Recurring concern

Unreliable coordination of mental health crisis responses

First to latest report 7 Apr 2014 — 24 Mar 2026

Reports that mention this concern
22
Times this concern has been raised
24
Stated actions linked to this concern
37

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.

What is 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 and published responses 22 reports

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

  1. Inner North London

    AI-generated summary

    Andrew Elliot FROST · 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

    Andrew Elliot Frost, aged 34, took his own life after jumping in front of an underground train on 25 September 2014. The report identified concerns about a lack of shared understanding between the crisis team and general practitioner, incomplete recording of information, and an inadequate pager messaging service.

    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 shared understanding between crisis teams and general practitioners about crisis team capabilities and limitations

    Wider context from the report

    “1. There was no shared understanding between the crisis team and the GP about what the crisis team could and could not do. The GP thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day. The GP regarded the crisis team as an emergency service, which the team leader told me in court is not the case. It seems that this GP, his partners, and the other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis team about their service, including its limitations. ”

    Source location

    Andrew Elliot FROST · 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

    Lack of shared understanding between referrers and crisis teams about crisis team capabilities and limitations

    Wider context from the report

    “During the second encounter on 24 September 2014, whilst police and paramedics were at Mr Frost’s home, you and he spoke on the telephone. You were worried about Mr Frost and made an immediate referral to the Islington Crisis Team at Highgate Mental Health Centre. You were told that the team did not have sufficient resources to go out to see Mr Frost that afternoon, but that someone would ring him. However, there was no shared understanding between you and the crisis team about what the crisis team could and could not do. You thought that the crisis team’s telephone call would include a conversation sufficiently detailed to allow the crisis team to decide whether to conduct a mental health act assessment that afternoon, whereas the crisis team simply intended to arrange an appointment for the following day. You regarded the crisis team as an emergency service, which the team leader told me in court is not the case. It seems that you, your partners, and other general practitioners who refer patients to crisis teams, would benefit from a very specific piece of training and education from the crisis teams about their service, including its limitations. I did not hear evidence that led me to conclude that different action by healthcare professionals on 24 September would have changed the outcome for Mr Frost, but it might for someone else. ”

    Source location

    Andrew Elliot FROST · 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

    Meet with Crisis Team managers to discuss service provision.

    Verbatim wording from the response

    “Following your requirement for our service to meet with the Crisis Team, I can confirm that we have now met with them on the 19th March and discussed the service provision with the Crisis Team. I met up with ████████ both senior Managers at the Crisis team. Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP’s at the practice and also to enable us to discuss individual clients.”

    Source location

    2015-0119-Response-by-Killick-Street-Health-Centre
    Page 1 · response
    Published 12 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

    Establish regular meetings between practice GPs and the Crisis Team to discuss service provision and individual clients.

    Verbatim wording from the response

    “Following your requirement for our service to meet with the Crisis Team, I can confirm that we have now met with them on the 19th March and discussed the service provision with the Crisis Team. I met up with ████████ both senior Managers at the Crisis team. Following discussion about the service we have decided to meet on a more regular basis to discuss the Crisis Team service provision with all the GP’s at the practice and also to enable us to discuss individual clients.”

    Source location

    2015-0119-Response-by-Killick-Street-Health-Centre
    Page 1 · response
    Published 12 February 2015

    Open published response

  2. Exeter & Greater Devon

    AI-generated summary

    Roger Clive DUGGAN · 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

    Roger Clive Duggan, aged 61, was in a heightened anxiety state when he left the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours on 11 February 2013. His body was found in the River Exe on 12 February 2013 and he was confirmed deceased at 14.30. Concerns included whether initial ambulance calls were treated sufficiently seriously and whether staff had the necessary training to deal with a mental health crisis.

    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 respond sufficiently seriously and promptly to mental health crisis calls

    Wider context from the report

    “(1) Whilst it was apparent in evidence that matters had reached fever pitch at Mr Duggan’s home, The Lindhay, The Old Farmhouse, Bramford Speke, on the evening of the 10th February 2013 as he reached a severe anxiety state. The family were firmly of the view the initial calls to Ambulance Control were not treated sufficiently seriously (despite the family being advised to do so by the Crisis Team). An ambulance visit only materialized after a further call to the Crisis Team and the latter’s instruction to Ambulance Control to attend. It appears that staff lacked the necessary training to deal with Mental Health Crisis. After subsequent arrival at the Royal Devon and Exeter Hospital (Wonford), Accident and Emergency Department, later that night 10th February 2013 Mr Duggan absconded only to be found deceased in the River Exe at 14.30 hours 12th February 2013. ”

    Source location

    Roger Clive DUGGAN · 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

    Investigate the ambulance response to the relevant calls and complete the investigation report.

    Verbatim wording from the response

    “Following notification of the incident by Northern, Eastern and Western (NEW) Devon Clinical Commissioning Group (CCG) the Trust conducted an investigation into the ambulance response to ████████ calls. This investigation was completed in May 2013 and forwarded to NEW Devon CCG for inclusion within the Serious Incident investigation which they led on. A meeting chaired by NEW Devon CCG, and attended by all agencies involved, subsequently took place to discuss the findings of the investigation and develop an action plan. A copy of the investigation report is appended to this letter, unfortunately this Trust was not aware that the inquest into Mr Duggan’s death was taking”

    Source location

    2014-0157-Response-by-South-Western-Ambulance-Service
    Page 1 · response
    Published 7 April 2014

    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

    Disseminate information on the correct process for arranging ambulance transport.

    Verbatim wording from the response

    “The investigation concluded that there appeared to be a misunderstanding by the Crisis team on the correct procedure for requesting ambulance transport for patients who required assessment or have a pre-arranged admission which subsequently led to communication difficulties. Following the meeting chaired by NEW Devon CCG, information was disseminated regarding the correct process for arranging transport and would have resulted in an appropriate ambulance response.”

    Source location

    2014-0157-Response-by-South-Western-Ambulance-Service
    Page 2 · response
    Published 7 April 2014

    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

    Upgrade the NHS Pathways system to version 6.5.1 with a dedicated Mental Health Pathway.

    Verbatim wording from the response

    “Following this incident, in July 2013, the Trust upgraded its version of ‘NHS Pathways’ to version 6.5.1 which included a dedicated Mental Health Pathway. This was developed in consultation with specialist Mental Health Teams and allows for patients with mental health symptoms to be dealt with more efficiently with the outcome of the triage (the disposition) being more appropriate. Prior to the implementation of version 6.5.1 all existing Clinical Hub staff were trained in the use of the Mental Health Pathway, this training is also provided for all new Clinical Hub staff as part of their ‘NHS Pathways’ training and includes scenarios.”

    Source location

    2014-0157-Response-by-South-Western-Ambulance-Service
    Page 2 · response
    Published 7 April 2014

    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

    Train Clinical Hub staff, including new starters, to use the Mental Health Pathway through NHS Pathways training and scenarios.

    Verbatim wording from the response

    “Following this incident, in July 2013, the Trust upgraded its version of ‘NHS Pathways’ to version 6.5.1 which included a dedicated Mental Health Pathway. This was developed in consultation with specialist Mental Health Teams and allows for patients with mental health symptoms to be dealt with more efficiently with the outcome of the triage (the disposition) being more appropriate. Prior to the implementation of version 6.5.1 all existing Clinical Hub staff were trained in the use of the Mental Health Pathway, this training is also provided for all new Clinical Hub staff as part of their ‘NHS Pathways’ training and includes scenarios.”

    Source location

    2014-0157-Response-by-South-Western-Ambulance-Service
    Page 2 · response
    Published 7 April 2014

    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

    Establish a Mental Health Group to monitor responses to mental health concerns and develop policies, procedures and guidelines.

    Verbatim wording from the response

    “In order to monitor the Trust’s response to patients with Mental Health concerns and develop robust policies, procedures and guidelines to improve the quality of care provided, a Mental Health Group has recently been established. This Group is chaired by a Trust Clinical Development Manager and is attended by managers from key areas of the Trust,”

    Source location

    2014-0157-Response-by-South-Western-Ambulance-Service
    Page 2 · response
    Published 7 April 2014

    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