Recurring concern

Failure to complete timely direct mental health assessments after referral

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First reported 24 Nov 2014•Latest report 25 Mar 2024

Definition

What this concern includes

Includes failure or material delay in arranging, contacting for, undertaking or completing a referred full, specialist or psychiatric assessment, including rejection or closure without required direct assessment.

Not included

Deficient assessment content after the referred assessment was completed unless non-completion is also identified.
Post-discharge or post-acceptance follow-up where no referred assessment remains incomplete.
General referral or service-access delay where completion of the referred mental health assessment is not the unsafe condition.

Reports: 12
Individual concerns: 13
Date range: 2014–2024
Stated actions: 21

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3

Norfolk and Suffolk NHS Foundation Trust2

North London NHS Foundation Trust2

Birmingham and Solihull Mental Health NHS Foundation Trust1

Black Country Healthcare NHS Foundation Trust1

Brighton and Hove City Council1

East London NHS Foundation Trust1

Hellesdon Hospital1

NHS Birmingham and Solihull Integrated Care Board1

NHS England1

Norfolk County Council1

North East London NHS Foundation Trust1

Practice Plus Group Health And Rehabilitation Services Limited1

Sussex Partnership NHS Foundation Trust1

West Midlands Police1

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.

5 Dec2014
Brighton and Hove
Concerns raised1
1. Delays in appropriately addressing referrals within the 28-day period
This report raised 5 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 4
1. Action
  Recruit an additional triage administrator.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
2. Action
  Review administration triage processes to reduce triage waiting times.
  Stated by Sussex Partnership NHS Foundation TrustStated planned
3. Action
  Strengthen clinical triage meetings through Consultant Psychiatrist, lead nurse, administrator and additional specialist participation.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
1. Action
  Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
AI-generated summary

Paul Leslie HYDE · 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

Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.

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 appropriately addressing referrals within the 28-day period
Wider context from the report
“(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety. (2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. (3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. ”
Source location
Paul Leslie HYDE · 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
Recruit an additional triage administrator.

Verbatim wording from the response
“████████ Service Director for Brighton & Hove has confirmed that he is in discussions with the CCG and there is in place a joint Performance Improvement Plan in relation to the 4 Week Wait for routine referrals into the Assessment & Treatment Service. Actions include, a review of the administration triage processes to address triage waiting times. This recognised the need for an additional administrator in Triage and I am pleased to say recruitment to this post has been completed. A further action was a review of the triage function/process to include increased involvement from Consultant Psychiatrists and additional members of ATS. All clinical triage meetings have a Consultant Psychiatrist, lead nurse, and administrator present. Following Mr Hyde’s inquest, ████████ Associate Specialist has been invited to attend the triage meetings on a regular basis.”

Source location
2014-0527-Response-by-Sussex-Partnership-NHS
Page 1 · response
Published 5 December 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
Review administration triage processes to reduce triage waiting times.

Verbatim wording from the response
“████████ Service Director for Brighton & Hove has confirmed that he is in discussions with the CCG and there is in place a joint Performance Improvement Plan in relation to the 4 Week Wait for routine referrals into the Assessment & Treatment Service. Actions include, a review of the administration triage processes to address triage waiting times. This recognised the need for an additional administrator in Triage and I am pleased to say recruitment to this post has been completed. A further action was a review of the triage function/process to include increased involvement from Consultant Psychiatrists and additional members of ATS. All clinical triage meetings have a Consultant Psychiatrist, lead nurse, and administrator present. Following Mr Hyde’s inquest, ████████ Associate Specialist has been invited to attend the triage meetings on a regular basis.”

Source location
2014-0527-Response-by-Sussex-Partnership-NHS
Page 1 · response
Published 5 December 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
Strengthen clinical triage meetings through Consultant Psychiatrist, lead nurse, administrator and additional specialist participation.

Verbatim wording from the response
“████████ Service Director for Brighton & Hove has confirmed that he is in discussions with the CCG and there is in place a joint Performance Improvement Plan in relation to the 4 Week Wait for routine referrals into the Assessment & Treatment Service. Actions include, a review of the administration triage processes to address triage waiting times. This recognised the need for an additional administrator in Triage and I am pleased to say recruitment to this post has been completed. A further action was a review of the triage function/process to include increased involvement from Consultant Psychiatrists and additional members of ATS. All clinical triage meetings have a Consultant Psychiatrist, lead nurse, and administrator present. Following Mr Hyde’s inquest, ████████ Associate Specialist has been invited to attend the triage meetings on a regular basis.”

Source location
2014-0527-Response-by-Sussex-Partnership-NHS
Page 1 · response
Published 5 December 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
Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.

Verbatim wording from the response
“The use of the Breach Tool has been extended and the system is now more robust. Medical Personal Assistants now complete this for all referrals, regardless of the triage decision. Team leads have oversight of the tool and it is a ‘live’ record of all pending contacts, whether by telephone or face to face with service users. All actions / outcomes from the clinical triage meetings are now recorded on the Breach Tool and these are closely monitored. The Breach Tool guidance has been reviewed and staff have received clear instruction on how to use the tool.”

Source location
2014-0527-Response-by-Sussex-Partnership-NHS
Page 1 · response
Published 5 December 2014
Open published response
24 Nov2014
Inner North London
Concerns raised1
1. Delays in arranging urgent Mental Health Act assessments
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 3
1. Action
  Record in the electronic patient record how risks from delays in Mental Health Act assessments will be mitigated.
  Stated by North London NHS Foundation TrustStated planned
2. Action
  Escalate delays caused by unavailable external agencies to senior management and add recurrent delays to the Trust risk register.
  Stated by North London NHS Foundation TrustStated planned
3. Action
  Alert commissioners to London Ambulance Service delays and poor GP attendance at Mental Health Act assessments.
  Stated by North London NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  A specific agreed timeframe for mental health act assessments was not possible because coordinating multiple agencies with competing priorities can be difficult.
  Stated by North London NHS Foundation TrustUnable to act
AI-generated summary

Sandra Bodrožič’ · 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

Sandra Bodrožič’ died after running to the attic, saying goodbye and jumping from a window, landing three storeys below. She had previously been detained under the Mental Health Act and treated in hospital and the community. The substantive concerns included delays in finding a hospital bed, arranging a Mental Health Act assessment, and the absence of clear urgency or timeframe protocols for such assessments.

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 arranging urgent Mental Health Act assessments
Wider context from the report
“3. The approved mental health professional (AMHP), a social worker, who visited Ms Bodrožič’ on Wednesday, 25 June 2014, decided that she needed a Mental Health Act assessment and immediately made the appropriate referral. However, once the referral was made, it took until the following week for this to be arranged, and Ms Bodrožič’ had killed herself in the meantime, on Sunday, 29 June. Healthcare professionals explained in court that Mental Health Act assessments are, by their very nature, urgent, yet there seemed to be a general acceptance by the team that they will usually take several days to take place, in this case from a Wednesday until the following Tuesday. The provision for assessment is open ended, with no apparent sense of urgency, and there is no protocol for the timeframe within which this should take place, nor is a time agreed as appropriate with patient or family. Ms Bodrožič’s family were not told that, realistically, they could only obtain an immediate assessment by attending a hospital emergency unit. ”
Source location
Sandra Bodrožič’ · 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
Record in the electronic patient record how risks from delays in Mental Health Act assessments will be mitigated.

Verbatim wording from the response
“3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

Source location
2014-0560-Camden-Islington-NHS-Trust
Page 3 · response
Published 24 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
Escalate delays caused by unavailable external agencies to senior management and add recurrent delays to the Trust risk register.

Verbatim wording from the response
“3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

Source location
2014-0560-Camden-Islington-NHS-Trust
Page 3 · response
Published 24 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
Alert commissioners to London Ambulance Service delays and poor GP attendance at Mental Health Act assessments.

Verbatim wording from the response
“d) An alert to delays by the London Ambulance Service to attend MHA assessments have been made to the Joint Commissioner in Camden, and also of the poor attendance of GP’s to MHA assessments with the Joint Commissioners in the London Borough of Islington.”

Source location
2014-0560-Camden-Islington-NHS-Trust
Page 3 · response
Published 24 November 2014
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
A specific agreed timeframe for mental health act assessments was not possible because coordinating multiple agencies with competing priorities can be difficult.

Verbatim wording from the response
“3. Although the approved Mental Health Professional (AMHP), decided Ms Bodrozic needed a mental health act assessment, it was not possible, because of the very nature of MHA assessments, to complete these within a specific and agreed timeframe. As part of the process, the AMHP service is required to co-ordinate other agencies such as the police, the ambulance service and Section 12 approved doctors to assist in the process. Arranging the availability of all these services can be prove difficult especially when there are conflicting pressures and priorities. In the future, in order to mitigate against any delays in obtaining a MHA assessment the Trust has put in place the following provisions:”

Source location
2014-0560-Camden-Islington-NHS-Trust
Page 3 · response
Published 24 November 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in appropriately addressing referrals within the 28-day period

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

Concerns raised1

Delays in arranging urgent Mental Health Act assessments

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 4

Actions described in response 3

Respondent positions 1