First reported 25 Aug 2022•Latest report 28 Oct 2025
Definition
What this concern includes
Includes failures or hazards in emergency-department environments used for people with acute, severe or crisis-related mental-health needs, including unsuitable physical conditions, prolonged holding while awaiting psychiatric placement, inadequate security or supervision, insufficient mental-health presence, and environmental arrangements that impede lawful, safe and clinically appropriate care.
Not included
Excludes general emergency-department crowding, noise or treatment-environment concerns where no mental-health patient or psychiatric-care safety condition is identified.
Excludes psychiatric bed shortages or delayed placement where the emergency-department environment is not itself identified as unsafe.
Excludes failures in mental-health assessment, treatment or detention law after care is provided in a suitable and adequately supervised environment.
Excludes generic hospital staffing, training or interagency-coordination deficiencies unless they directly make the emergency-department environment unsafe for people in mental health crisis.
Excludes unsuitable environments in community, inpatient psychiatric or non-emergency settings unless the assertion explicitly concerns emergency-department care.
Reports
8
Distinct published reports
Individual concerns
8
A report can raise multiple concerns
Date range
2022–2025
First to latest report issue date
Stated actions
24
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.
Department of Health and Social Care4
NHS England3
NHS Surrey and Sussex Integrated Care Board2
Bedfordshire Hospitals NHS Foundation Trust1
Epsom Hospital1
Health and Care Professions Council1
Health Services Safety Investigations Body1
NHS South West London Integrated Care Board1
Pennine Care NHS Foundation Trust1
South East Coast Ambulance Service NHS Foundation Trust1
Surrey and Borders Partnership NHS Foundation Trust1
West Hertfordshire Teaching Hospitals NHS Trust1
Executive non-departmental public body4
Ministerial department4
NHS trust4
Integrated care board3
Health and care professional regulator1
Healthcare site1
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.
West Sussex, Brighton and Hove
Concerns raised1
Failure of A&E environments to provide adequate security for people in mental health crisis
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.2
Action
Establish Mental Health Response Vehicles to assess and treat patients away from Emergency Departments.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.
Action
Establish Mental Health Emergency Departments co-located with Type 1 Emergency Departments.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 October 2025.
Surrey
Concerns raised1
Unsuitable emergency department environment for psychiatric patients
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.9
Action
Provide 24-hour Mental Health Support Worker coverage, including de-escalation, therapeutic engagement and support for patients with complex needs.
Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Provide dedicated psychiatric observation rooms and safer alternative observation areas when those rooms are occupied.
Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Introduce sensory kits and distraction equipment for mental health patients in the emergency department.
Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Support development of longer-term solutions addressing emergency-department environmental limitations.
Stated by Epsom and St Helier University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Action
Continue stakeholder work to consider support for people experiencing mental health crisis in A&E and improve community-based alternatives.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025.
Action
Increase the number of mental health emergency departments to around 85, providing short-term intensive crisis support as an alternative to A&E.
Stated by Department of Health and Social CareStatus unclearThe respondent did not make the status of this action clear when they made their response on 13 August 2025.
Action
Provide 24-hour NHS 111 mental health crisis access with trained professional assessment and routes to community support or alternative crisis services.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Deliver more mental health crisis care in communities through new care models, including 24/7 neighbourhood mental health centres integrating crisis and community services with short-stay beds.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Action
Launch an investigation into mental health crisis care for patients in emergency departments, covering resources, environments, and admission or discharge decisions.
Stated by Health Services Safety Investigations BodyStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
West Sussex, Brighton and Hove
Concerns raised1
Unsuitability of A&E as a holding environment for people awaiting mental health beds
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
Commission and extend 14 additional independent-sector acute adult mental health beds to support winter pressures and capacity.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 7 February 2025.
Action
Work with partners to improve timely discharge and support prompt admission for people awaiting mental health inpatient care.
Stated by NHS Surrey and Sussex Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2025.
Action
Measure response times for people presenting to urgent and emergency mental-health services to support faster access to appropriate care.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2025.
Action
Monitor patients waiting more than 72 hours in emergency departments for mental-health placements and escalate cases nationally for executive intervention.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 7 February 2025.
Action
Provide trusts and systems with action cards to reduce emergency-department waiting times, including actions for people with complex learning disabilities and autism.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 7 February 2025.
Action
Develop and finalise a South East standard operating procedure for managing mental-health presentations in A&E departments.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS Sussex has no role in setting up or managing NHS provider environments, including A&E mental health facilities.
Stated by NHS Surrey and Sussex Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Position
NHS provider organisations are responsible for ensuring existing environments follow national guidance and undertaking required risk assessments.
Stated by NHS Surrey and Sussex Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex, Brighton and Hove
Concerns raised1
Unsuitable A&E holding environment for autistic or neurodiverse people needing mental health beds
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The setup and environment of existing provider premises fall outside NHS Sussex’s role; providers must follow national guidance and conduct risk assessments.
Stated by NHS Surrey and Sussex Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
West Sussex, Brighton and Hove
Concerns raised1
Unsuitability of the A&E environment as a holding place for people awaiting mental health beds
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.3
Action
Commit £26 million in capital investment to open new mental health crisis centres.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2024.
Action
Establish Mental Health Response Vehicles to assess and treat people away from A&E.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 December 2024.
Action
Publish guidance for meeting autistic adults’ needs in mental health services, including sensory adjustments relevant to acute healthcare settings.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 December 2024.
North London
Concerns raised1
Lack of consistent guidance on observation levels for mental health patients awaiting assessment in the Emergency Department
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
Refine mental-health assessment tools and replace the previous proforma with an electronic assessment aligned with the current observation-level SOP.
Stated by West Hertfordshire Teaching Hospitals NHS Trust (WHTNHStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
Manchester South
Concerns raised1
Emergency Department environments unsuitable for delivering care to patients experiencing severe and enduring mental illness
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
Issues concerning Pennine Care NHS Foundation Trust should be addressed in the Trust’s response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Bedfordshire and Luton
Concerns raised1
Failure to prevent at-risk patients from leaving the emergency department while awaiting mental health assessment
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 the revised Transfer Policy, including requirements and supporting appendices for patients at risk of absconding.
Stated by Bedfordshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Review Emergency Department staff provision for Mental Capacity Act and restraint training with ELFT colleagues.
Stated by Bedfordshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Update Mental Capacity Act and restraint training for Emergency Department junior doctors.
Stated by Bedfordshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Pin
Get email alerts
Request correction
Includes failures or hazards in emergency-department environments used for people with acute, severe or crisis-related mental-health needs, including unsuitable physical conditions, prolonged holding while awaiting psychiatric placement, inadequate security or supervision, insufficient mental-health presence, and environmental arrangements that impede lawful, safe and clinically appropriate care.
