Recurring concern

Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pending

First to latest report 2 Feb 2015 — 19 Jan 2026

Reports that mention this concern
18
Times this concern has been raised
20
Stated actions linked to this concern
48

What this concern includes

Includes interim support and safeguarding for people awaiting mental-health assessment, detention arrangements or inpatient placement.

What is not included
  • Routine support during non-urgent referral or self-referral
  • Treatment quality after inpatient admission
  • General emergency-department care without an acute mental-health waiting period

Reports and published responses 18 reports

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

  1. Bedfordshire and Luton

    AI-generated summary

    Yuksel Bedri ISMAIL · 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

    Yuksel Bedri ISMAIL, aged 23, absconded from hospital while awaiting a mental health assessment and was struck by an HGV on the M1 motorway on 28 November 2021, suffering fatal injuries. The concerns included hospital transfer arrangements for patients at risk of absconding and insufficient staff training and understanding regarding the Mental Capacity Act and preventing high-risk patients from leaving the emergency department.

    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 prevent at-risk patients from leaving the emergency department while awaiting mental health assessment

    Wider context from the report

    “2. Although ELFT's SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) had highlighted that "There is a need for staff involved in transferring patients, including security staff, to have training in the exercise of the Mental Capacity Act to ensure that patients who are assessed as lacking capacity with identified risks to self are unable to leave the emergency department" and recommended that "training be provided to acute Trust colleagues on the application of the Mental Capacity Act, its use to restrain/prevent somebody leaving the department if they are deemed to lack capacity and there are concerns regarding their risk should they leave, and where the person has capacity but remains a risk to themselves", there was no evidence before the Inquest of Bedford Hospitals NHS Trust's acknowledgment or consideration of this. Instead: - The Court heard from several Trust witnesses including a ED Sister, that they considered they had no powers to detain someone within the ED; - The statement provided to the Inquest by the ED Lead, ████████ (provided to the Court along with notice that he would NOT be available to attend the Inquest even though at the PIRH the Court had made it clear that the witness providing evidence of relevant Trust Policy would need to attend the Inquest) appeared confused about the powers available: Para 12 "Physical restraint is permitted in circumstances where the patient is confirmed to lack mental capacity and the restraint is necessary to preserve life or health and is proportionate to risk" Para 17 "Even if a single security officer had assisted with the transfer, they would be unable to physically restrain as the restraint policy specifies a minimum of two security officers are required for this and Mr Ismail was not subject to lawful DOLS at that point"; - PLS Staff stated that they have known of other patients leaving the ED whilst awaiting a MHA assessment ”

    Source location

    Yuksel Bedri ISMAIL · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Implement the revised Transfer Policy, including requirements and supporting appendices for patients at risk of absconding.

    Verbatim wording from the response

    “We note that at the SI decision panel, PEARL, whilst we did identify that immediate improvements were required to our Transfer Policy, these had not been fully actioned by the time of the inquest. For this we apologise and have included a copy of the revised policy. The policy has been updated in collaboration with colleagues at ELFT and now more fully addresses patient needs. We have added Section 4.7 around patient transfers for those identified at risk of absconding, and Appendices 6, 7 and 8 now support this addition to the policy.”

    Source location

    Response from Bedfordshire Hospital NHS Foundation Trust
    Page 1 · response
    Published 3 October 2022

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    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

    Review Emergency Department staff provision for Mental Capacity Act and restraint training with ELFT colleagues.

    Verbatim wording from the response

    “In response to concerns regarding application of the Mental Capacity Act and restraint training, the Emergency Department together with the Trust’s Safeguarding Team have worked with colleagues at ELFT to review the current provision for staff in the Emergency Department. This has led to amendments which include updates to MCA and restraint training for junior doctors in the Emergency Department and monthly shared learning forums with the PLS and the acute medicine team where particularly complex cases are also reviewed.”

    Source location

    Response from Bedfordshire Hospital NHS Foundation Trust
    Page 2 · response
    Published 3 October 2022

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    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

    Update Mental Capacity Act and restraint training for Emergency Department junior doctors.

    Verbatim wording from the response

    “In response to concerns regarding application of the Mental Capacity Act and restraint training, the Emergency Department together with the Trust’s Safeguarding Team have worked with colleagues at ELFT to review the current provision for staff in the Emergency Department. This has led to amendments which include updates to MCA and restraint training for junior doctors in the Emergency Department and monthly shared learning forums with the PLS and the acute medicine team where particularly complex cases are also reviewed.”

    Source location

    Response from Bedfordshire Hospital NHS Foundation Trust
    Page 2 · response
    Published 3 October 2022

    Open published response

  2. Surrey

    AI-generated summary

    Cynthia Elizabeth Finlay · 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

    Cynthia Elizabeth Finlay had depression, cognitive difficulties and impulsive personality traits. After an overdose and discharge from hospital, she was assessed by mental health professionals, but no adequate safeguarding plan was put in place while she was awaiting consideration of a Mental Health Act assessment. She was left alone and subsequently died by suicide; expert evidence identified that no protocol governed safeguarding people in this situation who might be alone and at risk in the community.

    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 a protocol governing the safeguarding of people awaiting Mental Health Act assessments who may be alone and at risk in the community

    Wider context from the report

    “(1) Expert evidence was received from a Consultant Psychiatrist who indicated that there is no protocol in place which governs what steps should be taken to safeguard people who are awaiting Mental Health Act assessments and may be alone and at risk in the community whilst the assessment is set up. ”

    Source location

    Cynthia Elizabeth Finlay · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. South Yorkshire (Western)

    AI-generated summary

    Joshua Adey Rennard · 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

    Joshua Adey Rennard died by hanging at his parents’ home on 29 September 2021. The principal concern was an eight-day delay in actioning a professional view that he should be assessed for detention under section 2 of the Mental Health Act, with concern that similar delays could place people at risk of harm or death.

    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 protect people with mental illness while awaiting section assessment

    Wider context from the report

    “5.6 My particular concern is the delay between a professional view being reached that Joshua required assessment for S2 detention on 18th August 2022 and the actioning of that decision on 26th August 2021, 8 days later. The evidence was that Joshua was at risk during this period although I did not find that the delay specifically contributed to Joshua’s death on 29th September 2021. I am specifically concerned that others might be placed at risk if similar delays arise in the future. 5.7 Further evidence was given that this delay was due to the way that the required Approved Mental Health Professional (AMHP) input was allocated or available. The evidence was that delays of this nature were not unusual and that people with mental illness are at risk during these gaps and delays. I considered that such delays in promptly progressing recommendations for assessments for Section could place people at risk of harm and death. ”

    Source location

    Joshua Adey Rennard · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Brighton and Hove

    AI-generated summary

    Elena WELLS · 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

    Elena Wells, who had a history of mental health issues, died after placing a ligature around her neck while alone at home awaiting an urgent mental health admission. The report identified unclear responsibility and communication between the Local Authority and Mental Health Trust, and insufficient out-of-hours support and supervision while she waited for a bed.

    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 routine out-of-hours review and support for patients awaiting urgent admission

    Wider context from the report

    “2. In this case a clinical decision was made to leave Miss Wells at home until a bed was found with Miss Wells, who was already ill enough to need urgent admission, having to inform the services if she declined further. No provision was made for Miss Wells to be reviewed out of hours, overnight and into the early morning by, for example, the Crisis Team, and no advice offered on the existence of a place of safety at the local Mental Health Hospital. Evidence showed that professionals can contact the Crisis Team in these circumstances but that is not done as a routine and patients appear to be left to make important decisions for themselves in circumstances where their declining mental health may prohibit them from doing so. It is requested that the Trust consider ways of providing extra support and supervision to those patients who are waiting for an urgent admission, particularly those who may be left alone at home for any period until a bed is found. ”

    Source location

    Elena WELLS · Prevention of Future Deaths report
    Page 3 · 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

    Finalise the Trust-wide CRHT operational policy, including referral pathways and defined responsibilities for services supporting patients awaiting admission.

    Verbatim wording from the response

    “In response, the Trust is in the process of developing a new Crisis Resolution Home Treatment Team (CRHT) Operational Policy. An interim policy was presented to the Operational Management Board in December 2020 and it was agreed the CRHT teams would work to this whilst the policy is further developed by the newly appointed Trust wide Urgent Care Pathway Lead.”

    Source location

    2020-0248-Responses-from-Sussex-Partnership-Foundation-NHS-Trust-and-Brighton-Hove-City-Council-Redacted..pdf
    Page 2 · response
    Published 29 December 2020

    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

    Run a daily Urgent Demand Oversight meeting to review admission demand, available resources and support packages for patients awaiting hospital care.

    Verbatim wording from the response

    “Locally, the Care Delivery Services [CDS] in Brighton has established an Urgent Demand Oversight meeting that enables the CDS Leads to have daily oversight of our patients requiring admission to hospital. This meeting is informed by the various Operational meetings that take place daily in our Community, Urgent and Acute Care Services and is described in the enclosed Terms of Reference (appendix 1).”

    Source location

    2020-0248-Responses-from-Sussex-Partnership-Foundation-NHS-Trust-and-Brighton-Hove-City-Council-Redacted..pdf
    Page 2 · response
    Published 29 December 2020

    Open published response

  5. Birmingham and Solihull

    AI-generated summary

    Nigel Byron Abbott · 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

    On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.

    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

    Inadequacy of the Home Treatment Standard Operational Procedure for initially assessed and detainable patients awaiting a bed in the community

    Wider context from the report

    “Summary of Concerns In summary, the evidence raised five generic on-going matters of concern. The consequence is that acutely unwell people who need to be detained, because of the risk they pose to themselves and others, will remain unnecessarily free in public when in fact the agencies have the mechanism to detain them. The five generic on-going matters of concern: (1) The agencies involved in this area are not working together effectively and there is a misunderstanding around the Joint Memorandum of Understanding for Mental Health Professional Requesting Police Assistance with Mental Health Act Assessments. (2) There continues to be a chronic shortage of resources within the mental health services in Birmingham and Solihull. In particular, mental health professionals are operating caseloads well in excess of recommended levels and there is a chronic shortage of psychiatric beds. (3) Birmingham and Solihull CCG have not provided section 140 beds for BSMHFT. (4) Whilst section 4 is available to be used, it is not used. (5) The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed. ”

    Source location

    Nigel Byron Abbott · Prevention of Future Deaths report
    Page 10 · concerns

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    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

    Revise, approve and cascade the Home Treatment Team operational procedure to align safeguards with the Bed Management Policy.

    Verbatim wording from the response

    “15 The Home Treatment Standard Operational Procedure is inadequate to safeguard patients in the community who have been initially assessed and deemed detainable but are waiting in the community for a bed. This procedure is inconsistent with the corresponding safeguards for fully assessed and detained patients waiting in the community for a bed.”

    Source location

    2019-0284-Response-by-Birmingham-and-Solihull-CCG
    Page 7 · response
    Published 18 October 2019

    Open published response

  6. Inner South London

    AI-generated summary

    Dr Debatra Sircar · 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

    Dr Debatra Sircar had longstanding alcohol dependency and depression, and died on 20 February 2016 after a fall associated with alcohol intoxication, causing subdural and intracerebral haemorrhage. He had been assessed as unsuitable for home treatment, but a Mental Health Act assessment was scheduled 11 days later, and he died before it took place. Concerns included the delay in securing hospital care and the absence of a clear interim care plan and responsibility for psychiatric monitoring.

    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 an interim care plan for patients pending Mental Health Act assessment

    Wider context from the report

    “2. In the intervening 11 day period there was an absence of an interim care plan, identified in the SUI investigation. Although there were plans for increased contacts in future interim care for those pending MHA assessment, it was unclear who would take the lead and how a patient would be psychiatrically monitored in that period. ”

    Source location

    Dr Debatra Sircar · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 assign clinical leadership and psychiatric monitoring during interim care pending Mental Health Act assessment

    Wider context from the report

    “2. In the intervening 11 day period there was an absence of an interim care plan, identified in the SUI investigation. Although there were plans for increased contacts in future interim care for those pending MHA assessment, it was unclear who would take the lead and how a patient would be psychiatrically monitored in that period. ”

    Source location

    Dr Debatra Sircar · Prevention of Future Deaths report
    Page 2 · 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

    Hold thrice-weekly zoning meetings for high-risk individuals and minute agreed risk-mitigation actions.

    Verbatim wording from the response

    “• Zoning meetings to review those individuals considered high risk (i.e. those in the red zone) take place three times per week and agreed actions to mitigate risks are minuted. In addition, regular weekly interface meetings between community and home treatment teams now take place to ensure that the clinical pathway between services is working properly.”

    Source location

    2016-0352.Response-by-Oxlea-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    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

    Specify the Home Treatment Team’s expected risk-management role in referrals made while clients await Mental Health Act assessment.

    Verbatim wording from the response

    “Following our review, we have instigated the following change in practice:”

    Source location

    2016-0352.Response-by-Oxlea-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    Open published response

  7. Manchester City

    AI-generated summary

    Nicholas Patrick SULLIVAN · 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

    Nicholas Patrick SULLIVAN, who had a chronic mental illness and was experiencing suicidal ideation and auditory hallucinations, attended an emergency department but was not triaged or referred for a timely mental health assessment. He left after waiting, later reiterated that he was suicidal, ran into a road and was struck by a car, dying from his injuries on 30 November 2014. The principal concerns included failures to record mental health risks at reception, trigger urgent triage and safeguarding, activate escalation procedures, and ensure appropriate coordination and staffing.

    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

    Absence of a clear system for triggering urgent triage and safeguarding steps

    Wider context from the report

    “5.2 There was no clear system to trigger urgent triage and safeguarding steps prior to that. 5.3 There was no clear system following triage and mental health assessment referral, to safeguard the patient pending that assessment. ”

    Source location

    Nicholas Patrick SULLIVAN · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  8. Manchester City

    AI-generated summary

    Kimberley Lauren Lindfield · 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

    Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.

    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 a written protocol defining increased observations and required recording

    Wider context from the report

    “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done. I am concerned that at present such does not exist. ”

    Source location

    Kimberley Lauren Lindfield · Prevention of Future Deaths report
    Page 7 · 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

    Review and bring into effect the revised Mental Health Act Code of Practice, including guidance on enhanced patient observation.

    Verbatim wording from the response

    “Further guidelines for patient observation are contained in the Mental Health Act 1983 Code of Practice. This has recently been reviewed by the Department of Health and the revised edition came into effect on 1st April 2015. Within this code is a section which advises on enhanced observation for patients in hospital wards and services.”

    Source location

    2015-0036-Response-by-Department-of-Health
    Page 2 · response
    Published 2 February 2015

    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

    Develop a joint observation procedure and recording charts defining observation requirements, recording arrangements, and staff responsibility.

    Verbatim wording from the response

    “2. Whenever an increased level of observation is initiated, pending a mental health assessment, because of the concern about patients’ mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations involve and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done.”

    Source location

    2015-0036-Greater-Manchester-West-NHS-Trust
    Page 2 · response
    Published 2 February 2015

    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

    Provide UHSM with advice on developing its self-harm policy and guidance and protocols for observing patients at risk.

    Verbatim wording from the response

    “In respect of the other concerns raised in your report, MMHSCT has agreed to provide UHSM with advice in respect of their development of a self-harm policy and also with their development of guidance and protocols on observation of patients at risk. MMHSCT has suggested that they may wish to build on our existing observation policy.”

    Source location

    2015-0036-Response-by-Manchester-Mental-Health-NHS
    Page 2 · response
    Published 2 February 2015

    Open published response

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