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.
Surrey
Concerns raised1
Lack of custody staff training to recognise red flags of declining mental health
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.3
Action
Pilot mandatory online Introduction to Mental Health training for Care and Separation Unit staff, including all new staff applying to work there.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
Action
Provide Introduction to Mental Health Awareness training to all new prison officers through initial prison officer training.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
Action
Roll out mental health training for Custodial Managers and CSU staff, requiring completion before new CSU staff take up post.
Stated by The Treasury SolicitorStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
Surrey
Concerns raised1
Failure to appropriately assess declining mental health information and provide timely mental health referrals
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.4
Action
Require senior oversight of Single Point of Access triage and recording of referrer collateral information.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 September 2024.
Action
Use revised SBAR documentation to include carer and family views in decision-making.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 September 2024.
Action
Test new Single Point of Access procedures and apply quality-control review to assess consistent implementation and identify service improvements.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 September 2024.
Action
Deliver training across i-access services on recognising psychosis and making timely mental-health referrals.
Stated by Surrey and Borders Partnership NHS Foundation TrustStatus at responseThe respondent said that this action was partly complete when they made their response on 18 September 2024.
East London
Concerns raised1
Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state
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.2
Action
Deliver targeted provider training on safeguarding, escalation processes and risk identification, including notifying the Local Authority and making safeguarding referrals for identified self-harm or other health risks.
Stated by The Local AuthorityStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
Action
Inform care staff that local mental health teams accept referrals from patients, carers and other medical professionals.
Stated by The Evergreen Surgery, WansteadStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A mental-health referral required the consent of a patient assessed as having capacity, and depended on his willingness to consent.
Stated by The Evergreen Surgery, WansteadUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Lack of proactive care consideration during obvious mental health crisis
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
Share learning about proactive care during mental health crisis with the team.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 March 2024.
Action
Update policies to incorporate learning about proactive care during mental health crisis.
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 14 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responding to the Coroner’s specific concerns falls outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Trust is responsible for responding to the Coroner’s specific concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of awareness of menopause as a factor in mental health deterioration
This report raised 7 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
Provide funding to Mind in Greater Manchester to raise awareness of menopause and its effects on mental health.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 12 February 2024.
West Sussex, Brighton and Hove
Concerns raised1
Failure of Mental Health Liaison teams to detain or hold absconding patients in acute hospitals
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
Raise the case with the Department for Health and Social Care for consideration of the Mental Health Act issues identified.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
Action
Contact other integrated care boards to explore approaches to employing Mental Health Liaison Teams within acute hospitals.
Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
Action
Review provider workforce and practices to seek a local resolution to Mental Health Liaison Team employment issues.
Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Administering or delegating Mental Health Act holding powers within trusts or systems is outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
NHS Sussex Integrated Care Board is undertaking local pathway and safety improvements concerning detention powers in acute emergency departments.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Commissioners do not usually have a role in determining the employment model for particular services.
Stated by NHS Surrey and Sussex Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Position
No local solution is currently available because the employment issue is recognised as a national problem.
Stated by NHS Surrey and Sussex Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Gwent
Concerns raised1
Lack of awareness among reception staff of when patients require urgent clinical assessment for mental health concerns
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
Display a high-risk mental-health alert when records of patients with mental-health medication or history are opened.
Stated by Taff’s Well Medical Centre & Castle View SurgeryStated completedThe respondent said that this action was complete when they made their response on 17 September 2021.
Action
Offer patients contacting the practice about mental-health concerns the next available appointment and urgent same-day GP triage when requested.
Stated by Taff’s Well Medical Centre & Castle View SurgeryStated completedThe respondent said that this action was complete when they made their response on 17 September 2021.
Action
Provide e-consult depression risk assessment, continuously monitor submissions, and arrange immediate clinician callbacks for high-risk results.
Stated by Taff’s Well Medical Centre & Castle View SurgeryStated completedThe respondent said that this action was complete when they made their response on 17 September 2021.
Manchester West
Concerns raised1
Delay in seeking mental health practitioner advice for progressive agitation
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North East Kent
Concerns raised1
Absence of an urgent assessment and review pathway for deteriorating mental health
This report raised 8 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
Stated by Ministry of DefenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Sussex
Concerns raised1
Failure of weekly professional team meetings to review mental health deterioration and medication non-compliance
This report raised 8 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
Whether to discuss a patient at weekly MDT meetings is left to clinical judgment because experienced staff may review care without MDT discussion.
Stated by Sussex Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
