First reported 7 Apr 2014•Latest report 24 Mar 2026
Definition
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
Distinct published reports
Individual concerns
24
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
37
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 England4
North London NHS Foundation Trust3
Birmingham and Solihull Mental Health NHS Foundation Trust2
Birmingham City Council2
East London NHS Foundation Trust2
NHS Birmingham and Solihull Integrated Care Board2
Association of Ambulance Chief Executives1
Birmingham Women'S and Children'S NHS Foundation Trust1
British Telecommunications Limited1
Cheshire and Wirral Partnership NHS Foundation Trust1
Cornwall Health Limited1
Cornwall Partnership NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Essex Partnership University NHS Foundation Trust1
NHS trust17
Executive non-departmental public body4
Ministerial department4
Police force4
English metropolitan district council3
Integrated care board3
Healthcare site2
Private limited company2
Coronial office1
English county council1
English district council1
Health-sector membership body1
Local health board1
National policing body1
Police and crime commissioner1
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.
Birmingham and Solihull
Concerns raised1
Failure of agencies to work together effectively on mental health detention processes
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 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.5
Action
Develop electronic action cards setting out staff processes and inter-agency interactions.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
Action
Operate multi-agency call-in and prioritisation for Section 135 requests.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Action
Determine management arrangements for Section 136 cases.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
Action
Obtain formal multi-agency approval for the revised police-assistance memorandum.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Present the revised memorandum to frontline staff and deliver engagement, support and scenario testing.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Hampshire
Concerns raised1
Failure of 999 call triage to quickly and effectively identify the appropriate emergency response agency
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Portsmouth and South East Hampshire
Concerns raised1
Insufficient liaison between involved practitioners about crisis support
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.2
Action
Develop integrated pathways through monthly strategic workshops to improve joint crisis support, admission and discharge planning.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust and Hampshire County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2019.
Action
Maintain collaborative AMHP and AMHT arrangements, including staff shadowing and AMHT availability during Mental Health Act assessments.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust and Hampshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 29 July 2019.
Cornwall and Isles of Scilly
Concerns raised1
Lack of clarity about crisis response pathways and service roles
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 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.4
Action
Update the public website with crisis information explaining daytime and out-of-hours mental health services, helplines and team contact numbers.
Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Develop and provide patients with Safety Plans containing warning signs, coping strategies, crisis contacts, care-team details and carer guidance.
Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Review out-of-hours services to determine whether changes to Home Treatment Teams are needed.
Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Action
Publish guidelines clarifying community pathways for urgent, emergency and acute mental health services in 2018/19.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Responsibility for reviewing Cornwall-related recommended actions was passed to the new Cornwall Integrated Urgent Care provider.
Stated by Devon Doctors GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Devon Doctors could not implement the requested Cornwall changes because it no longer provided urgent care there.
Stated by Devon Doctors GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Some information-sharing recommendations were beyond Devon Doctors’ control.
Stated by Devon Doctors GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Disjointed coordination of care between crisis house and crisis team services
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.3
Action
Work with OneHousing to establish shared access to clinical records and risk assessments for Highbury Grove staff.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
Action
Introduce joint risk assessments completed by OneHousing and Camden and Islington staff.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 November 2017.
Action
Reinforce detailed feedback to OneHousing staff and agreement of a written action plan when crisis team staff complete risk assessments.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Information-sharing problems have been rectified through ready access to relevant clinical information and established communication channels.
Stated by North London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised1
Lack of coordinated mental health care during crisis and transfer
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to clearly communicate crisis team limitations to families and friends
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised2
Lack of cohesion in crisis care
Failure of communication within the crisis team and with crisis houses
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 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
Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 June 2015.
Birmingham and Solihull
Concerns raised1
Absence of a national multi-agency crisis team system for people in mental health crisis
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 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
Publish the Crisis Care Concordat to establish cross-sector expectations for local mental health crisis responses.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 March 2015.
Action
Fund street triage pilot schemes providing mental health professionals’ on-the-spot advice to police during possible mental health crises.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 March 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
National paramedic teams for acute mental health responses may be difficult to provide because of a recognised paramedic shortage and local commissioning arrangements.
Stated by Association of Ambulance Chief ExecutivesUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing local policies and crisis plans provide the arrangements for cross-agency mental health crisis responses rather than a single national system.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
Failure to ensure crisis team responsibility for providing assistance
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.1
Action
Develop a procedure defining the role of the duty officer.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 February 2015.
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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.
