Recurring concern

Insufficient multi-disciplinary coordination in mental health care

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First reported 21 Aug 2013•Latest report 5 Feb 2026

Definition

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

Distinct published reports

Individual concerns
24

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
28

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.

Department of Health and Social Care6
Avon and Wiltshire Mental Health Partnership NHS Trust2
Greater Manchester Mental Health NHS Foundation Trust2
Norfolk and Suffolk NHS Foundation Trust2
North East London NHS Foundation Trust2
Pennine Care NHS Foundation Trust2
Aneurin Bevan University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
BNF Publications1
British Association Of Dermatologists1
Cheshire and Wirral Partnership NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Droylsden Road Family Practice1
Essex Partnership University NHS Foundation Trust1
HCRG Care Services Ltd1

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.

  1. Norfolk

    AI-generated summary

    Matthew Christopher Dunham · 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

    Matthew Christopher Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.

    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 coordination and information sharing between mental health professionals

    Wider context from the report

    “e) Most disturbingly the evidence at the hearing displayed a lack of coordination between mental health professionals involved in Mr Dunham's care. Specifically when a mental health nurse saw Mr Dunham on the 8th of April he had no knowledge whatsoever that Mr Dunham was already being seen by a psychological wellbeing practitioner. This clearly demonstrates the need for effective information sharing between professionals involved in managing the care of a mentally ill person and the need for each and every professional to have access to all the records relating to the patient and details of interventions and actions by other practitioners. It is recognised that the Trust is working towards the implementation of a single electronic health record in 2014. ”

    Source location

    Matthew Christopher Dunham · Prevention of Future Deaths report
    Page 2 · 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

    Base a Crisis Resolution and Home Treatment team member within the Access and Assessment Team to support prompt joint working and care transitions.

    Verbatim wording from the response

    “To enhance the interface between the two clinical teams, Access and Assessment Team (AAT) and CRHT, a member of the CRHT is now based within the AAT. This enables joint working without any delay, supporting transition of care between the two teams. The Trust is monitoring its effectiveness in identifying people in need of this crisis support.”

    Source location

    Response
    Page 2 · response
    Published 26 January 2014

    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

    Work towards implementing a single electronic health record across the Trust’s services.

    Verbatim wording from the response

    “E) Most disturbingly the evidence at the hearing displayed a lack of coordination between mental health professionals involved in Mr Dunham's care. Specifically when a mental health nurse saw Mr Dunham on the 8 April he had no knowledge whatsoever that Mr Dunham was already being seen by a psychological wellbeing practitioner. This clearly demonstrates the need for effective information sharing between professionals involved in managing the care of a mentally ill person and the need for each and every professional to have access to all the records relating to the patient and details of interventions and actions by other practitioners. It is recognised that the Trust is working towards the implementation of a single electronic health record in 2014.”

    Source location

    Response
    Page 2 · response
    Published 26 January 2014

    Open published response

  2. West Sussex

    AI-generated summary

    Mr Walker · 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

    Mr Walker, who had depression, suicidal ideation and a history of impulsive self-harm attempts, died after leaving the hospital ward and hanging himself in nearby woodland. Concerns included insufficient risk care planning, unexplained reductions in observation levels, the time taken to declare him missing and inform police, and the scalability of the ward’s external fences.

    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 communicate risk-care-planning issues among all MDT members

    Wider context from the report

    “(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised. ”

    Source location

    Mr Walker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026