Recurring concern

Failure to provide the NHS 111 mental health crisis triage service

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First reported 29 Sep 2023•Latest report 29 Sep 2023

Definition

What this concern includes

Includes failures to establish, implement, make available or maintain the NHS 111 press 2 mental health crisis triage service intended to provide urgent mental health advice or divert people to appropriate crisis support.

Not included

  • Excludes general NHS 111 algorithm, call-handling, ambulance dispatch or response failures where the dedicated mental health crisis triage service is not the deficient process.
  • Excludes broader mental health crisis-team capacity, psychiatric-bed availability and 24-hour crisis-support deficiencies unless they specifically concern provision of the NHS 111 mental health crisis triage service.
  • Excludes failures in clinical assessment or treatment after the NHS 111 mental health crisis triage service has operated and provided access reliably.
  • Excludes generic service implementation, commissioning or staffing deficiencies without an explicit NHS 111 mental health crisis triage connection.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2023–2023

First to latest report issue date

Stated actions
1

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.

South Wales Police2

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. South Wales Central

    AI-generated summary

    Leighton Alan Dickens · 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

    Leighton Alan Dickens died by incomplete atypical hanging alone at his home address on 14 October 2020. The inquest heard that police did not detain him at hospital for mental health assessment, and identified limited access to qualified, clinically informed mental health advice and records for officers responding to community mental health crises.

    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 implement the intended “111 press 2” mental health triage service

    Wider context from the report

    “(1) Following the withdrawal of the mental health triage support provided to the police by mental health nurses, the medically qualified sources of urgent support available to police officers to assist them to safeguard the public are limited to the mental health crisis teams. (2) The crisis teams may not be readily available and deal with their own case load. (3) The alternative support available from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system. (4) The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place. (5) This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community ”

    Source location

    Leighton Alan Dickens · 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

    Develop and operate a police contact protocol with NHS Wales clarifying access to urgent mental health advice and signposting to crisis teams.

    Verbatim wording from the response

    “Since the concerns raised in this inquest, we have worked with NHS Wales to develop an ‘NHS 111 Press 2 - Police Contact Protocol’. This provides clarity on how a range of professionals, including the police can access advice relating to urgent mental health concerns.”

    Source location

    Response from South Wales Police
    Page 5 · response
    Published 2 October 2024

    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

    Police should continue using established crisis contact points for section 136 advice; NHS 111 Press 2 is not the replacement route.

    Verbatim wording from the response

    “Since the concerns raised in this inquest, we have worked with NHS Wales to develop an ‘NHS 111 Press 2 - Police Contact Protocol’. This provides clarity on how a range of professionals, including the police can access advice relating to urgent mental health concerns.”

    Source location

    Response from South Wales Police
    Page 5 · response
    Published 2 October 2024

    Open published response
  2. South Wales Central

    AI-generated summary

    Leighton Alan Dickens · 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

    Leighton Alan Dickens died by incomplete atypical hanging alone at his home on 14 October 2020, after police encountered him undressed by the roadside while his partner was trying to take him to hospital. The report raised concerns that police did not detain him under section 136 of the Mental Health Act for assessment and that officers had limited access to qualified, clinically informed mental health advice and records when responding to community mental health crises.

    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 the intended “111 press 2” replacement mental health triage service

    Wider context from the report

    “The intended replacement of the mental health triage support was to have been by the “111 press 2” service. This has not been put in to place and there is no current timescale for it to be put into place. ”

    Source location

    Leighton Alan Dickens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026