First reported 12 Sep 2013•Latest report 30 Oct 2025
Definition
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.
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
5
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
17
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.
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Department of Health and Social Care1
East Midlands Ambulance Service NHS Trust1
Herefordshire and Worcestershire Health and Care NHS Trust1
NHS Birmingham and Solihull Integrated Care Board1
NHS England1
Norfolk and Suffolk NHS Foundation Trust1
Northern Care Alliance NHS Foundation Trust1
Nottinghamshire Healthcare NHS Foundation Trust1
Pennine Care NHS Foundation Trust1
Royal College of General Practitioners1
West Midlands Police1
NHS trust5
English metropolitan district council1
Executive non-departmental public body1
Health professional body1
Integrated care board1
Ministerial department1
Police force1
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.
Nottinghamshire
Concerns raised2
Lack of joint-agency definition of roles and remits for Mental Capacity Act and Mental Health Act assessments
Lack of training of service providers on the process for referrals for Mental Health Act assessments
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.8
Action
Participate in a multi-agency workstream to develop a joint mechanism or protocol clarifying roles and remits for capacity assessments.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2025.
Action
Share the Trust’s local internal pathways and protocols at the next multi-agency workstream meeting.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 November 2025.
Action
Develop and implement formal referral pathways with mental health trusts for mental health assessments.
Stated by East Midlands Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2025.
Action
Participate in quarterly system meetings to review clinical and operational responsibilities and identify service provision gaps.
Stated by East Midlands Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2025.
Action
Work through a multi-agency group to strengthen decision-making and inter-agency pathways for Mental Health Act and Mental Capacity Act matters.
Stated by East Midlands Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2025.
Action
Develop and disseminate two flow charts supporting capacity considerations and referral decisions, including display in team offices.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Provide biennial Mental Health Awareness training covering statutory detention processes, roles and current pathways.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Review Mental Health Awareness training and seek Mental Health Trust input to align it with formalised referral pathways.
Stated by East Midlands Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 5 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Ambulance crews cannot determine whether a statutory Mental Health Act assessment is required because they are not mental health specialists.
Stated by East Midlands Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Mental Health Act assessment referrals are the responsibility of Approved Mental Health Practitioners within the Local Authority.
Stated by Nottinghamshire Healthcare NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
An established process and pathway for requesting Mental Health Act assessments is already in place across Nottingham City and County.
Stated by Nottinghamshire Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Nottinghamshire Healthcare NHS Foundation Trust should reassert processes for acceptable practitioners to initiate urgent referrals.
Stated by Royal College of General PractitionersRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester North
Concerns raised1
Lack of clarity about the role and remit of the Mental Health Liaison Team
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.5
Action
Implement and use a ratified policy defining clinical roles, referral pathways, mandatory specialist-team referrals, and Mental Health Liaison Team responsibilities.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Action
Share the ratified policy with Pennine Care NHS Foundation Trust for cross-trust review and suggested revision.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Action
Review and clarify referral policies and procedures for eating-disorder assessments and Mental Health Act considerations.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023.
Action
Make the referral policy available to staff in both organisations, including Accident and Emergency Department staff.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Action
Share inquest learning and policy details with the appropriate teams through managers.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing policy sufficiently clarifies responsibilities and referral pathways for adult patients with eating disorders across the Trusts.
Stated by Northern Care Alliance NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised1
Misunderstanding of the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments
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.3
Action
Develop electronic action cards setting out staff processes and inter-agency interactions.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
Action
Obtain formal multi-agency approval for the revised police-assistance memorandum.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Present the revised memorandum to frontline staff and deliver engagement, support and scenario testing.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Worcestershire
Concerns raised1
Failure to define and communicate mental health teams' roles and responsibilities for onward care
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised1
Lack of shared understanding of team referral roles and interfaces
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Base a Crisis Resolution and Home Treatment team member within the Access and Assessment Team to support prompt joint working and care transitions.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 January 2014.
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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.
