First reported 17 Dec 2013•Latest report 14 Jan 2026
Definition
What this concern includes
Includes failures of the explicitly identified mental health service system to integrate its sections, teams or care settings, including fragmented inpatient-community arrangements, service silos, unclear cross-service ownership and absent mechanisms for coordinated care.
Not included
Excludes generic communication, information-sharing or coordination failures unless they directly demonstrate fragmentation or failure to integrate mental health services across care settings.
Excludes deficiencies within a single mental health service or clinical intervention where no cross-service integration problem is identified.
Excludes integration failures involving non-mental-health services unless the assertion directly concerns the integration of mental health provision.
Excludes generic staffing, training, documentation or facility deficiencies that are not specifically tied to integration of mental health services.
Reports
33
Distinct published reports
Individual concerns
39
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
53
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.
NHS England11
Department of Health and Social Care8
Pennine Care NHS Foundation Trust4
Birmingham Women'S and Children'S NHS Foundation Trust2
Cornwall Partnership NHS Foundation Trust2
Greater Manchester Health and Social Care Partnership2
NHS Birmingham and Solihull Integrated Care Board2
NHS Greater Manchester Integrated Care Board2
NHS Northamptonshire Integrated Care Board2
Northamptonshire Healthcare NHS Foundation Trust2
Office of the Chief Coroner2
Aneurin Bevan University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Care Quality Commission1
NHS trust25
Executive non-departmental public body11
Integrated care board11
Ministerial department8
Healthcare site5
Clinical commissioning group2
Coronial office2
English metropolitan district council2
Health-system partnership2
Local health board2
Company limited by guarantee1
English county council1
English unitary authority1
Health and social care service regulator1
National policing body1
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.
Kent and Medway
Concerns raised1
Failure to assign ownership of urgent risk management across services
This report raised 4 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.
Northamptonshire
Concerns raised1
Lack of a consistent protocol for patients receiving private and NHS psychiatry
This report raised 2 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.
Northamptonshire
Concerns raised1
Lack of a protocol for patients receiving concurrent private and NHS psychiatry
This report raised 2 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
Develop and complete a Trust-wide protocol for managing patients receiving simultaneous NHS and private psychiatric care.
Stated by NHFTStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2026.
Surrey
Concerns raised1
Failure of secondary mental health services to ensure primary care follow-up has been undertaken after transfer
This report raised 2 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.
Manchester South
Concerns raised1
Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient
This report raised 6 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
Revise the repatriation procedure to support communication and continuity of care for international patients.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
Action
Share the revised community mental health policy’s final draft with the Trafford Strategic Safeguarding Partnership.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 October 2024.
Action
Share learning with the overseas hospital consultant and reinforce proactive communication before discharge.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
Action
Continue monitoring how providers work with other agencies during service transitions to prevent gaps in care.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Policing, mental health management, cross-service collaboration and GP decision-making do not concern Trafford Council’s actions or decisions, so it cannot address them.
Stated by Trafford Borough CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
Overseas healthcare providers cannot be mandated to share clinical information when patients are medically repatriated.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
A provider cannot reasonably be expected to know about a patient’s return when the patient independently arranged travel and gave no notification.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Concerns about police training, family notification, international mental health connectivity and GP list removals relate to other organisations and fall outside NWAS’s remit.
Stated by North West Ambulance Service NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Mental-health repatriation is not provided for by the Mental Health Act and presents infeasible data-protection, language and logistical challenges.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised1
Failure to provide continuity and handover between hospital and community psychology services
This report raised 2 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.5
Action
Provide formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Regularly audit handovers to verify safe transfer of psychological care to community teams.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Review the operational model for transitions and handovers between inpatient and community psychological services.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
Action
Introduce locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Patients do not always require immediate ongoing psychological therapy after discharge; treatment urgency should be determined by clinical need.
Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.
Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Hampshire, Portsmouth and Southampton
Concerns raised1
Fragmented connectivity between mental health and physical or neurodivergence services
This report raised 7 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
Establish a single community and mental health provider through Project Fusion.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
Action
Develop a countywide neurodiversity best-practice network and working groups to create measurable, sustainable operating procedures.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
Action
Recommission autism and ADHD assessment and prescribing pathways to provide a cohesive population-wide service.
Stated by NHS Hampshire and Isle of Wight Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
Action
Operate an all-age autism and ADHD improvement group to oversee transformation of the neurodiversity pathway.
Stated by NHS Hampshire and Isle of Wight Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
South London
Concerns raised1
Failure of Child & Adolescent Mental Health Service teams to work together effectively
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Local commissioners and providers are responsible for addressing local support provision and service integration concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England is mainly responsible for addressing the concerns about care provision for children and young people with complex needs.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Gwent
Concerns raised1
Failure to establish clear ownership of care between mental health and ENT teams
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.2
Action
Expand Adferiad through recurrent funding, broader eligibility and a multidisciplinary team providing assessment, care planning and rehabilitation expertise.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 4 October 2022.
Action
Map existing services to support appropriate pathway allocation for people referred to the expanded Adferiad service.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 4 October 2022.
North Yorkshire and York including North Yorkshire Western District
Concerns raised1
Failure of communication and shared information across autism and mental health teams
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.5
Action
Work with TEWV to resolve internal and external communication issues affecting patient care.
Stated by NHS Humber and North Yorkshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Share learning with clinical teams and work with external partners to improve timely, constructive communication and cohesive patient care.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
TEWV is responsible for delivering core mental health care and making reasonable adjustments for patients with autism.
Stated by NHS Humber and North Yorkshire Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of the explicitly identified mental health service system to integrate its sections, teams or care settings, including fragmented inpatient-community arrangements, service silos, unclear cross-service ownership and absent mechanisms for coordinated care.
