Recurring concern

Unreliable identification of urgent mental-health needs during initial screening

First to latest report 21 Oct 2015 — 4 Oct 2024

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
1

What this concern includes

Includes failures in initial or referral screening processes for new mental-health patients or potential service users where the screening does not reliably identify serious psychiatric illness, treatment interruption, material risk or the need for urgent mental-health assessment or treatment.

What is not included
  • Excludes failures in full psychiatric assessment, diagnosis or treatment after the initial screening has appropriately identified the need for care.
  • Excludes generic mental-health referral, appointment or service-capacity failures where the screening process itself is not deficient.
  • Excludes generic staffing, training, documentation or communication deficiencies unless they directly impair initial screening for urgent mental-health needs.
  • Excludes screening processes for non-mental-health conditions or neutral descriptions of screening activity without an identified safety deficiency.

Reports and published responses 3 reports

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

  1. South Yorkshire (Western)

    AI-generated summary

    Bryan Andrews and Mary Andrews · 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

    Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.

    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 identify urgency in referrals involving paranoia, delusions and suicidal ideation

    Wider context from the report

    “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths. This led to significant time lapses in treatment and rejection of referrals, most notably: i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service. ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines. iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this. iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist. v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed. vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out. vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team. viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened. ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner. x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral. The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion. ”

    Source location

    Bryan Andrews and Mary Andrews · 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

    No further action is proposed for Single Point of Access referrals because that service no longer operates and referrals now enter individual services.

    Verbatim wording from the response

    “The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:”

    Source location

    Response from Sheffield Health and Social Care
    Page 1 · response
    Published 8 October 2024

    Open published response

  2. Manchester North

    AI-generated summary

    Teresa Chmielek · 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

    Teresa Chmielek took her own life at home on 17 June 2023, after a referral to mental health services concerning her suicide risk was rejected without contact or a face-to-face review. The concerns included failure to identify or recognise the reported recent suicide attempt, lack of meaningful multidisciplinary discussion and direct contact, inadequate referral arrangements and documentation, and the absence of procedures and auditing for referral 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

    Failure to identify or recognise suicide risk during referral screening

    Wider context from the report

    “(1) The notes made by the SPoE Nurse for use during discussion at the screening MDT meeting did not include any reference to the report of a recent suicide attempt and the Court was not satisfied that the risk of suicide had been identified or recognised by the SPoE Nurse ”

    Source location

    Teresa Chmielek · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    David Baddeley · 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

    David Baddeley, who had a history of schizophrenia, died at home on 23 June 2015 after tying a ligature around his neck; the cause of death was recorded as hanging, with schizophrenia also noted. Concerns included delays and gaps in transferring and reviewing medical records, incompatibility between electronic systems, and the failure to identify his psychiatric illness and lack of antipsychotic medication during primary-care handovers and checks.

    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 of initial new-patient health screening to identify serious psychiatric illness and absence of antipsychotic medication

    Wider context from the report

    “The fact that the initial new patients health screenings did not note that Mr Baddeley had a serious psychiatric illness, which could have made him a risk to himself or indeed others as he was not taking his antipsychotic medication. ”

    Source location

    David Baddeley · 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

    Remind practices to screen patients for serious psychiatric illness during new-patient health checks.

    Verbatim wording from the response

    “17. Practices will be reminded to ensure that when patients are seen at new patient health checks that they are screened for serious psychiatric illness.”

    Source location

    2015-0451-Response
    Page 2 · response
    Published 21 October 2015

    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