First reported 12 Sep 2013•Latest report 25 Jun 2026
Definition
What this concern includes
Includes failures by mental health or care services to identify deterioration or serious acute mental health risk and take an appropriate response, including assessment, escalation, communication, safeguarding action or urgent intervention when these controls are dedicated to the deteriorating mental-health response.
Not included
Excludes generic staffing, leadership, training, documentation or communication deficiencies that are not explicitly tied to recognising or responding to deteriorating mental health.
Excludes failures concerning physical deterioration or medical emergencies unless the report explicitly links them to deterioration of the service user’s mental health.
Excludes failures in a separate safeguarding, emergency alarm, welfare-check or treatment-refusal process where the report does not identify deteriorating mental health as the shared concern.
Reports
28
Distinct published reports
Individual concerns
31
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
57
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.
NHS England5
Central and North West London NHS Foundation Trust3
Department of Health and Social Care3
HM Prison and Probation Service3
Ministry of Justice3
Essex Partnership University NHS Foundation Trust2
Norfolk and Suffolk NHS Foundation Trust2
All Care In One Limited1
All Care In One Ltd1
Bolton Borough Council1
Cambridge Nursing Home Ltd1
Care Quality Commission1
Coldingley Prison1
Cumbria Constabulary1
Department of Community Mental Health, Woolwich Station Medical Centre1
NHS trust17
Ministerial department8
Executive non-departmental public body5
Executive agency3
Healthcare site3
English county council2
Integrated care board2
Police force2
Prison or young offender institution2
Private limited company2
Clinical commissioning group1
Domiciliary care provider1
English metropolitan district council1
Health and social care service regulator1
Health-system partnership1
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.
Devon, Plymouth and Torbay
Concerns raised1
Failure to initiate follow-up after presentation with deteriorating mental health
This report raised 4 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
Review records, clinical actions, and processes for supporting, referring, and liaising about high-risk patients with mental health teams.
Stated by The Foxhayes SurgeryStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
Milton Keynes
Concerns raised1
Delays or insufficiency in psychiatric assessment and proactive mental health review
This report raised 15 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
Improve waiting-list management by setting escalation thresholds, increasing remote clinics and reviewing priority weekly by clinical risk and waiting time.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Expand clinical capacity through advanced clinical practitioner roles for routine reviews and direct escalation of complex cases to consultant psychiatrists.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Manchester West
Concerns raised1
Failure to recognise mental health deterioration and consider appropriate escalation
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.8
Action
Deliver co-occurring-conditions training using the Dual Diagnosis Capability Framework, experts by experience and initial Wigan-focused workforce development, then share learning across the Trust.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2026.
Action
Roll out mandatory professional-curiosity training to Community Care Group clinical staff, with attendance and feedback monitored through the care-group training group.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2026.
Action
Develop and provide formulation training for clinical staff across the Community and Acute Care Groups.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2026.
Action
Deliver and prioritise STORM training across urgent-care and community teams, including high-rate boroughs, under the 2026 programme and agreed 2027 schedule.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2026.
Action
Review all individuals awaiting care-coordinator allocation to identify risk, need and required interventions.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 11 February 2026.
Action
Strengthen identification, clinical oversight and multi-agency coordination for people at risk of mental-health deterioration.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2026.
Action
Develop Referral and Assessment Hub infrastructure and strengthen neighbourhood team functions during the second and third quarters of 2026/27.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 February 2026.
Action
Embed revised pathways with enhanced outreach, improved crisis interfaces and stronger support for co-occurring conditions during the third and fourth quarters of 2026/27.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 February 2026.
Kent and Medway
Concerns raised1
Failure to coordinate real-time escalation across services
This report raised 4 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
Introduce visual prompts at every call station and workstation directing staff to arrange Rapid Response assessment within four hours when risk is concerning.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Action
Train staff in the appropriate pathway and method for requesting an emergency Police response under Right Care Right Person.
Stated by Kent and Medway Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2026.
City of London
Concerns raised1
Failure to review medication, consider admission, or escalate care for an acutely deteriorating patient
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.2
Action
Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Operate a 24/7 Emergency Department Low Intensity Area at King’s College Hospital with capacity for six patients.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Medication discontinuation was not clearly the main cause of relapse, and the presentation did not indicate medication review by liaison psychiatry.
Stated by South London and Maudsley NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Admission was not clearly beneficial for this condition, so community treatment was considered an appropriate alternative when the patient initially engaged.
Stated by South London and Maudsley NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Doctor referral was not initially indicated because the established pathway covered admission, medication changes and other clinical complexities, with senior psychiatric doctors available continuously.
Stated by South London and Maudsley NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Recovery House was unsuitable for homeless patients and therefore unavailable as an alternative to admission in this case.
Stated by South London and Maudsley NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised1
Failure to inform the ongoing ECT consultant of mental health deterioration
This report raised 12 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
Review information-sharing protocols for collaboration with professionals in other organisations.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Introduce structured handovers and shared care plans accessible to involved health, care-home and social-care professionals.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Essex
Concerns raised2
Failure to review records and identify the need for urgent mental health assessment
Failure to review medication during deteriorating mental health
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
Require full biopsychosocial mental health assessments, with documented rationale for omissions.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 June 2025.
Action
Conduct monthly evidence-based assessment quality audits and provide feedback on findings.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 June 2025.
Action
Continue reviewing urgent-care learning, deadlines and impact through monthly quality and safety meetings.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 June 2025.
South Yorkshire (Western)
Concerns raised1
Failure to use a sufficiently assertive approach to engage people with deteriorating mental health, including in complex cases
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.4
Action
Conduct an organisation-wide review of intensive and assertive community support provision through an established working group.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2025.
Action
Identify service users requiring intensive or assertive support and ensure they receive the appropriate level of care.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2025.
Action
Develop enhanced-team oversight of intensive and assertive care journeys, including clinical scrutiny of discharge planning, risk assessments and care plans.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 March 2025.
Action
Pilot a caseload-management tool requiring enhanced-team cases to be discussed with clinical leads or team managers and recording contacts, attempted contacts and meetings.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
South London
Concerns raised1
Failure to recognise high-risk mental health patients
This report raised 11 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
Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Birmingham and Solihull
Concerns raised2
Failure of staff to take appropriate action on serious acute mental health issues
Failure of staff to recognise serious acute mental health issues
This report raised 6 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.4
Action
Provide external group safeguarding training, including Birdie re-briefing, practical scenarios and competency checks.
Stated by All Care in OneStated completedThe respondent said that this action was complete when they made their response on 4 March 2025.
Action
Provide supervision that develops staff understanding, reflection, performance, policy compliance and responses to deteriorating mental health.
Stated by All Care in OneStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2025.
Action
Establish and implement a pin-chart process requiring escalation of concerns, written documentation and follow-through with appropriate support.
Stated by All Care in OneStated completedThe respondent said that this action was complete when they made their response on 4 March 2025.
Action
Revise internal safeguarding policies to clarify recognition, escalation and record-keeping for acute mental health issues.
Stated by All Care in OneStated completedThe respondent said that this action was complete when they made their response on 4 March 2025.
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Includes failures by mental health or care services to identify deterioration or serious acute mental health risk and take an appropriate response, including assessment, escalation, communication, safeguarding action or urgent intervention when these controls are dedicated to the deteriorating mental-health response.
