Recurring concern

Unreliable access to specialist mental health treatment for serious mental illness

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First reported 30 Apr 2014•Latest report 6 Jul 2026

Definition

What this concern includes

Includes failures of arrangements dedicated to providing or securing specialist mental health assessment or treatment, including specialist hospital treatment, timely psychiatric input, diagnosis and treatment access, and provision for people whose mental health needs exceed available general or non-specialist care.

Not included

  • Excludes generic mental health service capacity, staffing or waiting-time concerns unless they directly impair access to specialist mental health assessment or treatment.
  • Excludes failures limited to a named crisis, referral, discharge, observation or care-coordination pathway where that pathway supplies the more specific supported concern.
  • Excludes failures in physical-health specialist input for mental health inpatients unless the asserted unsafe condition is access to specialist mental health treatment itself.
  • Excludes treatment-quality or clinical-decision failures occurring after appropriate specialist mental health treatment has been obtained.
Reports
14

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
21

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 Care5
NHS England5
Ministry of Justice4
HM Prison and Probation Service3
HM Inspectorate of Prisons2
Prisons and Probation Ombudsman2
Central and North West London NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Greater Manchester Mental Health NHS Foundation Trust1
Guys Marsh Prison1
Leeds Teaching Hospitals NHS Trust1
Ministry of Defence1
NHS South West London Integrated Care Board1
NHS Wirral Clinical Commissioning Group1
Nottinghamshire Healthcare NHS Foundation Trust1

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. Inner South London

    AI-generated summary

    Dr Debatra Sircar · 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

    Dr Debatra Sircar had longstanding alcohol dependency and depression, and died on 20 February 2016 after a fall associated with alcohol intoxication, causing subdural and intracerebral haemorrhage. He had been assessed as unsuitable for home treatment, but a Mental Health Act assessment was scheduled 11 days later, and he died before it took place. Concerns included the delay in securing hospital care and the absence of a clear interim care plan and responsibility for psychiatric monitoring.

    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

    Delays in securing hospital admission and Mental Health Act assessment for patients unfit for community treatment

    Wider context from the report

    “1. He was at risk from falls, associated with his alcohol abuse and had frequently presented in A&E department with symptoms and injuries associated with intoxication. He was unfit to be treated in the community. There appeared to be no sense of urgency in securing a bed. He was booked for a Mental Health Act (MHA) Assessment 11 days after it was advised he needed hospitalization, by which time he had died. The court was informed the delay related to the unavailability of a local authority MHA practitioner. ”

    Source location

    Dr Debatra Sircar · 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

    Rezone clients referred for a Mental Health Act assessment to Red until the assessment is completed.

    Verbatim wording from the response

    “Following our review, we have instigated the following change in practice:”

    Source location

    2016-0352.Response-by-Oxlea-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    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

    The delay in arranging the Mental Health Act assessment was not caused by an unavailable Approved Mental Health Act Practitioner.

    Verbatim wording from the response

    “The Trust acknowledges the long period of time it took to arrange a Mental Health Act assessment however this was not, despite what the court heard, due to the unavailability of an Approved Mental Health Act Practitioner (AMHP).”

    Source location

    2016-0352.Response-by-Oxlea-NHS-Trust
    Page 1 · response
    Published 19 February 2017

    Open published response

  2. Cheshire

    AI-generated summary

    Kevin Dermott · 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

    Kevin Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his death.

    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 specialist hospital treatment for serious mental illness

    Wider context from the report

    “The seriousness of the deceased’s condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed. During a hyponamic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment. The evidence showed that his illness was not properly addressed. At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur. At HMP Haverigg there was inadequate mental health cover with at times only one mental health nurse and no provision for psychiatric referral. He was transferred to HMP Kirkham. A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased’s care whilst in prison, the fact that the deceased was relapsing into depression was not recognised. The jury concluded that the deceased’s death by hanging was partly due to deficiencies in mental health care and failure to properly observe ACCT procedures. ”

    Source location

    Kevin Dermott · 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

    Work with specialised commissioning teams and partner organisations to address the shortage of secure psychiatric beds and delays transferring acutely unwell prisoners.

    Verbatim wording from the response

    “NHS England recognises that there is a national issue regarding lack of secure psychiatric beds which impacts on the timely transfer of acutely unwell prisoners. The Health and Justice commissioning team are working with colleagues in the NHS England Specialised Commissioning teams, who are responsible for secure mental health provision, and other partners in Department of Health, National Offender Management Services and Ministry of Justice and Home Office to look at this issue and try to resolve it.”

    Source location

    2016-0220-Response-by-NHS-England
    Page 2 · response
    Published 13 June 2016

    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

    Develop updated guidance for transferring prisoners to and from secure mental-health hospitals.

    Verbatim wording from the response

    “NHS England Health and Justice and Specialised Commissioning teams have developed updated guidelines for the transfer of prisoners to and remission from”

    Source location

    2016-0220-Response-by-NHS-England
    Page 2 · response
    Published 13 June 2016

    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

    Complete consultation and publish the updated guidance for transferring prisoners to and from secure mental-health hospitals.

    Verbatim wording from the response

    “secure mental health hospitals. This guidance is due for final consultation in autumn 2016 prior to publication and until the Department of Health 2011 guidelines remain extant. The HJIPs data set also contains transfer timelines to mental health secure units.”

    Source location

    2016-0220-Response-by-NHS-England
    Page 3 · response
    Published 13 June 2016

    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

    Specialised Commissioning teams are responsible for secure mental health provision, including addressing shortages affecting transfers of acutely unwell prisoners.

    Verbatim wording from the response

    “NHS England recognises that there is a national issue regarding lack of secure psychiatric beds which impacts on the timely transfer of acutely unwell prisoners. The Health and Justice commissioning team are working with colleagues in the NHS England Specialised Commissioning teams, who are responsible for secure mental health provision, and other partners in Department of Health, National Offender Management Services and Ministry of Justice and Home Office to look at this issue and try to resolve it.”

    Source location

    2016-0220-Response-by-NHS-England
    Page 2 · response
    Published 13 June 2016

    Open published response

  3. The Wirral

    AI-generated summary

    Samarjit Natasha SINGH · 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

    Samarjit Natasha Singh developed postnatal depression after giving birth to her son and had acts of deliberate self-harm and a threat of self-harm. On 4 December 2012, she was found in cardiac arrest following hanging and sustained an irreversible hypoxic brain injury; she died the following day. The report identified concerns about the absence of a Specialist Community Perinatal Mental Health Service and a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region.

    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 Specialist Community Perinatal Mental Health Service in the Wirral

    Wider context from the report

    “Mrs Singh suffered from severe postnatal depression following the birth of her son. Clearly she needed to be with her son whilst she was being treated for her perinatal mental health issues, given his needs. 1. There was no Specialist Community Perinatal Mental Health Service in the Wirral to meet both her son’s and her needs. The treatment that was available was sub-optimal. 2. There is not a Mother and Baby Perinatal Mental health—in-patient Unit in the Liverpool City Region serving the needs of Lancashire, Merseyside and East Cheshire. 50% of referrals from this area to the Manchester Unit decline because it is too far from family and support networks but more relevantly from older sibling children who remain in the family home ”

    Source location

    Samarjit Natasha SINGH · 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

    Recruit and establish an additional perinatal mental health midwife post to increase specialist capacity, continuity, cover, teaching and supervision.

    Verbatim wording from the response

    “• an additional Perinatal Midwife should be recruited as a secondment opportunity for 6-12 months on a rolling basis from within existing workforce to skill up all midwives and to allow for postnatal appointments to be given, continuity of care, annual leave, teaching and clinical supervision to be undertaken. Thus supporting the Tier 2 provision and allowing post natal care to be also given.”

    Source location

    2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
    Page 3 · response
    Published 23 May 2014

    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

    Include specialist-staffing requirements in the new IAPT service specification and inform providers that perinatal clinicians must liaise with other professionals involved in care.

    Verbatim wording from the response

    “The provision for urgent access to psychological therapies was already included in IAPT Provider contracts; however, this case has been raised and discussed with the IAPT providers, who have been informed of the need to liaise with the other professionals who are likely to be involved with the other professionals involved in the lady’s care. The requirement for specialist staff has been included within the new specification for IAPT, which is due to go out for tender with a new service starting in April 2015.”

    Source location

    2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
    Page 3 · response
    Published 23 May 2014

    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 an integrated, consultant-led perinatal mental health pathway for Wirral patients by the end of 2014.

    Verbatim wording from the response

    “It is acknowledged that progress has not been made as quickly as originally anticipated, and as required by the gravity of this case. As such, following this Regulation 28 notice, the CCG can provide assurance to the Coroner and to all parties involved that the development of an integrated pathway will become a high priority for the CCG during 2014/15. We will require this integrated pathway to be in place, led by the Consultant Psychiatrist, by the end of the calendar year 2014.”

    Source location

    2014-0239-Response-by-Wirral-Clinical-Commissioning-Group
    Page 3 · response
    Published 23 May 2014

    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

    Clinical Commissioning Groups commission local perinatal mental health services and should address concerns about Wirral provision.

    Verbatim wording from the response

    “Specialised Perinatal Mental Health Services (Mother and Baby Units) are a part of a wider network of services that provide care for this patient group and the commissioning of the ‘specialist’ (local) and ‘specialised’ (national) pathway is a responsibility shared between NHS England, Clinical Commissioning Groups and Local Authorities.”

    Source location

    2014-0239-Response-by-Department-of-Health
    Page 1 · response
    Published 23 May 2014

    Open published response

  4. West Yorkshire (East)

    AI-generated summary

    Mary WANYA · 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

    Mary Wanya died after falling through a hospital window on 1 November 2011 while in an acutely confused and agitated state. The window restrictor was defective, allowing the window to be fully opened. Concerns included delays in psychiatric assessment, the assessment and treatment of mental illness on the Medical Admissions Unit, her earlier diagnosis and discharge, and the inadequacy of the Trust’s investigation report.

    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 prompt assessment, diagnosis and treatment of mental illness

    Wider context from the report

    “1. (i) There was a considerable delay of over 60 hours before a psychiatrist attended St James’s University Hospital to assess Mary Wanya. In fact the psychiatrist arrived 5 minutes after her fall had occurred and hence she never received a psychiatric assessment. (ii) The Trust should review the system for obtaining urgent psychiatric assessments, particularly out of hours, with a view to speeding up and providing a more efficient service. (iii) In view of the size and scale of the St James’s University site the Trust should consider having an on site resident psychiatrist to avoid the obvious delay in bringing psychiatrists from St Mary’s Hospital, which is some distance away and will exacerbate delay. (iv) The Trust should consider making arrangements with the Mental Health Trust responsible for the Becklin Centre so that the Becklin Centre staff should be involved with such patients, particularly out of hours, to avoid delay and to provide earlier diagnosis and treatment. Had Mrs Wanya been transferred to the Becklin Centre and been psychiatrically assessed and her treatment had commenced much earlier, it is likely that this death could have been avoided. (v) There is an inferior system for the assessment and treatment of patients on the Medical Admissions Unit of patients suffering from mental illness in comparison with those who are physically ill. The Trust should therefore review this urgently and ensure that the systems are developed to provide for a faster system to rule out physical illness that might cause or contribute to mental disturbance and when this has been achieved to provide a prompt assessment, diagnosis and treatment for such patients in respect of their obvious mental illness. ”

    Source location

    Mary WANYA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026