First reported 19 Feb 2015•Latest report 5 Feb 2026
Definition
What this concern includes
Includes failures of the named crisis team care process involving insufficient capacity, staffing or demand management, fragmented or unreliable continuity, delayed handover, or other dedicated controls that prevent reliable support for people requiring crisis team care.
Not included
Excludes general mental health service capacity or waiting-time concerns without a direct crisis team connection.
Excludes failures of unrelated crisis, urgent-referral or community mental health pathways unless the assertion specifically concerns crisis team care provision.
Excludes generic staffing, communication or funding deficiencies unless they directly make crisis team care provision unreliable.
Excludes clinical assessment or treatment failures occurring after reliable crisis team care has been provided.
Reports
20
Distinct published reports
Individual concerns
30
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
37
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.
Leicestershire Partnership NHS Trust3
North London NHS Foundation Trust3
Department of Health and Social Care2
Norfolk and Suffolk NHS Foundation Trust2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Berkshire Healthcare NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Devon Partnership NHS Trust1
East London NHS Foundation Trust1
Gloucestershire Health and Care NHS Foundation Trust1
Home Office1
Lincolnshire County Council1
Lincolnshire Partnership NHS Foundation Trust1
London Borough of Camden1
Metropolitan Police Service1
NHS trust18
Ministerial department2
Type not available2
Coronial office1
English county council1
English unitary authority1
Health-system partnership1
Integrated care board1
Local health board1
London borough council1
Police force1
Public corporation1
Registered charity1
Registered provider of social housing1
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.
West London
Concerns raised1
Crisis team gatekeeping and rejection of referrals for crisis care
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Pilot trusted assessments for Ealing referrals to the crisis, assessment and home treatment team.
Stated by West London NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.
Action
Recruit a Clinical Lead to support trusted-assessment changes and improvements across the relevant Ealing services.
Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Action
Provide universal access to urgent mental health helplines through NHS 111 and alternative crisis services.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Action
Invest up to £120 million to expand mental health emergency departments to 85.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
West London NHS Trust is handling the specific local issues arising from Kallum’s death and responding separately to the report.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Gloucestershire
Concerns raised1
Failure to enquire about additional resources when the local crisis team has no capacity
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North Yorkshire and York
Concerns raised2
Failure to establish whether an assessed risk of harm had increased and required emergency intervention
Failure to provide practical emergency-care advice to carers
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (Eastern)
Concerns raised1
Lack of crisis support and specialist assessment access for patients over 65
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 concerns
Each 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.6
Action
Issue a written operating protocol requiring crisis referrals for older people to be accepted and assessed regardless of age or time of day.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 September 2024.
Action
Remove age-based access barriers from mental health services through revised service arrangements and additional staff training.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2024.
Action
Disseminate revised crisis pathways, referral routes and advice arrangements to staff, primary care, NHS111, communities, carers and patients.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 September 2024.
Action
Roll out DIALOG/DIALOG+ to replace the Care Programme Approach and support outcome-focused care planning across services.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2024.
Action
Embed the revised crisis and community mental health arrangements in local team induction.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 September 2024.
Action
Work with clinical audit to consider evaluating older adults’ access to crisis presentations in the 2025/26 audit programme.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Crisis provision was not considered a relevant factor in what happened; missed referrals to the established older people’s community team were the issue.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
A compelling case for creating dedicated older people’s crisis services has not been identified, so existing teams should improve their response instead.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
Leicester City and South Leicestershire
Concerns raised1
Failure to review patients’ records before CRISIS team MDT meetings
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Berkshire
Concerns raised1
Failure to ensure crisis-team discharges include additional support when needed
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 concerns
Each 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
Action
Commission and accept referrals for Elmore floating support for people with complex needs who risk falling between existing services.
Stated by Berkshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 June 2023.
Action
Make outreach workers fully operational to provide short-term support and safety planning for people unable to access existing services.
Stated by Berkshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 June 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The patient was not discharged without additional support; community support, group support, online support and a medication review were already arranged.
Stated by Berkshire Healthcare NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Delays between Crisis Review Team referrals and patient assessments
Responses linked to these concerns
Each 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
Position
There were no delays between the Crisis Response Team referral and assessment; the referral requested assessment the following day.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Failure of the crisis team to reassess patients and reopen crisis-team cases when clinically indicated
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Lincolnshire
Concerns raised1
Failure of the Crisis Assessment and Home Team Protocol to provide adequately for Dual Diagnosis
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Review Dual Diagnosis pathways across the treatment system jointly with partner organisations and commissioners.
Stated by WithYouStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.
Action
Review and revise the joint working protocol and implement a more robust referral pathway across mental health and substance misuse services.
Stated by Lincolnshire County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2020.
Action
Strengthen dual-diagnosis policies and protocols to provide an enhanced Care Programme Approach with joint substance-misuse working.
Stated by Lincolnshire Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.
Action
Review internal policies and protocols and embed care pathways with We Are With You, including discussion with commissioners about required investment.
Stated by Lincolnshire Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.
East London
Concerns raised1
Failure to make arrangements to address risks when closing crisis team referrals
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.1
Action
Require senior multidisciplinary review, documented communication, and updated crisis and contingency plans before closing non-engagement referrals.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 May 2021.
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Includes failures of the named crisis team care process involving insufficient capacity, staffing or demand management, fragmented or unreliable continuity, delayed handover, or other dedicated controls that prevent reliable support for people requiring crisis team care.
