Recurring concern
Insufficient multi-disciplinary coordination in mental health care
Pin
Get email alerts
Request correctionFirst reported 21 Aug 2013•Latest report 5 Feb 2026
What this concern includes
Includes failures of multi-disciplinary involvement, discussion, coordination or joint working that are directly part of mental health care, including failures involving complex needs, discharge planning, referrals or multiple treatment pathways.
Not included
- Excludes failures of communication, referral, assessment or documentation that are not directly tied to multi-disciplinary coordination in mental health care.
- Excludes generic staffing, training, facility or service-capacity deficiencies unless the report directly identifies their effect on multi-disciplinary coordination.
- Excludes multi-agency coordination concerns where the central issue is not also multi-disciplinary mental health care.
- Reports
- 22
- Individual concerns
- 24
- Date range
- 2013–2026
- Stated actions
- 28
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
-
Concerns raised1
Failure of mental health professionals to work collaboratively to find a safe crisis-care solution
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 concernsEach 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.3
-
Action
Implement a borough-based mental-health service structure to support integrated, less fragmented care.
Stated by West London NHS Trust -
Action
Bring Ealing Psychiatry Liaison and crisis teams under a single senior manager.
Stated by West London NHS Trust -
Action
Transform mental health services into community-based mental health centres bringing crisis services and short-stay beds together.
Stated by Department of Health and Social Care
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 Care
-
Concerns raised1
Failure of internal multidisciplinary joint working
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 concernsEach 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
Establish and staff a dedicated Early Days in Custody Nurse role to oversee reception screening, risk assessment, information sharing, escalation, supervision, and quality assurance.
Stated by HCRG Care Group -
Action
Provide structured reception-nurse supervision, coaching, documentation audits, case-based feedback, and governance reporting to improve recording and escalation of mental-health risks.
Stated by HCRG Care Group -
Action
Review mental-health operational procedures and referral processes to clarify urgent-referral thresholds, escalation routes, and expected 24-hour response times.
Stated by HCRG Care Group
-
Action
Standardise sample-based community mental health caseload audits across localities.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Reissue mandatory escalation guidance and introduce MDT agendas and case-presentation templates for changing risk or uncertainty.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Require teams to record cases needing MDT discussion and require team leaders to review compliance weekly.
Stated by Essex Partnership University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing supervision, MDT escalation, governance, and proportionate sample-based audits are considered sufficient; exhaustive case-by-case auditing is not required.
Stated by Essex Partnership University NHS Foundation Trust
-
Concerns raised1
Lack of an embedded mechanism for cross-sector MDT meetings and liaison in foreign-body cases
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
Trial a joint physical and mental health policy for managing patients who insert foreign bodies, including joint meetings and impact review.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Implement and approve a new guideline for managing deliberately inserted foreign bodies, including clear MDT and mental-health consultation requirements.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
-
Concerns raised1
Lack of a clear prescribing decision-making and coordination system for mental health medication
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 concernsEach 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.3
-
Action
Add prescribing responsibilities and communication instructions to standard letters sent to GPs when service users join CRHT caseloads.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Remind staff to liaise directly with GPs when requesting adjustments to medications already prescribed by GPs.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Undertake a joint clinical audit with primary care colleagues three months after implementing the revised CRHT wording and report results to the Trust-wide Safety Group.
Stated by Norfolk and Suffolk NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Commissioning NHS 111 Option 1 and out-of-hours GP services is outside the respondent’s responsibility.
Stated by Norfolk and Suffolk NHS Foundation Trust
-
Concerns raised1
Lack of clarity about the role and remit of the Mental Health Liaison Team
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 concernsEach 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
Implement and use a ratified policy defining clinical roles, referral pathways, mandatory specialist-team referrals, and Mental Health Liaison Team responsibilities.
Stated by Northern Care Alliance NHS Foundation Trust -
Action
Share the ratified policy with Pennine Care NHS Foundation Trust for cross-trust review and suggested revision.
Stated by Northern Care Alliance NHS Foundation Trust -
Action
Review and clarify referral policies and procedures for eating-disorder assessments and Mental Health Act considerations.
Stated by Pennine Care NHS Foundation Trust
-
Action
Make the referral policy available to staff in both organisations, including Accident and Emergency Department staff.
Stated by Pennine Care NHS Foundation Trust -
Action
Share inquest learning and policy details with the appropriate teams through managers.
Stated by Pennine Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The existing policy sufficiently clarifies responsibilities and referral pathways for adult patients with eating disorders across the Trusts.
Stated by Northern Care Alliance NHS Foundation Trust
-
Concerns raised1
Failure to conduct meaningful multi-team discussion at screening MDT meetings
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of care-coordinator oversight for complex cases outside secondary mental health services
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of multi-disciplinary team discussion to ensure a safe community plan following discharge
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Delays in taking patients onto the mental health caseload and providing allocated CPN and MDT oversight
Absence of a psychiatrist from the mental health MDT
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 concernsEach 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
Run a three-month pilot providing weekly Consultant Psychiatrist attendance at prison MDT meetings.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Review the clinical outcomes of the Consultant Psychiatrist MDT attendance pilot after three months.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
A psychiatrist need not be included in every mental health MDT; membership depends on the patient's history and presentation.
Stated by NHS England
-
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 concernsEach 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 LHB -
Action
Map existing services to support appropriate pathway allocation for people referred to the expanded Adferiad service.
Stated by Aneurin Bevan University LHB
Data last updated 7 September 2026