First reported 30 Nov 2016•Latest report 13 May 2026
Definition
What this concern includes
Includes failures of the end-to-end 24-hour mental health crisis-support system, including its availability, response, support provision and admission gatekeeping, where the failure is specifically tied to supporting people in mental health crisis.
Not included
Excludes generic healthcare staffing, capacity or service-availability failures not specifically tied to mental health crisis support.
Excludes failures limited to a particular assessment, documentation, communication, follow-up or review step unless they demonstrate unreliability of the wider crisis-support system.
Excludes specialist treatment services or supervision arrangements unrelated to mental health crisis support.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England4
Department of Health and Social Care3
NHS Greater Manchester Integrated Care Board3
Greater Manchester Combined Authority2
North West Ambulance Service NHS Trust2
Aneurin Bevan University LHB1
Brighton and Hove City Council1
Central and North West London NHS Foundation Trust1
Coldingley Prison1
Greater Manchester Police1
Herefordshire and Worcestershire Health and Care NHS Trust1
HM Prison and Probation Service1
Humber Bridge Board1
Liverpool City Council1
Merseyside Police1
NHS trust7
Executive non-departmental public body4
Integrated care board4
Ministerial department4
Mayoral policing body2
Police force2
English metropolitan district council1
English unitary authority1
Executive agency1
Local health board1
Police and crime commissioner1
Prison or young offender institution1
Public transport authority1
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.
Cumbria
Concerns raised1
Lack of 7-day mental health support for prisoners in crisis
This report raised 2 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
Review and finalise the national NHS England health and justice service specifications, incorporating learning to support tailored prison healthcare provision.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 10 July 2026.
Action
Rectify communication of weekend and out-of-hours healthcare arrangements to the primary care provider.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Action
Review weekend on-site healthcare provision over six months against patient need and demand.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing out-of-hours community access and HMP Haverigg’s seven-day on-call service are considered sufficient despite no overnight healthcare provision.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Regional commissioners, rather than NHS England nationally, are responsible for delivering the national health and justice service specifications under contract management.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West London
Concerns raised1
Failure of mental health professionals to work collaboratively to find a safe crisis-care solution
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Implement a borough-based mental-health service structure to support integrated, less fragmented care.
Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Action
Bring Ealing Psychiatry Liaison and crisis teams under a single senior manager.
Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Action
Transform mental health services into community-based mental health centres bringing crisis services and short-stay beds together.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
West London NHS Trust is handling the specific local issues arising from Kallum’s death and responding separately to the report.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Unclear provision for mental health services to deal with emergency situations
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.6
Action
Continue collaborative work with health partners to maintain and refine coordinated mental health response arrangements.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2026.
Action
Operate an agreed process for GMP call handlers to transfer or signpost people with mental-health welfare concerns to NHS 111 option 2.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Provide 24/7 mental-health tactical advice to ambulance services through a dedicated team based in the NWAS Emergency Operations Centre.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Provide commissioned mental-health crisis spaces in every Greater Manchester borough with drop-in access.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Expand 24/7 crisis resolution and home-based treatment services across Greater Manchester to support people in crisis at home or their place of residence.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2026.
Action
Continue working with system partners, including emergency services, to improve urgent and emergency care across Greater Manchester.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The reported concern required urgent, not emergency, intervention and therefore did not meet the threshold for police attendance.
Stated by Greater Manchester PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Urgent mental health intervention is the responsibility of health-based resources and clinical partners, rather than policing.
Stated by Greater Manchester PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Mental health services provide crisis, not emergency, responses; the concern incorrectly treats them as responsible for 999 emergencies.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
999 services, rather than commissioned mental health services, are responsible for emergency responses requiring immediate intervention.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Commissioned mental health services cannot provide 999 emergency responses, contact nonresponsive individuals, or force entry to protect someone at risk.
Stated by NHS Greater Manchester Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West Sussex, Brighton and Hove
Concerns raised2
Failure to answer a sufficient proportion of 111 and Blue Light Line calls
Inadequate 24/7 crisis response and formal gatekeeping of inpatient admissions
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.10
Action
Invest in local urgent and emergency mental health infrastructure, including crisis cafes, crisis houses, places of safety, emergency departments and crisis lines.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.
Action
Review local system plans for suitable 111-service investment and provide feedback on required improvements.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2025.
Action
Monitor delivery of Sussex mental health-crisis improvement plans through joint ICB and provider oversight meetings.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2025.
Action
Introduce a mental health crisis option through NHS 111.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.
Action
Expand 24/7 liaison mental health teams to all general acute hospitals.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.
Action
Deploy mental health professionals in 999 emergency operation centres and clinical assessment services.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2025.
Action
Transform neighbourhood mental health services to shift crisis care from hospitals to communities.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 31 October 2025.
Action
Roll out dedicated 24/7 neighbourhood mental health centres through the pilot and subsequent implementation support programme.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2025.
Action
Open more specialist Mental Health Emergency Departments alongside general Emergency Departments.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2025.
Action
Provide 24/7 psychiatric liaison teams alongside Emergency Departments.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2025.
Surrey
Concerns raised1
Unavailability of clinical mental health provision outside weekday office hours
This report raised 10 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
Implement re-commissioned prison healthcare services, including seven-day mental health provision, on-site attendance and out-of-hours urgent referral protocols.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
East Riding and Hull
Concerns raised1
Delays in emergency and mental health support responses
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Gwent
Concerns raised1
Unavailability of 24-hour crisis support
This report raised 2 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.6
Action
Extend Community Mental Health Team operating hours into evenings and weekends through a six-month pilot funded with additional clinical staff.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Consider the completed pilot’s findings and recommendations for future crisis-service provision.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023.
Action
Extend the Shared Lives crisis-support project to include older people.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Make Tŷ Cynnаl crisis-sanctuary support available to older people known to the mental health service.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Explore alternative crisis-service models, review other Welsh Health Boards’ provision, and develop associated standards for ongoing audit.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023.
Action
Continue auditing older adults’ use of current crisis pathways to inform service development.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023.
Liverpool and the Wirral
Concerns raised1
Unavailability of commissioned mental-health crisis intervention resources
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Mental health response vehicles are health-led, with their scope and operating model agreed through a regional steering group involving ICBs and mental health trusts.
Stated by North West Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Yorkshire and York including North Yorkshire Western District
Concerns raised1
Gap in acute and crisis mental health support alongside commissioned autism care
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.1
Action
Invest £40 million to improve seven-day specialist multidisciplinary and crisis support capacity for autistic people and people with learning disabilities.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
TEWV is responsible for delivering core mental health care and making reasonable adjustments for patients with autism.
Stated by NHS Humber and North Yorkshire Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Brighton and Hove
Concerns raised1
Failure to provide routine out-of-hours review and support for patients awaiting urgent admission
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Finalise the Trust-wide CRHT operational policy, including referral pathways and defined responsibilities for services supporting patients awaiting admission.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2020.
Action
Run a daily Urgent Demand Oversight meeting to review admission demand, available resources and support packages for patients awaiting hospital care.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2020.
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Includes failures of the end-to-end 24-hour mental health crisis-support system, including its availability, response, support provision and admission gatekeeping, where the failure is specifically tied to supporting people in mental health crisis.
