Recurring concern

Failure to integrate mental health services across care settings

First to latest report 17 Dec 2013 — 14 Jan 2026

Reports that mention this concern
33
Times this concern has been raised
39
Stated actions linked to this concern
53

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.

What is 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 and published responses 33 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Derby and Derbyshire

    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

  2. Powys, Bridgend and Glamorgan Valleys

    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

  3. Worcestershire

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026