Recurring concern

Failure to provide effective consultant psychiatrist oversight in mental health care

First to latest report 7 Sep 2016 — 4 Feb 2026

Reports that mention this concern
13
Times this concern has been raised
15
Stated actions linked to this concern
18

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.

What is 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 and published responses 13 reports

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

  1. Shropshire, Telford and Wrekin

    AI-generated summary

    Jeff David ANTWIS · 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

    Jeff David ANTWIS, a 14-year-old teenager with Asperger’s syndrome and a history of self-harm and suicide attempts, was struck by a train at Harlescott level crossing on 30 January 2017 and died later that day. The principal concern was that, despite indicating that he wished to die, he was given a routine medical review appointment for 17 March rather than an urgent review, alongside concerns about risk assessment, referral mechanisms and recognition of how his conditions may have affected the presentation of suicidal ideation.

    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 a mechanism for referring cases back to the consultant psychiatrist

    Wider context from the report

    “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete. (2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017. (3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it. (4) On the 30th January 2017 Jeff killed himself on the railway line. (5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff. (6) Other matters of concern arose from the evidence. The mental health practitioner: a) Was aware of the deliberate self-harm protocol but not its content. b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant. c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not. (7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized. (8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider review. ”

    Source location

    Jeff David ANTWIS · Prevention of Future Deaths report
    Page 1 · 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

    Failure to provide an urgent medical review after suicidal ideation was identified

    Wider context from the report

    “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete. (2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017. (3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it. (4) On the 30th January 2017 Jeff killed himself on the railway line. (5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff. (6) Other matters of concern arose from the evidence. The mental health practitioner: a) Was aware of the deliberate self-harm protocol but not its content. b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant. c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not. (7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized. (8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider review. ”

    Source location

    Jeff David ANTWIS · Prevention of Future Deaths report
    Page 1 · 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

    Establish clear care pathways enabling case-holding clinicians to obtain additional psychology, family therapy and consultant psychiatry support.

    Verbatim wording from the response

    “• When a young person is accepted within the service, a clear pathway for their care is identified, this enables the case holding clinician to access additional support for example, psychology, family therapy consultant psychiatry (Also points 2, 3, 6 & 7) Healios are delivering one therapeutic interventions as part of core MH service (point 8).”

    Source location

    2017-0392-Response
    Page 3 · response
    Published 15 February 2018

    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 escalation processes within clinical pathways to obtain urgent psychiatric reviews when concerns arise.

    Verbatim wording from the response

    “• Escalation processes have been agreed within clinical pathways so that urgent psychiatric reviews can be obtained when concerns are raised (points 2, 4, 5 & 7)”

    Source location

    2017-0392-Response
    Page 3 · response
    Published 15 February 2018

    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

    Reserve one weekly appointment in each consultant psychiatrist job plan for urgent assessments.

    Verbatim wording from the response

    “• One assessment appointment each week is ring fenced for urgent assessments in each Consultant Child & Adolescent Psychiatrist job plan to ensure that young people presenting in crisis are provided with urgent psychiatric review (points 2, 4, 5 & 7)”

    Source location

    2017-0392-Response
    Page 3 · response
    Published 15 February 2018

    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

    Shropshire Community Health NHS Trust was responsible for investigating care because it provided CAMHS services in Shropshire at the relevant time.

    Verbatim wording from the response

    “As identified in your letter South Staffordshire and Shropshire Healthcare NHS Foundation Trust were not providing CAMHS services within Shropshire at the time of Jeff’s death therefore South Staffordshire and Shropshire Healthcare NHS Foundation Trust were not in a position to have carried out an investigation into the care of Jeff prior to his death. The Serious Incident Investigation presented at the inquest was carried out by Shropshire Community Health NHS Trust who were providing CAMHS services in Shropshire in January 2017.”

    Source location

    2017-0392-Response
    Page 1 · response
    Published 15 February 2018

    Open published response

  2. Inner North London

    AI-generated summary

    Jamie Neil Elliott · 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

    Jamie Neil Elliott died by hanging at his home on 18 November 2016, with an inquest conclusion of suicide. Before his death, he had expressed clear, detailed and escalating suicidal ideation and had declined offered voluntary inpatient admission. Concerns included failures to contact his private therapist and to provide a face-to-face psychiatric assessment after his condition deteriorated.

    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 Consultant Psychiatrist assessment for worsened conditions referred to the Home Treatment Team

    Wider context from the report

    “2. There should be a psychiatric assessment, by a Consultant Psychiatrist in circumstances where there is a referral to the Home Treatment Team where a patient’s condition has worsened. Ideally this should be within 48 hours and should be a face to face psychiatric assessment. ”

    Source location

    Jamie Neil Elliott · Prevention of Future Deaths report
    Page 3 · 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

    Require escalation of Home Treatment referrals not seen within 48 hours to a consultant psychiatrist or team manager for prioritised review.

    Verbatim wording from the response

    “In relation to face to face psychiatric assessments by the Home Treatment team the Operational Policy has been updated to include the following:”

    Source location

    2017-0135-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 10 July 2017

    Open published response

  3. North Wales (East and Central)

    AI-generated summary

    Christopher Glyn Jones · 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

    Christopher Glyn Jones died after placing himself into collision with a train while under the care of the Community Mental Health Team. The inquest identified delays in treatment plans and risk assessments, failures in providing intended treatments, and inadequate escalation of concerns during a significant decline in his mental health; it also identified possible service deficiencies in staffing cover.

    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

    Infrequent consultant psychiatrist review of recently sectioned and treated inpatients

    Wider context from the report

    “1. Evidence at the inquest indicated that the deceased was discharged from inpatient treatment on the 6th of January 2015 but his Care Treatment Plan was not completed until the end of April 2015 and that this would then only require review within a period of twelve months from that date, as a result it could have been the case that a patient who had recently been sectioned and treated as an inpatient may not then be seen by a consultant psychiatrist for a period in the region of sixteen months. ”

    Source location

    Christopher Glyn Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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