Recurring concern

Insufficient residential rehabilitation placements

First to latest report 29 Apr 2019 — 27 Jun 2024

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 5

What this concern includes

Includes shortages, prolonged waits and inadequate availability of residential rehabilitation placements or rehabilitation housing needed to provide rehabilitation, recovery support or structured care.

What is not included

Excludes ordinary residential care, care-home or nursing-home capacity concerns where rehabilitation is not the material purpose of the placement.
Excludes acute hospital, psychiatric inpatient and general community-care capacity concerns unless they directly concern access to a residential rehabilitation placement.
Excludes failures in assessing, referring, funding or coordinating a placement when insufficient residential rehabilitation capacity is not the shared unsafe condition.
Excludes failures in care after a suitable residential rehabilitation placement has been secured.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Central and North West London NHS Foundation Trust1

Department of Health and Social Care1

Ministry of Housing, Communities and Local Government1

NHS England1

NHS South East London Integrated Care Board1

Royal Borough of Kensington and Chelsea1

Reports and published responses 2 reports

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

27 Jun2024
Outer South London
Concerns raised1
1. Delays in accessing residential rehabilitation care
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Department of Health and Social Care
Ministry of Housing, Communities and Local Government
NHS England
Stated actions 2
1. Department of Health and Social Care
  Provide ring-fenced funding, targets, guidance and targeted support to improve inpatient detoxification and residential rehabilitation capacity and quality.
2. Department of Health and Social Care
  Publish further guidance for local areas on improving access to residential rehabilitation.
Respondent positions 5
1. Department of Health and Social Care
  Local alcohol and drug treatment services are expected to minimise placement delays, support people awaiting care, and regularly review their needs.
  Redirects responsibility
1. NHS England
  Responsibility for commissioning the Pier Road Project and drug and alcohol rehabilitation services sits with local government.
  Redirects responsibility
2. NHS England
  Government should address concerns about waiting times for residential rehabilitation placements.
  Redirects responsibility
3. Ministry of Housing, Communities and Local Government
  The report has no specific policy implications for this department, so it will not provide a response.
  Outside remit
4. Ministry of Housing, Communities and Local Government
  The Department for Health and Social Care is the lead department responsible for responding to the report.
  Redirects responsibility
AI-generated summary

Emily Rose Collishaw · 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

Emily Rose Collishaw, who was aged 35, was found dead in her flat on 6 September 2023 in non-suspicious circumstances. She had alcohol dependency and had been receiving mental health and substance misuse support, but was awaiting an inpatient rehabilitation placement. Concerns included delays and insufficient coordination and support, particularly the prolonged wait for residential rehabilitation and the associated risks to patients.

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
Delays in accessing residential rehabilitation care
Wider context from the report
“1. Emily’s mother reported that it took some time for the organizations working with her daughter to agree their roles and that the degree of support was insufficient to maintain her physical health or promote abstinence over such a long period of six months before she died. The family felt that the referral for residential care should have been made earlier, especially as her housing situation was a risk to her health. It was accepted that Emily did not engage consistently but did reduce intake on a number of occasions, only to relapse. 2. The inquest heard from professionals that the period of waiting for a residential rehabilitation placement was about three months, but could be as long as seven months. Evidence was heard from the manager of the Pier Project that the delay in accessing residential care had been progressively getting longer over the last 10 years, which posed risks such as sudden death to patients. ”
Source location
Emily Rose Collishaw · 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
Provide ring-fenced funding, targets, guidance and targeted support to improve inpatient detoxification and residential rehabilitation capacity and quality.

Verbatim wording from the response
“My department recognises the need to improve specialist drug and alcohol treatment services. Additional funding has been available since 2022/23 for local authorities to improve the quality and capacity of drug and alcohol treatment, including inpatient detoxification and residential rehabilitation services, and an additional £266.7 million was made available to them this year.”

Source location
Response from DHSC
Page 2 · response
Published 9 August 2024
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
Publish further guidance for local areas on improving access to residential rehabilitation.

Verbatim wording from the response
“I am aware of variability across the country in access to inpatient detoxification and/or residential rehabilitation. To address this (as part of the increased funding provided since 2022/2023), combinations of ring-fenced funding, targets, additional guidance and targeted support have been used to improve capacity and quality of inpatient detoxification and residential rehabilitation. We also plan to publish further guidance for local areas on improving access to residential rehabilitation later this year.”

Source location
Response from DHSC
Page 2 · response
Published 9 August 2024
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
Local alcohol and drug treatment services are expected to minimise placement delays, support people awaiting care, and regularly review their needs.

Verbatim wording from the response
“At a local level we would expect alcohol and drug treatment services to do what they can to minimise delays in accessing inpatient detoxification and residential rehabilitation, provide individual support to anyone waiting for it, and to regularly review their needs. The UK Clinical guidelines on alcohol treatment (to be published later this year) will include recommendations to promote this good practice.”

Source location
Response from DHSC
Page 2 · response
Published 9 August 2024
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
Responsibility for commissioning the Pier Road Project and drug and alcohol rehabilitation services sits with local government.

Verbatim wording from the response
“The PRP is commissioned locally by the Local Authority, London Borough of Bexley, as is usual for drug and alcohol rehabilitation services for which responsibility sits with local government, overseen by the Department of Health and Social Care (DHSC). I note that you have also addressed your Report to the DHSC, as well as the Department of Levelling Up, Housing and Communities, and it would be more appropriate for the government to comment on your concerns about wait times for residential rehabilitation placements.”

Source location
Response from NHS England
Page 1 · response
Published 9 August 2024
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
Government should address concerns about waiting times for residential rehabilitation placements.

Verbatim wording from the response
“The PRP is commissioned locally by the Local Authority, London Borough of Bexley, as is usual for drug and alcohol rehabilitation services for which responsibility sits with local government, overseen by the Department of Health and Social Care (DHSC). I note that you have also addressed your Report to the DHSC, as well as the Department of Levelling Up, Housing and Communities, and it would be more appropriate for the government to comment on your concerns about wait times for residential rehabilitation placements.”

Source location
Response from NHS England
Page 1 · response
Published 9 August 2024
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 report has no specific policy implications for this department, so it will not provide a response.

Verbatim wording from the response
“Many thanks for sharing a copy of this coroner’s report into the death of Ms Emily Rose Collishaw. After reviewing the report, MHCLG officials do not consider that there is a specific policy angle here for us to respond to, so I am writing to confirm that there will not be a response from this Department. I have informed the Department for Health and Social Care who will be the lead Department responding to this report.”

Source location
Response from Ministry of Housing, Communities & Local Governments
Page 1 · response
Published 9 August 2024
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 Department for Health and Social Care is the lead department responsible for responding to the report.

Verbatim wording from the response
“Many thanks for sharing a copy of this coroner’s report into the death of Ms Emily Rose Collishaw. After reviewing the report, MHCLG officials do not consider that there is a specific policy angle here for us to respond to, so I am writing to confirm that there will not be a response from this Department. I have informed the Department for Health and Social Care who will be the lead Department responding to this report.”

Source location
Response from Ministry of Housing, Communities & Local Governments
Page 1 · response
Published 9 August 2024
Open published response
29 Apr2019
Inner West London
Concerns raised1
1. Severe shortage of rehabilitation housing placements
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Central and North West London NHS Foundation Trust
Royal Borough of Kensington and Chelsea
Westminster City Council
Stated actions 3
1. Central and North West London NHS Foundation Trust
  Work with commissioners and the local authority to secure a wider choice of rehabilitation services for patients.
2. Royal Borough of Kensington and Chelsea and Westminster City Council
  Continue multidisciplinary work with health and social care partners to assess mental health support and accommodation needs through the monthly placement panel.
3. Royal Borough of Kensington and Chelsea and Westminster City Council
  Work with partner organisations to identify ongoing local rehabilitation needs and potential service developments for closer-to-home mental health rehabilitation placements.
Respondent positions 4
1. Central and North West London NHS Foundation Trust
  Housing provision for young people and rehabilitation placements is outside the Trust’s commissioning functions.
  Outside remit
1. Central and North West London NHS Foundation Trust
  The Royal Borough of Kensington and Chelsea is responsible for developing and commissioning the relevant housing provision and should respond to these concerns.
  Redirects responsibility
2. Royal Borough of Kensington and Chelsea and Westminster City Council
  Where suitable local services are unavailable, specialist housing and rehabilitation placements will be purchased outside the borough.
  Redirects responsibility
3. Royal Borough of Kensington and Chelsea and Westminster City Council
  The Council disputes that RBKC has a severe shortage of rehabilitation housing placements, citing 707 supported-accommodation units and ongoing capacity reviews.
  Disputes the concern
AI-generated summary

Georgia Sylvia Nelson · 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

Georgia Sylvia Nelson, who had treatment-resistant schizophrenia and severe persistent symptoms, stepped in front of a train at Gloucester Road Underground Station on 11 May 2018 and was killed instantly. The report raised concerns about the lack of suitable long-term and rehabilitation housing for young people with severe mental illness, inadequate discharge planning, and missed opportunities to improve treatment and consider rehabilitation before discharge.

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
Severe shortage of rehabilitation housing placements
Wider context from the report
“3. There is a severe shortage of rehabilitation housing placements in RBKC for patients who require them. ”
Source location
Georgia Sylvia Nelson · 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
Work with commissioners and the local authority to secure a wider choice of rehabilitation services for patients.

Verbatim wording from the response
“NICE are due to produce guidelines on Rehabilitation in adults with complex psychosis and related severe mental health conditions that we know are likely to propose a wider range of options to provide patients with rehabilitation not just in an inpatient setting. This is the national direction of travel, with patients being brought back from out of area placements to their local community and rehabilitation being provided in high supported accommodation or even in patients’ independent accommodation. We are working with our commissioner and local authority to ensure that services are commissioned for our patients that give the widest choice of rehabilitation options and keep up to date with modern ways of working. This will mean that as discharge planning starts at admission, we will follow the new NICE guidance on considering rehabilitation as appropriate.”

Source location
2019-0140-Response-by-CNWL-NHS-Trust
Page 3 · response
Published 14 June 2019
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
Continue multidisciplinary work with health and social care partners to assess mental health support and accommodation needs through the monthly placement panel.

Verbatim wording from the response
“Out of this number of young people with severe mental health issues, there may be a few who can be referred to supported housing services through the Single Homeless Team. The Housing Department agrees with and will continue to work with Adult Social Care, WL CCG and colleagues in the Central North West London NHS Foundation (CNWL) in any decision-making process in regard to the type of support and accommodation needed, ensuring decisions are made through an assessed process and agreed through a multi-disciplinary approach and monthly panel meeting. The Mental Health Placement Panel consists of Adult Social Care representatives and the Clinical Commissioning Group commissioners and care co-ordinator. Where services are not available within the borough, specialist placements outside of the borough can be purchased to best meet the individual’s needs.”

Source location
2019-0140-Response-by-RBKC_Redacted
Page 3 · response
Published 14 June 2019
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 partner organisations to identify ongoing local rehabilitation needs and potential service developments for closer-to-home mental health rehabilitation placements.

Verbatim wording from the response
“As part of the review, the two CCG’s, RBKC, Westminster City Council and CNWL are all working together to identify and explore any on-going needs and service developments within the local areas which may arise from this. We all recognise the need to move service users closer to their homes for mental health rehabilitation placements, to ensure better connections are maintained with family, friends, and local mental health services that can support service users on discharge. This is in line with best practice guidance, working collaboratively to align with GP practices, health and support services, and existing accommodation pathways across both boroughs, to create smoother step-down and step-up transitions for people and contributing to a better experience and outcomes for service users. The focus will be on improved quality and best value across the partnership.”

Source location
2019-0140-Response-by-RBKC_Redacted
Page 9 · response
Published 14 June 2019
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
Housing provision for young people and rehabilitation placements is outside the Trust’s commissioning functions.

Verbatim wording from the response
“Concerns 1, 2 and 3 are within the domain of the Royal Borough of Kensington & Chelsea, who develop and commission housing provision, including a range of supported accommodation. Whilst the Trust does not commission these services, as the major provider of NHS mental health care within the Borough, we do work closely with the local authority to inform and assist them in developing new services. We think however, they will want to respond to these 3 points separately as the responsible organisation, and we are aware they are currently in the process of responding to you in this respect.”

Source location
2019-0140-Response-by-CNWL-NHS-Trust
Page 2 · response
Published 14 June 2019
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 Royal Borough of Kensington and Chelsea is responsible for developing and commissioning the relevant housing provision and should respond to these concerns.

Verbatim wording from the response
“Concerns 1, 2 and 3 are within the domain of the Royal Borough of Kensington & Chelsea, who develop and commission housing provision, including a range of supported accommodation. Whilst the Trust does not commission these services, as the major provider of NHS mental health care within the Borough, we do work closely with the local authority to inform and assist them in developing new services. We think however, they will want to respond to these 3 points separately as the responsible organisation, and we are aware they are currently in the process of responding to you in this respect.”

Source location
2019-0140-Response-by-CNWL-NHS-Trust
Page 2 · response
Published 14 June 2019
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
Where suitable local services are unavailable, specialist housing and rehabilitation placements will be purchased outside the borough.

Verbatim wording from the response
“Out of this number of young people with severe mental health issues, there may be a few who can be referred to supported housing services through the Single Homeless Team. The Housing Department agrees with and will continue to work with Adult Social Care, WL CCG and colleagues in the Central North West London NHS Foundation (CNWL) in any decision-making process in regard to the type of support and accommodation needed, ensuring decisions are made through an assessed process and agreed through a multi-disciplinary approach and monthly panel meeting. The Mental Health Placement Panel consists of Adult Social Care representatives and the Clinical Commissioning Group commissioners and care co-ordinator. Where services are not available within the borough, specialist placements outside of the borough can be purchased to best meet the individual’s needs.”

Source location
2019-0140-Response-by-RBKC_Redacted
Page 3 · response
Published 14 June 2019
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 Council disputes that RBKC has a severe shortage of rehabilitation housing placements, citing 707 supported-accommodation units and ongoing capacity reviews.

Verbatim wording from the response
“In RBKC we currently have 707 units providing supported accommodation to people with a range of mental health needs, each with an individualised support plan which would include rehabilitation to enable people to develop greater independence. This would include, for example, developing daily living skills, managing medication, accessing specialist services, budgeting, managing own tenancies, developing peer relationships and accessing universal services including training and getting back into employment. This is supported by the key workers along with Community Mental Health Teams, through a process of reviews and assessments. Within our offer, we do not consider there is a severe shortage, but we recognise the need to continually assess demand and capacity, which we do through the various placement boards and project groups.”

Source location
2019-0140-Response-by-RBKC_Redacted
Page 7 · response
Published 14 June 2019
Open published response