Recurring concern

Failure to integrate mental health services across care settings

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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
Individual concerns: 39
Date range: 2013–2026
Stated actions: 53

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

16 Oct2015
Derby and Derbyshire
Concerns raised1
1. Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities
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.
Actions described in response 3
1. Action
  Review and clarify the respective roles and responsibilities of mental health and social care workers at the Service Manager Interface Meeting.
  Stated by Derbyshire County Council and Derbyshire Healthcare NHS Foundation TrustStated planned
2. Action
  Update the Care Programme Approach Policy with clearer guidance on the relationship between CPA and Self-Directed Support.
  Stated by Derbyshire County Council and Derbyshire Healthcare NHS Foundation TrustStated planned
3. Action
  Cascade the Service Manager Interface Meeting's role-clarification outcomes to staff through line-management supervision.
  Stated by Derbyshire County Council and Derbyshire Healthcare NHS Foundation TrustStated planned
AI-generated summary

Louise Sharon Henry · 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

Louise Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and procedures.

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 ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities
Wider context from the report
“1. The CMHT from the evidence I heard did not understand that the DCC Recovery Team is not following the Care Programme approach, neither are lead professionals from the DCC Recovery Team acting as care co-ordinators for the purposes of the Care Programme Approach [CPA]. I heard evidence that the Psychiatrist from the CMHT understood that the social worker from the DCC Recovery Team was Louise Henry’s Care coordinator for CPA purposes and was following the Care Programme Approach. I also heard evidence that when the services of the DCC Recovery Team and CMHT ceased to be an Integrated service the understanding of the psychiatrist had been that the DCC Recovery Team workers would be following the CPA. I heard evidence from DCC Recovery Team that this was not the case and that they were not following the CPA or acting as the care co-ordinator for the purposes of CPA but instead worked to the Self Directed Support framework. It is important that the CMHT understand the roles and responsibilities of the Lead professional from the DCC Recovery Team and that they are not following the Care Programme approach or acting as the care co-ordinator. It is of concern that workers from the CMHT and DCC Recovery Team who often are involved in providing multi agency mental health services and joint working to patients misunderstand each others roles, responsibilities and processes. The care co-ordinator is a key role in the management of a patient with mental health difficulties and it is important that there is no ambiguity in respect of who is acting in this capacity. ”
Source location
Louise Sharon Henry · Prevention of Future Deaths report
Page 3 · 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
Review and clarify the respective roles and responsibilities of mental health and social care workers at the Service Manager Interface Meeting.

Verbatim wording from the response
“In order to address these concerns the Council and DCHFT intend to review:-”

Source location
2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Page 3 · response
Published 16 January 2015
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
Update the Care Programme Approach Policy with clearer guidance on the relationship between CPA and Self-Directed Support.

Verbatim wording from the response
“2. Preliminary discussions have already taken place between Health and Social Care senior managers about the interface between CPA and SDS. Both organisations are clear that the two policies are intended to be complementary. It is acknowledged there may be cases where the individual is subject to CPA but where a social worker is the lead practitioner. The Council is clear that in following SDS, this will also fulfil the requirements of CPA. A plan involving senior managers from both organisations has been agreed to update the DCHFT Care Programme Approach Policy to provide clearer updated guidance upon this issue.”

Source location
2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Page 4 · response
Published 16 January 2015
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
Cascade the Service Manager Interface Meeting's role-clarification outcomes to staff through line-management supervision.

Verbatim wording from the response
“4. The Council has also established that there is still some work to be done in terms of education for health and social care workers on the expectations of each service pathway. The outcomes of the Service Manager Interface Meeting described above will be cascaded down to staff via line management supervision.”

Source location
2015-0013-Response-by-Derbyshire-Healthcare-NHS-Trust
Page 4 · response
Published 16 January 2015
Open published response
19 Feb2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Lack of a formal communication mechanism between mental health out-patient and acute services
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 1
1. Action
  Review the Care Treatment Plan Policy and Procedures used in the outpatients department.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated completed
AI-generated summary

Barrie Lewis · 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

Barrie Lewis was found by his family hanging from a rope attached to a garage rafter on 31 August 2014. The inquest concluded that his death was suicide. Concerns included the absence of a specific risk assessment for suicidal ideation, poor communication between mental health services, no reliable system assigning responsibility for assistance, and a lack of clinical records of crisis-team contact.

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 formal communication mechanism between mental health out-patient and acute services
Wider context from the report
“[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) A clinical review was undertaken of the contact the deceased had with the mental health services in the days prior to his death and it was apparent from that review, and from the evidence heard that: a) That no risk assessment was undertaken to detail risks specifically associated with the deceased’s suicidal ideation which, on the evidence, would have assisted the crisis team in assessing his risk of suicide or self harm. b) There was little formal mechanism for communication between the mental health out patients department and the acute services which he accessed in the days prior to his death. c) There was no reliable system to ensure that a member of the crisis team took responsibility for providing assistance to the deceased – simply leaving the deceased to make his own telephone call to the appropriate department. d) No clinical recordings were made of the contact the deceased had with the crisis team (Crisis Resolution Home Treatment team) following his contact with them. ”
Source location
Barrie Lewis · 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
Review the Care Treatment Plan Policy and Procedures used in the outpatients department.

Verbatim wording from the response
“2. Actions implemented”

Source location
2015-0065-Response-by-University-Health-Board
Page 1 · response
Published 19 February 2015
Open published response
17 Dec2013
Worcestershire
Concerns raised2
1. Failure of effective communication of patient risk between mental health teams
2. Failure to define and communicate mental health teams' roles and responsibilities for onward care
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.
AI-generated summary

Sean Christopher Seabourne · 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

Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.

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 effective communication of patient risk between mental health teams
Wider context from the report
“(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests. (2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient. (3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team. It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself. It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself. Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case. ”
Source location
Sean Christopher Seabourne · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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 define and communicate mental health teams' roles and responsibilities for onward care
Wider context from the report
“(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests. (2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient. (3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team. It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself. It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself. Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case. ”
Source location
Sean Christopher Seabourne · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to ensure shared understanding of care co-ordinator roles and Care Programme Approach responsibilities

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.3

Concerns raised1

Lack of a formal communication mechanism between mental health out-patient and acute services

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

Concerns raised2

Failure of effective communication of patient risk between mental health teams

Failure to define and communicate mental health teams' roles and responsibilities for onward care

Actions described in response 3

Actions described in response 1