Recurring concern
Insufficient multi-disciplinary coordination in mental health care
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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.
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Concerns raised1
Lack of planned CMHT/HBTT involvement with the GP in overall management and treatment
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.1
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Action
Audit CMHT care plans and CPA reviews to verify GP contact and contribution to reviews, sharing findings and any action plan with divisional leadership.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Lack of co-ordinated and multi-agency working in care for persons subject to Community Mental Health Treatment Orders
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The local NHS is responsible for reviewing the case circumstances and taking necessary action to ensure services are safe and high quality.
Stated by Department of Health and Social Care
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Concerns raised1
Lack of joined-up mental health care and information sharing between professionals
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 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.
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Concerns raised2
Failure to implement a revised Multi Disciplinary Team agenda approach
Failure of mental health liaison practitioners to maintain records, follow systems and protocols, and involve practitioners in decision making
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 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.
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Concerns raised1
Insufficient multi-disciplinary working for complex mental health needs
This report raised 14 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.
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Concerns raised1
Lack of joint coordination between mental health and primary care services
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 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.1
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Action
Continue joint NELFT–Fullwell Cross meetings to agree the process for referrals, prescribing during medication changes and communication, including reconvening to resolve prescribing responsibilities.
Stated by North East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
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Position
NELFT cannot undertake prescribing because prescribers lack an overview of patients’ full medication and may miss interactions or contraindications.
Stated by North East London NHS Foundation Trust
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Position
NELFT cannot undertake prescribing because it lacks arrangements with community pharmacists to ensure frail patients receive medication.
Stated by North East London NHS Foundation Trust -
Position
NELFT cannot use FP10 prescribing for many Older Adult Mental Health Team patients who lack capacity.
Stated by North East London NHS Foundation Trust -
Position
NELFT cannot facilitate compliance aids through local pharmacists, so medication for patients using them must be organised by GPs.
Stated by North East London NHS Foundation Trust -
Position
NELFT cannot undertake FP10 prescribing for many patients in care or sheltered accommodation because those settings will not accept such prescriptions.
Stated by North East London NHS Foundation Trust
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Concerns raised1
Lack of active input from outside consultants into mental health unit patient care
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.
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Concerns raised1
Insufficient involvement of a multi-disciplinary team in care
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing multidisciplinary team oversight and supervision are considered sufficient even when one professional delivers the care plan.
Stated by Midlands Partnership University NHS Foundation Trust
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Concerns raised1
Failure to hold multi-disciplinary team meetings when pregnant women have known mental health conditions
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 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.1
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Action
Produce and prominently issue a reflective training vignette through the internal safety alert system, requiring confirmation of action and monitoring implementation through supervision and appraisal.
Stated by Avon and Wiltshire Mental Health Partnership NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
No revision of existing policies, systems or procedures was considered necessary in light of the deaths.
Stated by Avon and Wiltshire Mental Health Partnership NHS Trust
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Concerns raised1
Prescribing medication that is not preferred for a known mental-health condition without discussion with the responsible mental-health care team
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 concernsEach 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.3
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Position
Prescribing medication after hospital mental-health referral was conventional within multidisciplinary care and was not inherently concerning.
Stated by MDU Services Limited
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Position
The prescription was not based solely on verbal patient information; the relevant hospital office was contacted to verify recommendations.
Stated by MDU Services Limited -
Position
Using the existing medication was not shown to be unsafe: it had been tolerated previously and the subsequent psychiatrist did not change it.
Stated by MDU Services Limited
Data last updated 7 September 2026