Recurring concern

Inadequate 24-hour mental health crisis support

First to latest report 30 Nov 2016 — 13 May 2026

Reports that mention this concern
14
Times this concern has been raised
15
Stated actions linked to this concern
40

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.

What is 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.
  • Excludes failures concerning routine mental healthcare outside crisis situations.

Reports and published responses 14 reports

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

  1. Manchester North

    AI-generated summary

    Mr Gregory Rekowski · 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 Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.

    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

    Unavailability of an out-of-hours mental-health community response service for face-to-face assessment

    Wider context from the report

    “The Court heard evidence there is no Mental Health Community Response team available to deal with mental health issues out of hours. The only out of hours service is in A&E which would necessitate someone attending there. Evidence was given as to the substantial increase in such issues being reported to GMP. The Court heard how there is now a mental health professional within the GMP control room to assist with the calls received. However the main issues are in attending to conduct face to face assessments. The police are the service who have a power to enter property, unlike other services. Therefore whilst they may not be best placed in respect of the assessment they are often called. Given the issue in respect of resources laid throughout this Inquest the Court would question the lack of this Mental Health provision. ”

    Source location

    Mr Gregory Rekowski · Prevention of Future Deaths report
    Page 2 · 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

    CRT cannot respond to all mental-health incidents because demand exceeds its commissioned capacity and requires triage.

    Verbatim wording from the response

    “However, it must be recognised that the most significant limitation on the service is the availability of CRT resources. The volume of incidents where a relevant person has mental health needs exceeds CRT capacity and this burden requires the VSU to act as a filter focusing CRT staff time to providing the commissioned service.”

    Source location

    2018-0411-Response-by-Greater-Manchester-Police
    Page 4 · response
    Published 28 December 2018

    Open published response

  2. Milton Keynes

    AI-generated summary

    Caroline Antoinette Scott · 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

    Caroline Antoinette Scott, who had depression and thoughts of suicide, was found hanging at home on 30 May 2017 and died in hospital on 2 June 2017. The inquest identified a failure to carry out a mental health assessment after recognising that she was in crisis, resulting in a lost opportunity to refer her for treatment. Concerns were also raised about the adequacy of out-of-hours emergency mental health services and whether emergency referral policy was understood by all medical services in Milton Keynes.

    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

    Inadequate out-of-hours emergency service provision for mental health emergencies

    Wider context from the report

    “(1) That the provision of out of hours emergency service for mental health emergencies is inadequate ”

    Source location

    Caroline Antoinette Scott · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Andrew Reid · 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

    Andrew Reid was found suspended from a ligature at Longford Park on 17 October 2017. The inquest concluded that his death was suicide and recorded the medical cause of death as hanging. Concerns related to differences in mental-health service provision and referral routes for residents of Manchester and Trafford, including the lack of out-of-hours emergency GP referrals in Trafford and the requirement for patients to attend A&E.

    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 provide consistent levels of emergency mental health support and access routes across Greater Manchester

    Wider context from the report

    “1. The inquest heard that when Mr Reid went to see his GP she was very concerned about the risk he posed to himself and wanted him to be seen urgently by the Home Based Treatment Team (HBTT). The initial call was to the Manchester team -because the GP practice was within the City Of Manchester-who accept referrals from GPs. The Manchester HBTT are commissioned to provide a 24/7 Urgent Assessment Team that GPs can refer into. However, as Mr Reid was a Trafford resident the referral was not accepted and the GP called the Trafford HBTT. Under the terms of their commissioned service they cannot accept referrals from GPs and contact is via the RAID team in A and E. In this case that meant Mr Reid was told he would have to go to A and E. The inquest was told that the differences in level of provision for those with mental health are based on the decisions made by each commissioning authority. As a result residents of GM with mental health issues have a different level of support and route to access services. 2. In Trafford the outcome of the commissioning is that there are no emergency GP referrals dealt with OOH. They can only be dealt with Monday to Friday by the CMHT. GPs outside these times dealing with emergency mental health issues for Trafford residents have to ask patients to make their way to A and E for assessment. If they are concerned that a patient may not make it to A and E then they have to ask the Police to check with A and E -as happened in the case of Mr Reid ”

    Source location

    Andrew Reid · 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

    Maintain reciprocal commissioning arrangements so patients can access mental health services across Manchester and Trafford borders.

    Verbatim wording from the response

    “The deceased was a registered patient with a Manchester GP at Chorlton Health Centre and he lived in Stretford in the borough of Trafford. This is important as NHS services are commissioned on the basis of GP registration (so Manchester in this case). Importantly, commissioners across both Manchester and Trafford CCGs have put in place reciprocal arrangements to cover mental health patients needing support but who are registered in separate areas to where they reside. In this case, therefore the GP should have been able to refer to either the Manchester service or the Trafford service.”

    Source location

    Andrew-REID-Response2
    Page 2 · response
    Published 4 April 2018

    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

    Align Manchester and Trafford mental health service specifications and agree clear cross-border arrangements with other Greater Manchester commissioners and trusts.

    Verbatim wording from the response

    “An arrangement does exist between all GM mental health Trusts, which operates to ensure the most appropriate service for a patient resident or registered on or near the border of another service. This incident has highlighted the need to revisit this arrangement to reduce unnecessary variation in service commissioning and ensure that all providers are clear on service arrangements. Service provision must be based on a flexible, common-sense”

    Source location

    Andrew-REID-Response2
    Page 5 · response
    Published 4 April 2018

    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 disputed referrals promptly to service managers for timely resolution and use the Cross Border Matrix to clarify registration and residency responsibilities.

    Verbatim wording from the response

    “In Greater Manchester, required adherence with Responsible Commissioner principles has been communicated across all the GM MH Commissioners and Trusts. This included summary Cross Border Matrix tables to resolve any issues involving the service users registered and residency status shared with all specialist mental health out-of-hours and inpatient services.”

    Source location

    Andrew-REID-Response2
    Page 8 · response
    Published 4 April 2018

    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

    Maintain reciprocal additional funding for cross-boundary specialist mental health services, including crisis out-of-hours support.

    Verbatim wording from the response

    “Manchester GPs might be resident in Trafford. On recognition of this, there was also a need to invest additional funding to ensure timely access to local specialist mental health services in Trafford (and vice versa). This was put in place with Manchester commissioners providing specific additional funding for mental health services in Trafford (including crisis out-of-hours support) so that any such patients were supported rapidly with the minimum possibility of confusion related to Responsible Commissioner considerations. The same reciprocal model was enacted by Trafford commissioners providing specific additional funding for mental health services in Manchester (including crisis out-of-hours support).”

    Source location

    Andrew-REID-Response
    Page 3 · response
    Published 4 April 2018

    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

    Communicate Responsible Commissioner requirements and share Cross Border Matrix tables with specialist mental health out-of-hours and inpatient services.

    Verbatim wording from the response

    “In Greater Manchester, required adherence with Responsible Commissioner principles has been communicated across all the GM MH Commissioners and Trusts. This included summary Cross Border Matrix tables to resolve any issues involving the service users registered and residency status shared with all specialist mental health out-of-hours and inpatient services.”

    Source location

    Andrew-REID-Response
    Page 3 · response
    Published 4 April 2018

    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 disputed referrals involving Manchester teams promptly to the Service Manager for timely resolution.

    Verbatim wording from the response

    “Trafford CCG and MHCC have been in contact with senior GMMH managers. It has been agreed that any referrals that are being disputed by each other or another team in Manchester are promptly escalated to the Service Manager, so that the issue can be resolved in a timely way. In their response, GMMH also stated that “[The service managers] reminded the teams of their responsibilities in that our priority is ensuring that the service user receives the care they need and to utilise and promote the use of the Cross Border Matrix to resolve any issues involving the service users registered and residency status.” The Trafford and Manchester commissioners have also agreed to work together with GMMH to see what else can be done to ensure the current differences in commissioning priorities between localities does not result in any further incidents.”

    Source location

    Andrew-REID-Response
    Page 4 · response
    Published 4 April 2018

    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

    Work with GMMH to identify further measures preventing commissioning differences from causing future incidents.

    Verbatim wording from the response

    “Trafford CCG and MHCC have been in contact with senior GMMH managers. It has been agreed that any referrals that are being disputed by each other or another team in Manchester are promptly escalated to the Service Manager, so that the issue can be resolved in a timely way. In their response, GMMH also stated that “[The service managers] reminded the teams of their responsibilities in that our priority is ensuring that the service user receives the care they need and to utilise and promote the use of the Cross Border Matrix to resolve any issues involving the service users registered and residency status.” The Trafford and Manchester commissioners have also agreed to work together with GMMH to see what else can be done to ensure the current differences in commissioning priorities between localities does not result in any further incidents.”

    Source location

    Andrew-REID-Response
    Page 4 · response
    Published 4 April 2018

    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

    Coordinate communications and related work across Greater Manchester commissioners and providers to prevent recurrence of confusion or support breakdowns.

    Verbatim wording from the response

    “The Greater Manchester Health & Social Care Partnership will also now work with mental health commissioners and providers across Greater Manchester to ensure the required additional communications and work is undertaken to remove the risk of such similar confusion or breakdown in support reoccurring.”

    Source location

    Andrew-REID-Response
    Page 4 · response
    Published 4 April 2018

    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 support breakdown was not caused by inappropriate differential commissioning models between Trafford CCG and Manchester commissioners.

    Verbatim wording from the response

    “Therefore, it seems the breakdown in understanding and support to this patient does not appear to be due to inappropriate differential models of commissioning of specialist mental health services between Trafford CCG and MHCC commissioners – but further action is clearly needed, as colleagues from MHCC have set out.”

    Source location

    Andrew-REID-Response
    Page 4 · response
    Published 4 April 2018

    Open published response

  4. Worcestershire

    AI-generated summary

    Emma Louise TIMBRELL · 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

    Emma Louise TIMBRELL, who had a significant mental health history, died by hanging at her home; the inquest concluded that her death was suicide. A concern was that she might not have been able to afford the out-of-hours telephone call provided for use if her suicidal ideation increased.

    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 affordable access to out-of-hours telephone support for increased suicidal ideation

    Wider context from the report

    “(1) the deceased was given an out of hours telephone number for use should her suicidal ideation increase. However she was known to have limited finances and there was a concern that she would not have been able to afford to make the telephone call if it had become necessary. ”

    Source location

    Emma Louise TIMBRELL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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