Recurring concern
Failure to provide effective consultant psychiatrist oversight in mental health care
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Request correctionFirst reported 7 Sep 2016•Latest report 4 Feb 2026
What this concern includes
Includes failures of consultant psychiatrist oversight in mental health care, including absent or ineffective consultant input, unclear or unreliable escalation to consultant review, lack of an allocated consultant psychiatrist, and inadequate consultant involvement in inpatient, community, liaison or home-treatment care where consultant oversight is needed for safe assessment, treatment or risk management.
Not included
- Excludes generic mental health staffing shortages, specialist-service access failures or psychiatric appointment delays unless the asserted unsafe condition is specifically absent or ineffective consultant psychiatrist oversight.
- Excludes failures limited to a separately named pathway, such as Mental Health Act assessment, CPA coordination, home-treatment access or psychiatric appointment provision, where that pathway itself is the more specific supported concern.
- Excludes failures of non-psychiatric consultant or specialist oversight unless the assertion explicitly concerns consultant psychiatrist oversight in mental health care.
- Excludes poor clinical decisions made after effective consultant psychiatrist oversight was available and provided.
- Reports
- 13
- Individual concerns
- 15
- Date range
- 2016–2026
- Stated actions
- 18
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
Lack of consultant-level expertise in treating adults with complex, treatment-resistant depression
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 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
The prescribing psychiatrist had substantial adult psychiatry training and experience despite specialising in child and adolescent psychiatry.
Stated by Curaleaf Clinic
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Concerns raised1
Failure to provide instructions for challenging an inappropriate crisis-house placement decision
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.2
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Action
Require senior clinical review, an alternative plan, documented accountability and formal escalation before finalising any declined crisis house referral.
Stated by North London NHS Foundation Trust -
Action
Provide clinicians with 24/7 Crisis Hub access to senior clinical advice for urgent escalation and referral guidance.
Stated by North London NHS Foundation Trust
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Concerns raised2
Lack of Consultant Psychiatrist oversight for vulnerable patients
Lack of clear mechanisms and criteria for escalation to a Consultant Psychiatrist
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.2
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Action
Review the Liaison Service Standard Operating Procedure to incorporate the described consultant-oversight provisions, completing the review by May 2026.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Monitor the consultant-oversight provisions to assess whether they contribute to patient safety and therapeutic care.
Stated by Essex Partnership University 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
Existing Core 24, multidisciplinary review, referral, escalation and on-call arrangements provide sufficient Consultant oversight for liaison patients.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to discuss referrals during consultant psychiatric review
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of consultant psychiatrist leadership within CAMHS teams
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.
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
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Action
Attract, train, recruit, retain and reskill the current and future mental health workforce.
Stated by Department of Health and Social Care -
Action
Continue increasing education and training commissions across mental health training programmes.
Stated by Department of Health and Social Care -
Action
Develop a business case for additional CAMHS funding, including proposals for extended working and face-to-face initial assessments.
Stated by NHS North East London
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Action
Work with NELFT and other providers to support consultant psychiatrist recruitment and develop innovative recruitment approaches.
Stated by NHS North East London
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Local support provision and related actions must be addressed by the relevant local commissioners and providers.
Stated by NHS England
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Position
Delivery of expanded children’s mental health access and workforce ambitions is subject to future funding settlements.
Stated by NHS England
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Concerns raised1
Failure to provide Consultant Psychiatrist review after 30 May 2018
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 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
Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs
This report raised 15 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
Appoint a consultant psychiatrist and establish standard operating procedures for specialist eating disorder advice.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Approve and implement an expanded adult community eating disorder service with psychiatric, physical-health, psychological and dietetic capacity.
Stated by NHS Bury Clinical Commissioning Group -
Action
Implement the expanded adult eating disorder service to provide medical monitoring, specialist treatment, consultation and coordinated pathways.
Stated by NHS Greater Manchester Integrated Care Board
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
GMMH has been unable to recruit a second eating-disorder consultant psychiatrist because of local and national workforce shortages.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Lack of mandated face-to-face consultant psychiatrist review after acute-unit discharge
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.
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
Medical review decisions remain risk- and needs-led through multidisciplinary processes rather than being governed by a fixed post-discharge Consultant Psychiatrist review mandate.
Stated by Surrey and Borders Partnership NHS Foundation Trust
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Concerns raised1
Unavailability of consultant-level psychiatric input to eating disorder 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 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
Increase psychiatry placements in the Foundation Programme and continue working with the Royal College of Psychiatrists to improve specialty-training fill rates.
Stated by NHS England -
Action
Work through a joint eating-disorder expert advisory group to plan future commissioning and determine workforce requirements.
Stated by NHS England -
Action
Work with workforce bodies and healthcare providers to identify and implement solutions to the shortage of eating-disorder specialists.
Stated by General Medical Council
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Concerns raised1
Failure to progress and communicate recruitment arrangements for the dedicated consultant psychiatrist post
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026