Recurring concern
Unreliable coordination of mental health crisis responses
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Request correctionFirst reported 7 Apr 2014•Latest report 24 Mar 2026
What this concern includes
Includes failures of the mental health crisis-response process involving coordination, role clarity, shared situational awareness, operational direction, staff readiness or timely recognition and response when these deficiencies directly affect coordinated crisis care.
Not included
- Excludes generic inter-agency, multidisciplinary or organisational coordination failures not specifically tied to a mental health crisis response.
- Excludes failures limited to routine mental health care, referral access, discharge, follow-up or ongoing care coordination outside a crisis response.
- Excludes generic staff training, staffing or communication deficiencies unless they directly impair coordination or operational readiness during a mental health crisis.
- Excludes failures concerning the availability or capacity of crisis services where no coordination or operational-response deficiency is identified.
- Reports
- 22
- Individual concerns
- 24
- Date range
- 2014–2026
- Stated actions
- 37
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Absence of national guidance for frontline emergency crews dealing with time-critical mental health situations
Responses linked to these concernsEach 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
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Position
NHS England is responsible for addressing concerns about national guidance for frontline emergency crews and will respond directly.
Stated by Department of Health and Social Care
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Concerns raised1
Failure of mental health professionals to work collaboratively to find a safe crisis-care solution
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 concernsEach 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
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Action
Implement a borough-based mental-health service structure to support integrated, less fragmented care.
Stated by West London NHS Trust -
Action
Bring Ealing Psychiatry Liaison and crisis teams under a single senior manager.
Stated by West London NHS Trust -
Action
Transform mental health services into community-based mental health centres bringing crisis services and short-stay beds together.
Stated by Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
West London NHS Trust is handling the specific local issues arising from Kallum’s death and responding separately to the report.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to explain anticipated police assistance
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 concernsEach 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
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Action
Present the case to the Trust Urgent Care Board to address learning from the incident.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust -
Action
Share incident learning across Trust clinical networks and the Organisational Learning Group to reinforce clear communication about contacting police.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Police advice was correct because violence and aggression required an emergency response with police powers, rather than Crisis Team intervention alone.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust
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Concerns raised1
Failure to notify the mental health team when a person has contacted the café71 service
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 concernsEach 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
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Action
Remind crisis line staff to include contact information in referrals and complete warm call transfers where possible.
Stated by Cheshire and Wirral Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Existing procedures require Café 71 to contact relevant mental-health teams, attend professionals’ meetings and notify the Trust after three failed contact attempts.
Stated by Cheshire and Wirral Partnership NHS Foundation Trust
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Position
Cafe 71 disputes that EJD contacted it, that it was a crisis line, or that referral information indicated immediate risk.
Stated by Spider Project Café71 -
Position
The NHS Crisis Line, which received the call, was responsible for notifying the mental health team.
Stated by Spider Project Café71
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Concerns raised1
Lack of contact details for neighbouring psychiatric liaison and crisis mental health teams
Responses linked to these concernsEach 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
Existing NHS Service Finder and website directories provide professionals with current neighbouring mental health service contact details and referral information.
Stated by NHS England
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Concerns raised1
Lack of structured, clinically informed training for staff identifying and interacting with people in mental health crisis
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to establish the changed risk and immediacy of serious or fatal harm when a patient escapes from a secure mental health ward
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 concernsEach 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
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Action
Create and disseminate an SBARD aide-mémoire guiding staff escalation to police for patients absent from authorised leave or absconded, including Mental Health Act status and risk information.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Audit missing-person calls with Essex Police to assess the aide-mémoire’s effectiveness and establish and share further learning.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Share national guidance on restricted patients who abscond with Essex Police and relevant external agencies.
Stated by Essex Police
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Concerns raised1
Lack of shared understanding of neighbourhood team patient-contact response times
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 concernsEach 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
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Action
Require Serious Incident reviewers to consider integrated working practices between different services during quality assurance.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure of ambulance, police and health services to coordinate and share mental-health crisis intervention resources
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 concernsEach 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
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Action
Review and assess NWAS interoperability models and relevant best practice when establishing and evaluating the mental-health triage service.
Stated by Merseyside Police
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
A shared mental health response vehicle is not appropriate because ambulance and police services face different demands, calls, triage and dispatch processes.
Stated by North West Ambulance Service NHS Trust
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Position
Mental health response vehicles are health-led, with their scope and operating model agreed through a regional steering group involving ICBs and mental health trusts.
Stated by North West Ambulance Service NHS Trust -
Position
Existing separate police and NWAS cars are considered more effective than joint operability for Merseyside communities.
Stated by Merseyside Police
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Concerns raised1
Failure to assign responsibility for risk management and crisis referral
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 concernsEach 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
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Action
Review daily-meeting documentation and audit clinical records to verify recording of identified risk, actions and responsible staff.
Stated by Sussex Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Ongoing audits of red-zone risk recording and crisis referral arrangements were considered sufficient, so no additional action was required.
Stated by Sussex Partnership NHS Foundation Trust
Data last updated 7 September 2026