Recurring concern

Unreliable access to physical health specialist input for mental health inpatients

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First reported 3 Mar 2014•Latest report 5 Jun 2026

Definition

What this concern includes

Includes failures of the dedicated arrangements for obtaining physical health specialist advice or input for mental health inpatients, including access barriers, unavailable specialist support and requirements to transfer patients to emergency departments solely to obtain that input.

Not included

  • Excludes deficiencies in general clinical advice that are not specifically tied to physical health specialist input for mental health inpatients.
  • Excludes shortages or unavailability of inpatient mental health beds, psychological services or other services unrelated to physical health specialist input.
  • Excludes generic staffing, training, communication or documentation deficiencies unless they directly concern the dedicated provision of physical health specialist input for mental health inpatients.
Reports
7

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
5

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 Care3
Royal College of Psychiatrists2
South London and Maudsley NHS Foundation Trust2
BNF Publications1
British Association Of Dermatologists1
Cwm Taf Morgannwg University Local Health Board1
Greater Manchester Mental Health NHS Foundation Trust1
NHS England1
Pennine Care NHS Foundation Trust1
Royal College of Physicians1
Welsh Government1

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.

  1. East Sussex

    AI-generated summary

    Neeshat Dalal · 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

    Neeshat Dalal was admitted for severe depression after experiencing difficulty eating and drinking and undergoing three attempts to end her life with an insulin overdose. She collapsed during her third ECT treatment on 13 December 2022, was transferred to the emergency department, and died in the Acute Medicine Unit in the early hours of 14 December 2022. The concerns included inadequate consideration of her nutritional needs and vomiting, insufficient medical information before ECT, and delays or omissions in aspects of her acute hospital care.

    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 appropriately qualified dietitian provision for inpatients undergoing psychiatric care

    Wider context from the report

    “Funding is required for the specific provision of appropriately qualified dieticians who can meet the nutritional needs of inpatients undergoing psychiatric care in SPFT and in other Trusts where such support does not already exist. ”

    Source location

    Neeshat Dalal · 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

    Develop safer staffing standards for Allied Health Professionals, including principles applicable to mental health services.

    Verbatim wording from the response

    “There are currently no AHP safer staffing standards, but these are being developed by NHS England. They will be considered by NHS England’s National Quality Board in September 2026. This guidance will include principles that would apply to mental health services.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 August 2026

    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

    Continue supporting multidisciplinary and integrated approaches to care through published specifications and guidance.

    Verbatim wording from the response

    “Workforce models and local arrangements for dietetic provision are determined by providers and commissioners. NHS England will continue to support multidisciplinary and integrated approaches to care through its published specifications and guidance.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 August 2026

    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

    ICBs are responsible for commissioning appropriate nutritional care for psychiatric inpatients and should answer enquiries about local provision.

    Verbatim wording from the response

    “Integrated Care Boards (ICBs) are responsible for commissioning services in line with population need. This includes providing appropriate care for people with additional nutritional needs when they are admitted to hospital whether their primary issue is due to a physical or mental health need. NHS England also published coproduced Culture of Care Standards for mental health inpatient services in 2024 which sets the expectation that “Staff (working in psychiatric hospitals) are equipped to support people with their physical health needs, and understand the higher risk of premature mortality and co-morbidities ...”. NHS England also delivered a two year Culture of Care Improvement Programme which all NHS and major independent mental health providers participated in.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 6 August 2026

    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

    Providers and commissioners determine workforce models and local arrangements for dietetic provision.

    Verbatim wording from the response

    “Workforce models and local arrangements for dietetic provision are determined by providers and commissioners. NHS England will continue to support multidisciplinary and integrated approaches to care through its published specifications and guidance.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 August 2026

    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

    Individual NHS Trusts and employers determine staffing levels and workforce composition to meet patients’ needs safely.

    Verbatim wording from the response

    “Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 6 August 2026

    Open published response

  2. Manchester South

    AI-generated summary

    Corinne Haslam · 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

    Corinne Haslam died at Tameside General Hospital on 18 March 2022 following complications involving myocardial ischaemia, acute exacerbation of chronic obstructive pulmonary disease, left ventricular hypertrophy and treated pulmonary thromboemboli. Concerns included barriers to obtaining physical-health specialist input for mental-health ward patients, incompatible electronic records between Mental Health and Acute Trusts, and unclear guidance on venous thromboembolism risk assessments.

    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

    Barriers to obtaining physical health specialist input for mental health ward patients

    Wider context from the report

    “1. The court heard evidence as to the barriers which exist and make it difficult for staff working on mental health wards to obtain input from physical health specialists without sending a patient to hospital via the Emergency Department. Whilst there are occasions where review in an Emergency Department is most appropriate, the court also heard evidence that these can be extremely busy and intensive environments which may not be a conducive to delivering care for patients experiencing severe and enduring mental illness; ”

    Source location

    Corinne Haslam · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Issues concerning Pennine Care NHS Foundation Trust should be addressed in the Trust’s response.

    Verbatim wording from the response

    “I note that you have also addressed matters of concern to the Chief Executive of Pennine Care NHS Foundation Trust and I would expect the Trust’s response to address those issues.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 28 July 2023

    Open published response

  3. Manchester City

    AI-generated summary

    Jude Daryl Lloyd · 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

    Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.

    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

    Unavailability of appropriate specialist advice for a psychiatric inpatient with a serious physical health condition

    Wider context from the report

    “e. Whilst a psychiatric inpatient and suffering from a serious physical health condition which requires monitoring and treatment it was not possible to obtain appropriate specialist advice because the deceased was not an inpatient in hospital and was not registered with a GP in that area. Consequently, there was a gap in care provision which requires local NHS primary and secondary care procedural review to resolve. ”

    Source location

    Jude Daryl Lloyd · Prevention of Future Deaths report
    Page 4 · 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

    Make diabetes care a principal Trust quality-improvement project, led by the physical-health care group and supported by primary-care connections.

    Verbatim wording from the response

    “Going forward the Trust physical health care group will reinstate a Diabetes workstream to continue to improve the management of people with diabetes across the Trust. We will ensure that the Diabetes workstream have oversight of compliance with training about diabetes management and are involved in the management and risk analysis incidents around diabetes care. We intend to make the care of someone with diabetes as one of our main quality improvement care projects in the organisation that will be led by the physical health care group who will act as the lead for this. This will involve further enhancing the connections and communication with primary care and will involve the new primary healthcare practitioners, which are new joint posts working across the new primary care networks and GMMH.”

    Source location

    2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 13 October 2021

    Open published response

  4. South Wales Central

    AI-generated summary

    Deidre Harvey · 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

    Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.

    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 active input from outside consultants into mental health unit patient care

    Wider context from the report

    “Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”

    Source location

    Deidre Harvey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner South London

    AI-generated summary

    Michael George · 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

    Michael George died after developing a life-threatening hyperglycaemic condition while receiving long-term Olanzapine treatment. The report identified concerns about inadequate monitoring for diabetes, delays and insufficient urgency in transfer to A&E, incomplete referral information, and gaps in the subsequent oversight and care arrangements for the physical health of mental health inpatients.

    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 provide domiciliary consultant physician visits to mental health wards

    Wider context from the report

    “(3) The Trust response to 2654-11 in September 2014 was that a research bid was being mounted and discussions held with commissioners and Kings College Hospital (KCH). Progress on this was not provided to the court and there had apparently not been action to reduce risks of deaths by ensuring there were domiciliary visits from consultant physicians at KCH (which is across the road from the Maudsley) to mental health wards, as reported to the Trust in 2014. The need to implement such a service was again reiterated by a different expert in this inquest. It is inferred from the expert opinion that failure to do so would mean that patients in SLAM in-patient units would be more at risk than those mental health patients in a district general hospital. ”

    Source location

    Michael George · 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

    Submit and revise a bid with Kings College Hospital for a Medical Liaison Team providing medical-management advice to inpatients.

    Verbatim wording from the response

    “5. In relation to the previous recommendation of Inreach medicine into the system, the Trust collaborated with KCH to put in a bid for a Medical Liaison Team to consult on the medical management of our inpatients. After repeated revisions, this was turned down. This was unfortunate as we had clearly demonstrated the need as evidenced in Appendix II, where we show that over 10% of our admissions are medically unstable enough to require a night in a general hospital as part of their SLAM inpatient stay. However, to my knowledge, no Mental Health Trusts have Inreach medical care on their general psychiatry wards, although many forensic units have GPs who visit (in keeping with the long length of stay). We plan tp continue to lobby for resources to establish such a service.”

    Source location

    2015-0264-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 2 · response
    Published 9 July 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

    Lobby for resources to establish an inpatient medical liaison service.

    Verbatim wording from the response

    “5. In relation to the previous recommendation of Inreach medicine into the system, the Trust collaborated with KCH to put in a bid for a Medical Liaison Team to consult on the medical management of our inpatients. After repeated revisions, this was turned down. This was unfortunate as we had clearly demonstrated the need as evidenced in Appendix II, where we show that over 10% of our admissions are medically unstable enough to require a night in a general hospital as part of their SLAM inpatient stay. However, to my knowledge, no Mental Health Trusts have Inreach medical care on their general psychiatry wards, although many forensic units have GPs who visit (in keeping with the long length of stay). We plan tp continue to lobby for resources to establish such a service.”

    Source location

    2015-0264-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 2 · response
    Published 9 July 2015

    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

    A medical liaison service could not be established because the funding bid was rejected; resource lobbying will continue.

    Verbatim wording from the response

    “5. In relation to the previous recommendation of Inreach medicine into the system, the Trust collaborated with KCH to put in a bid for a Medical Liaison Team to consult on the medical management of our inpatients. After repeated revisions, this was turned down. This was unfortunate as we had clearly demonstrated the need as evidenced in Appendix II, where we show that over 10% of our admissions are medically unstable enough to require a night in a general hospital as part of their SLAM inpatient stay. However, to my knowledge, no Mental Health Trusts have Inreach medical care on their general psychiatry wards, although many forensic units have GPs who visit (in keeping with the long length of stay). We plan tp continue to lobby for resources to establish such a service.”

    Source location

    2015-0264-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 2 · response
    Published 9 July 2015

    Open published response

  6. Inner South London

    AI-generated summary

    Sadik Miah · 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

    Sadik Miah, who had schizophrenia and was detained in hospital, collapsed suddenly and died in Lambeth Hospital on 15 October 2011 despite resuscitation. Concerns included the monitoring of ECG abnormalities and antipsychotic-related arrhythmia risk, delays in obtaining specialist advice about hyponatraemia, and the lack of regular physician support for psychiatric in-patients with physical health problems.

    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 physician input into management of in-patients with physical health problems

    Wider context from the report

    “(1) ████████ said that consultant psychiatrists caring for in-patients with physical health problems did not have the benefit of a fellow consultant physician visiting, examining and advising on management, as would occur in a DGH. This did create a risk of other deaths occurring and should be a concern for the coroner. ”

    Source location

    Sadik Miah · 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

    Unavailability of timely medical opinions for non-emergency physical illness

    Wider context from the report

    “During the inquest evidence was heard that he developed hyponatraemia from excessive drinking but the aetiology was not clear, although he was thought to have psychogenic polydipsia. A referral was made to an endocrinologist for a routine out patient appointment, for which there would be a 6-12 week wait. One of the possibilities of the cause was that it was medication related and it was agreed that such a delay was not appropriate. The court heard that there was a facility for emergency treatment for a physical illness, but apparently no facility for a medical opinion that was not an emergency but should not wait several weeks. ”

    Source location

    Sadik Miah · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Inner South London

    AI-generated summary

    Kirabo Kiwanuka · 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

    Kirabo Kiwanuka, a 28-year-old woman with bipolar disorder, died on 11 June 2011 after developing tachycardia, tachypnoea, pyrexia and markedly raised creatinine kinase during psychiatric treatment. The inquest recorded sudden unexpected death in a patient treated with multiple drugs, while NMS could not be confirmed or excluded as a contributory factor. Concerns included uncertainty about diagnosing and managing NMS, whether patients with physical illness in psychiatric facilities should receive medical review or be transferred, and limited family involvement in treatment decisions.

    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

    Unavailability of timely physician assessment for acutely ill psychiatric-facility patients

    Wider context from the report

    “2. There is lack of clarity about whether acutely manic patients in a psychiatric facility with physical illness should receive domiciliary visits from physicians and medical care in the psychiatric facility or be transferred to a medical facility, where psychiatric staff attend and visit. She was not examined by a physician when she developed abnormal vital signs. At the time it appears that there was no facility for a physician from the neighbouring hospital to be called out for a medical opinion, although this is currently being explored by SLAM and KCH and is included in a draft protocol. When are patients best under the care of a medical and when a psychiatric ITU? How are Trusts to know what is the optimal model of care? ”

    Source location

    Kirabo Kiwanuka · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026