Recurring concern

Unclear inter-service roles and responsibilities for mental health assessment and liaison

First to latest report 12 Sep 2013 — 30 Oct 2025

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
17

What this concern includes

Includes failures in explicitly inter-service arrangements for mental health assessment and liaison where roles, remits, referral responsibilities, requested actions or escalation ownership between acute, mental health and related providers are unclear, conflicting or not jointly understood; include the MHLT remit concern and conflicting responsibility for Mental Health Act assessment requests.

What is not included
  • Excludes generic inter-agency communication or accountability failures where no mental health assessment or liaison process is identified.
  • Excludes failures confined to the clinical quality of a mental health assessment or treatment after responsibilities and referral routes are clear.
  • Excludes standalone staff training, documentation or service-capacity deficiencies unless they directly cause unclear roles or responsibilities within the inter-service mental health assessment and liaison arrangement.
  • Excludes Mental Capacity Act or Mental Health Act process failures where the inter-service role and responsibility arrangement is not itself deficient.
  • Excludes unrelated referral, crisis-team, police-assistance or appointment processes unless the assertion specifically concerns the same inter-service mental health assessment and liaison responsibility boundary.

Reports and published responses 5 reports

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

  1. Nottinghamshire

    AI-generated summary

    Mr Gunaratnam Kannan · 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

    Mr Gunaratnam Kannan took an overdose of Metformin and Indapamide tablets on 18 March 2025 and initially refused hospital treatment after being assessed as having mental capacity. He was later found confused, with limited consciousness and lacking mental capacity, was taken to hospital, suffered a cardiac arrest and was pronounced deceased on 19 March 2025. The concerns identified were a lack of joint-agency policy and training on Mental Capacity Act and Mental Health Act assessments, including uncertainty about which service should request or undertake a Mental Health Act assessment.

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    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 joint-agency definition of roles and remits for Mental Capacity Act and Mental Health Act assessments

    Wider context from the report

    “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers. • Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments. I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who. In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action. ”

    Source location

    Mr Gunaratnam Kannan · Prevention of Future Deaths report
    Page 2 · concerns

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    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 training of service providers on the process for referrals for Mental Health Act assessments

    Wider context from the report

    “• Lack of joint agency working/policy work on the Mental Capacity Act Assessments and Mental Health Act Assessments setting out the roles and remit of service providers. • Lack of training of service providers on the Mental Capacity Act assessments and the process for referrals for Mental Health Act assessments. I heard evidence at the inquest from EMAS that it would be for the NHCT crisis team to attend for a MHA assessment if the patient was deemed to have capacity and that EMAS do not make referrals for mental health act assessments. I heard evidence from NHCT that it would be for either the family, GP or the attending medical practitioner , in this case EMAS, to request a MHA assessment. There is a clear lack of understanding between these service providers as to what actions should be taken and by who. In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action. ”

    Source location

    Mr Gunaratnam Kannan · Prevention of Future Deaths report
    Page 3 · concerns

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    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

    Participate in a multi-agency workstream to develop a joint mechanism or protocol clarifying roles and remits for capacity assessments.

    Verbatim wording from the response

    “In addition, prior to the commencement of the inquest, Nottinghamshire Healthcare NHS Foundation Trust contacted the Safeguarding Adults Board (SAB) to make them aware of the concerns that the coroner had made organisations aware of when gathering the evidence of the case. The request was for SAB to facilitate a workstream forum involving all key agencies within the Nottingham area, with the aim to come together and agree a joint working mechanism / protocol setting out the roles and remits of service providers in the context of assessments via both the Mental Capacity and Mental Health Acts. The first meeting took place on 3 December 2025, with the plan to meet again on 7 January 2026. The initial meeting provided opportunity to discuss the case of Mr. Kannan and the current practices being followed by each agency in attendance.”

    Source location

    Response from Nottinghamshire Healthcare
    Page 2 · response
    Published 5 November 2025

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    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 Trust’s local internal pathways and protocols at the next multi-agency workstream meeting.

    Verbatim wording from the response

    “waiting for the outcome of the national discussion. The plan from this first meeting was then for all agencies to share their local internal pathway and protocol in terms of response and remit and EMAS to provide an update on the national forum at the next meeting in January 2026.”

    Source location

    Response from Nottinghamshire Healthcare
    Page 3 · response
    Published 5 November 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and implement formal referral pathways with mental health trusts for mental health assessments.

    Verbatim wording from the response

    “Ambulance crews are not mental health specialists and therefore cannot determine whether a statutory MHA assessment is required. At present, EMAS does not have formalised referral pathways with local crisis teams; however, we are actively working with mental health trusts to develop and implement these pathways.”

    Source location

    Response from East Midlands Ambulance Service
    Page 2 · response
    Published 5 November 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Participate in quarterly system meetings to review clinical and operational responsibilities and identify service provision gaps.

    Verbatim wording from the response

    “Locally, EMAS participates in a quarterly Right Care Right Person Meeting led by Nottingham and Nottinghamshire Integrated Care Board, alongside system partners, to review clinical and operational responsibilities and identify gaps in service provision. Following the inquest, a wider multi-agency group has been convened to specifically consider how to strengthen decision-making and pathways between agencies when considering the mental health act and the mental capacity act.”

    Source location

    Response from East Midlands Ambulance Service
    Page 2 · response
    Published 5 November 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work through a multi-agency group to strengthen decision-making and inter-agency pathways for Mental Health Act and Mental Capacity Act matters.

    Verbatim wording from the response

    “Locally, EMAS participates in a quarterly Right Care Right Person Meeting led by Nottingham and Nottinghamshire Integrated Care Board, alongside system partners, to review clinical and operational responsibilities and identify gaps in service provision. Following the inquest, a wider multi-agency group has been convened to specifically consider how to strengthen decision-making and pathways between agencies when considering the mental health act and the mental capacity act.”

    Source location

    Response from East Midlands Ambulance Service
    Page 2 · response
    Published 5 November 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and disseminate two flow charts supporting capacity considerations and referral decisions, including display in team offices.

    Verbatim wording from the response

    “Two flow charts were also developed (Appendix A and B) to help support staff in what considerations need to be given regarding mental capacity upon receipt of a call such as that in the case of Mr. Kannan. This includes when liaising with EMAS to ensure that there is significant consideration on how a person’s mental health and consumption of substances may alter their thinking and capacity. These have been shared with all staff and are displayed in team offices for quick reference.”

    Source location

    Response from Nottinghamshire Healthcare
    Page 1 · response
    Published 5 November 2025

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide biennial Mental Health Awareness training covering statutory detention processes, roles and current pathways.

    Verbatim wording from the response

    “Supporting tools such as non-conveyance checklists and MCA prompts are embedded within our patient record system to guide staff in practice. Furthermore, all front-line crews undertake Mental Health Awareness training every two years, covering statutory detention processes, roles, and current pathways. This training is under review for January 2026, and we will seek input from Mental Health Trust partners to ensure alignment with formalised pathways for MHA assessments.”

    Source location

    Response from East Midlands Ambulance Service
    Page 2 · response
    Published 5 November 2025

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    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 Mental Health Awareness training and seek Mental Health Trust input to align it with formalised referral pathways.

    Verbatim wording from the response

    “Supporting tools such as non-conveyance checklists and MCA prompts are embedded within our patient record system to guide staff in practice. Furthermore, all front-line crews undertake Mental Health Awareness training every two years, covering statutory detention processes, roles, and current pathways. This training is under review for January 2026, and we will seek input from Mental Health Trust partners to ensure alignment with formalised pathways for MHA assessments.”

    Source location

    Response from East Midlands Ambulance Service
    Page 2 · response
    Published 5 November 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Ambulance crews cannot determine whether a statutory Mental Health Act assessment is required because they are not mental health specialists.

    Verbatim wording from the response

    “Ambulance crews are not mental health specialists and therefore cannot determine whether a statutory MHA assessment is required. At present, EMAS does not have formalised referral pathways with local crisis teams; however, we are actively working with mental health trusts to develop and implement these pathways.”

    Source location

    Response from East Midlands Ambulance Service
    Page 2 · response
    Published 5 November 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Mental Health Act assessment referrals are the responsibility of Approved Mental Health Practitioners within the Local Authority.

    Verbatim wording from the response

    “The process for referring for Mental Health Act assessments is held by the Approved Mental Health Practitioners (AMHP) who are part of the Local Authority. There is a clear process and pathway already in place (Appendix C).”

    Source location

    Response from Nottinghamshire Healthcare
    Page 1 · response
    Published 5 November 2025

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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

    An established process and pathway for requesting Mental Health Act assessments is already in place across Nottingham City and County.

    Verbatim wording from the response

    “The process for referring for Mental Health Act assessments is held by the Approved Mental Health Practitioners (AMHP) who are part of the Local Authority. There is a clear process and pathway already in place (Appendix C).”

    Source location

    Response from Nottinghamshire Healthcare
    Page 1 · response
    Published 5 November 2025

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Nottinghamshire Healthcare NHS Foundation Trust should reassert processes for acceptable practitioners to initiate urgent referrals.

    Verbatim wording from the response

    “Re-examining specific issues of Mr Kannan’s case is beyond the remit of the College, but it highlights the need for Nottinghamshire HCT to reassert their processes of acceptable medical practitioners instigating urgent referrals to enable best outcomes and prevent future deaths in similar circumstances.”

    Source location

    Response from Royal College of General Practitioners
    Page 2 · response
    Published 5 November 2025

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  2. Manchester North

    AI-generated summary

    Donna Marie Donnellan · 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

    Donna Marie Donnellan had a long-standing history of disordered eating, severe weight loss and peripheral neuropathy. She was found deceased at home on 10 October 2022, and the investigation recorded death from complications arising from malnutrition likely due to an undiagnosed atypical eating disorder. Concerns included unclear roles between acute clinicians and the Mental Health Liaison Team, and a lack of understanding about referral pathways to specialist eating disorder services.

    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 clarity about the role and remit of the Mental Health Liaison Team

    Wider context from the report

    “1) There was a lack of understanding between the Acute Trust clinicians and the Mental Health Trust as to the role of the Mental Health Liaison Team. Clarity is required as to whether the MHLT when asked to review a patient by the acute clinicians are reviewing so as to (i) make a diagnosis of an eating disorder or (ii) assess and assist in the consideration as to whether the Mental Health Act can be used to treat someone if they are refusing treatment. ”

    Source location

    Donna Marie Donnellan · Prevention of Future Deaths report
    Page 2 · concerns

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    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 and use a ratified policy defining clinical roles, referral pathways, mandatory specialist-team referrals, and Mental Health Liaison Team responsibilities.

    Verbatim wording from the response

    “I respectfully refer you to the policy Management of Medical Emergencies in Adult Patients with Eating Disorders which can be found in the inquest bundle at §A141-186 (also attached to this response for ease of reference). This policy is finalised and ratified and is now in use within the Trust and was shared again with PCFT on 19th of October 2023 for any suggested revision. Notwithstanding its effect being limited to the NCA it is imperative that both Trusts are sighted on and satisfied with its content, as the successful management of this patient cohort is dependent on a coherent, multi-disciplinary approach spanning both Trusts.”

    Source location

    Response from Northern Care Alliance NHS Foundation Trust
    Page 1 · response
    Published 8 December 2023

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    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 ratified policy with Pennine Care NHS Foundation Trust for cross-trust review and suggested revision.

    Verbatim wording from the response

    “I respectfully refer you to the policy Management of Medical Emergencies in Adult Patients with Eating Disorders which can be found in the inquest bundle at §A141-186 (also attached to this response for ease of reference). This policy is finalised and ratified and is now in use within the Trust and was shared again with PCFT on 19th of October 2023 for any suggested revision. Notwithstanding its effect being limited to the NCA it is imperative that both Trusts are sighted on and satisfied with its content, as the successful management of this patient cohort is dependent on a coherent, multi-disciplinary approach spanning both Trusts.”

    Source location

    Response from Northern Care Alliance NHS Foundation Trust
    Page 1 · response
    Published 8 December 2023

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    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 and clarify referral policies and procedures for eating-disorder assessments and Mental Health Act considerations.

    Verbatim wording from the response

    “Teams at Pennine Care NHS Foundation Trust have worked closely with colleagues at the Northern Care Alliance NHS Foundation Trust to review policies and procedures following the Inquest, to add clarity regarding referral. We have agreed to jointly review the policy owned by Northern Care Alliance NHS Foundation Trust, Management of Medical Emergencies in Adult Patients with Eating Disorders, which provides clear guidance for staff working within the Accident and Emergency”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 1 · response
    Published 8 December 2023

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    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

    Make the referral policy available to staff in both organisations, including Accident and Emergency Department staff.

    Verbatim wording from the response

    “As teams work in partnership to meet the needs of patients within the Accident and Emergency Department, the policy will be available to staff from both organisations. The learning from this inquest and the policy detail has been shared with the appropriate teams by managers to support understanding.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 8 December 2023

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    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 inquest learning and policy details with the appropriate teams through managers.

    Verbatim wording from the response

    “As teams work in partnership to meet the needs of patients within the Accident and Emergency Department, the policy will be available to staff from both organisations. The learning from this inquest and the policy detail has been shared with the appropriate teams by managers to support understanding.”

    Source location

    Response from Pennine Care NHS Foundation Trust
    Page 2 · response
    Published 8 December 2023

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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 existing policy sufficiently clarifies responsibilities and referral pathways for adult patients with eating disorders across the Trusts.

    Verbatim wording from the response

    “I respectfully refer you to the policy Management of Medical Emergencies in Adult Patients with Eating Disorders which can be found in the inquest bundle at §A141-186 (also attached to this response for ease of reference). This policy is finalised and ratified and is now in use within the Trust and was shared again with PCFT on 19th of October 2023 for any suggested revision. Notwithstanding its effect being limited to the NCA it is imperative that both Trusts are sighted on and satisfied with its content, as the successful management of this patient cohort is dependent on a coherent, multi-disciplinary approach spanning both Trusts.”

    Source location

    Response from Northern Care Alliance NHS Foundation Trust
    Page 1 · response
    Published 8 December 2023

    Open published response

  3. Birmingham and Solihull

    AI-generated summary

    Nigel Byron Abbott · 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

    On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.

    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

    Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments

    Wider context from the report

    “Summary of Concerns In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them. The five generic on-going matters of concern: (1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments. (2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds. (3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT. (4) Whilst section 4 is available to be used, it is not used. (5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed. ”

    Source location

    Nigel Byron Abbott · Prevention of Future Deaths report
    Page 9 · concerns

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    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 electronic action cards setting out staff processes and inter-agency interactions.

    Verbatim wording from the response

    “3.5 The group is currently overseeing five main work streams in response to the Coroner’s recommendations, which are:”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 2 · response
    Published 18 October 2019

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    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

    Obtain formal multi-agency approval for the revised police-assistance memorandum.

    Verbatim wording from the response

    “5.1 A new Memorandum of Understanding has been developed and agreed by all of the relevant agencies, WMP, BCC, BSMHFT and BWCH. This memorandum has been developed and will receive formal approval at the multi-agency working group on 22nd January 2020.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 2 · response
    Published 18 October 2019

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    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

    Present the revised memorandum to frontline staff and deliver engagement, support and scenario testing.

    Verbatim wording from the response

    “5.3 The new memorandum provides clarity for front line staff working in pressured situations, is clear on the roles and responsibilities of the agencies involved and seeks to remove the ambiguity relating to the incorrect perception that WMP require 24 hours’ notice when providing police support. This approach has been communicated to staff in advance of the final sign off of the full document.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 3 · response
    Published 18 October 2019

    Open published response

  4. Worcestershire

    AI-generated summary

    Sean Christopher Seabourne · 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

    Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.

    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 define and communicate mental health teams' roles and responsibilities for onward care

    Wider context from the report

    “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests. (2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient. (3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team. It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself. It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself. Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case. ”

    Source location

    Sean Christopher Seabourne · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Norfolk

    AI-generated summary

    Matthew Christopher Dunham · 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

    Matthew Christopher Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.

    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 shared understanding of team referral roles and interfaces

    Wider context from the report

    “b) There appears not to have been a clear shared understanding between professionals as to which team it was appropriate to refer Mr Dunham too. There was some lack of understanding revealed as to whether a referral to the assessment team or the crisis resolution and home treatment team was appropriate. This highlights the need for there to be a clear understanding about the roles of each team and the interface between them. ”

    Source location

    Matthew Christopher Dunham · 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

    Base a Crisis Resolution and Home Treatment team member within the Access and Assessment Team to support prompt joint working and care transitions.

    Verbatim wording from the response

    “To enhance the interface between the two clinical teams, Access and Assessment Team (AAT) and CRHT, a member of the CRHT is now based within the AAT. This enables joint working without any delay, supporting transition of care between the two teams. The Trust is monitoring its effectiveness in identifying people in need of this crisis support.”

    Source location

    Response
    Page 2 · response
    Published 26 January 2014

    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