership Forum (which includes the ICB, Trust and General Practice) will also take this issue forward, to reiterate the process and ensure any concerns are addressed.”

    Source location

    Response from NHS Herefordshire and Worcestershire
    Page 2 · response
    Published 20 December 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

    Disseminate information to GPs about urgent psychiatric review routes through direct communications, Teamnet and primary care network meetings.

    Verbatim wording from the response

    “The Trust’s investigation did identify that the GP in this case would have liked to refer directly to a psychiatrist. We understood that they were reassured that the Trust follows the national model. Within our process the patient can see a consultant psychiatrist if they were taken on by the Home Treatment Team, as medical reviews are an integral part of how that team operates. The action from the investigation was therefore to ensure that local GPs were supported and provided with this information going forward. Again, this was achieved by sending all GPs direct communications with a reminder of this information on 31st December 2022. In addition, we have ensured that the relevant information is on Teamnet and also regularly discussed in the local primary care network meetings between GPs and their local mental health teams.”

    Source location

    Response from NHS Herefordshire and Worcestershire
    Page 3 · response
    Published 20 December 2022

    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

    The established urgent-access process, including Single Point of Access, Home Treatment, Crisis Team and out-of-hours arrangements, is considered sufficient.

    Verbatim wording from the response

    “The Trust’s current process for enabling urgent access to mental health services is longstanding and we thought well recognised. GPs can contact the Single Point of Access (SPA) who pass the referral on to the relevant/local Home Treatment Team (HTT) who then triage the referral and either allocate themselves or the Crisis Team dependent on risk and clinical presentation. If a call comes through out of hours, it goes straight to the Crisis team which is a 24/7 service.”

    Source location

    Response from NHS Herefordshire and Worcestershire
    Page 1 · response
    Published 20 December 2022

    Open published response

  3. East London

    AI-generated summary

    Lee Leslie Carpenter · 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 Leslie Carpenter took his own life on 1 October 2019 after being referred by his GP to mental health services for an urgent review. Concerns included the referral being triaged as non-urgent without a documented rationale or discussion with Mr Carpenter or the GP, a lack of robust risk assessment, care planning and medication review, and the absence of a response when the Home Treatment Team visited his home on the day of his death. The report also identified no system for clearly documenting important clinical triage decisions or identifying the staff member responsible.

    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 discuss downgraded GP referral urgency with the patient or GP

    Wider context from the report

    “The matter of concern during the course of the Inquest, was that a GP had made a referral to the mental health team requesting an urgent review of Mr Carpenter. This was sent on the 9th August 2019 to the Havering Access Assessment and Brief Intervention Team. The referral was received on the same date and appears to have been triaged for a non-urgent response. The decision determining the non-urgent response was not documented. There was no documented rationale for overriding the GP’s request for an urgent review. There was no discussion with the patient or the GP before the decision to downgrade the urgency. The member of staff who made the decision was not identified within the medical records. The first telephone assessment of Mr Carpenter did not take place until the 23rd August 2019. As at the date of the Inquest, there is no system in place within the Trust for important clinical decision relating to the triage of GP referrals to be clearly documented within patient records and for the member of staff making the decision, to be clearly identified and accountable. ”

    Source location

    Lee Leslie Carpenter · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. London Inner (West)

    AI-generated summary

    GILLIAN O’KEEFFE · 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

    Gillian O’Keeffe had a serious mental illness and died at home on 19 March 2017 after taking her own life while the balance of her mind was disturbed. The concerns included her discharge from community mental health services for non-engagement despite family and professional concerns, inadequate communication with her GP and family, and the absence of a clear process for following up urgent concerns or referrals.

    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

    Lack of a procedure for following up urgent GP concerns or referrals

    Wider context from the report

    “(4) Evidence was given at the inquest that there was no procedure or policy in place at the Trust to follow up GP concerns or referrals particularly where there was likely to be a degree of urgency. ”

    Source location

    GILLIAN O’KEEFFE · 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

    Formalise guidance for GPs on raising urgent concerns and referrals with lead CCG involvement.

    Verbatim wording from the response

    “The referral was never sent by the GP but this concern highlights the need for some clear guidance for GPs regarding concerns they may have. The Trust is in the process of formalising this with the lead CCG GP involvement. It will be shared with GP colleagues once it has been signed off.”

    Source location

    2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
    Page 4 · response
    Published 3 October 2017

    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

    Share the formalised GP concerns and referrals guidance with GP colleagues after sign-off.

    Verbatim wording from the response

    “The referral was never sent by the GP but this concern highlights the need for some clear guidance for GPs regarding concerns they may have. The Trust is in the process of formalising this with the lead CCG GP involvement. It will be shared with GP colleagues once it has been signed off.”

    Source location

    2017-0233-Response-by-South-West-London-and-St-Georges-Hospital-NHS-Trust
    Page 4 · response
    Published 3 October 2017

    Open published response

  5. Surrey

    AI-generated summary

    Vanessa Christine DADSWELL · 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

    Vanessa Dadswell died from injuries after placing herself in the path of an oncoming train at Whitley Railway Station on 2 April 2015. She had been urgently referred to Mental Health Services by her GP, requesting that she be seen within 24 hours, but she was not seen before her death. The principal concern was the lack of an intermediate referral option between four hours and within five days, and the absence of contact within the requested 24-hour period.

    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

    Lack of an intermediate urgent mental health referral timeframe

    Wider context from the report

    “During the course of the inquest the evidence revealed that any urgent referral by a GP would be categorised by West Sussex Community Mental Health as either as a ‘4 hour’ referral or as a ‘within 5 day’ referral. A ‘4 hour’ referral would involve the service user having to attend A&E urgently for an assessment within 4 hours. A ‘within 5 day referral’ was exactly as described, an appointment within 5 days. The issue arose where a referring GP did not consider it necessary nor appropriate for a 4 hour referral and yet believed a 24 hour visit was necessary as 5 days would be too long. The deceased was not seen within 24 hours and committed suicide 3 days after the referral with no direct contact having been made. Evidence given by the Service manager for the Trust agreed that an intermediate option for referral would not be unreasonable. Consideration should be given to an alternative, intermediate referral time between the current ‘4 hour’ and ‘within 5 day’ periods for referrals together with effective management thereof. ”

    Source location

    Vanessa Christine DADSWELL · 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

    Enable Triage Team Leaders to book priority appointments directly.

    Verbatim wording from the response

    “• Triage Team Leaders now have direct bookable Priority Appointment slots and do not need to pass priority referrals to the Assessment & Treatment Duty Worker for booking.”

    Source location

    Vanessa-DADSWELL-Response
    Page 1 · response
    Published 17 February 2016

    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

    Require daily review of out-of-hours referrals and arrange appointments within 24 hours when clinically indicated.

    Verbatim wording from the response

    “• Every morning the Triage Team Leader assesses all incoming referrals received out of hours and, if the referrer has requested the service user to be seen within 24 hours but did not consider a 4 hour response was clinically required, appointments within 24 hours are arranged.”

    Source location

    Vanessa-DADSWELL-Response
    Page 1 · response
    Published 17 February 2016

    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

    Fast-track referrals to the first available appointment based on risk assessment.

    Verbatim wording from the response

    “• Referrals can be fast track allocated by the Triage Team Leader so they do not wait up to 5 days for a slot; they are given the first available appointment, dependent on assessment of risk, often within 2–3 days.”

    Source location

    Vanessa-DADSWELL-Response
    Page 1 · response
    Published 17 February 2016

    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 Coastal West Sussex protocol documenting the improved referral system, with the inquest checklist and flowchart appended.

    Verbatim wording from the response

    “Penny Fenton, General Manager Coastal West Sussex Care Delivery Service (CDS), Nadia Anderson, Service Manager Western, Working Age Mental Health Services, Coastal West Sussex Care Delivery Service (CDS) and Liam Rudden, Service Manager for Adur, Arun & Worthing Assessment and Treatment Service are currently drafting a protocol encompassing the improved system throughout Coastal West Sussex CDS. The checklist and flowchart developed and exhibited at the inquest will be appended so there is a clear user friendly guide for staff. Dr Brian Solts, Divisional Clinical Director – Coastal West Sussex Care Delivery Service (CDS) has confirmed he will present the protocol, together with the learning from Mrs Dadswell’s inquest, to the Adult Management Board to maximize learning and embed the improvements introduced.”

    Source location

    Vanessa-DADSWELL-Response
    Page 2 · response
    Published 17 February 2016

    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

    Meet West Sussex mental health commissioners to jointly review the urgent care pathway in light of the improvements and current practice.

    Verbatim wording from the response

    “The Service Specification for the Urgent Care Pathway detailing the 4 hour and 5 day referral options was developed in partnership with our West Sussex Commissioners and is due for renewal. Dr Solts has requested a meeting to be arranged with the West Sussex Mental Health commissioners to review the pathway jointly with us, in light of the improvements we have made, and the greater flexibility we have introduced, so it reflects current practice.”

    Source location

    Vanessa-DADSWELL-Response
    Page 2 · response
    Published 17 February 2016

    Open published response

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