Failure to provide clinically indicated psychiatric admission
First to latest report 13 Dec 2013 — 24 Nov 2025
Reports that mention this concern
12
Times this concern has been raised
12
Stated actions linked to this concern
26
What this concern includes
Includes failures to consider, offer, arrange or provide psychiatric hospital admission when a person's mental state, risk, symptoms or clinical needs indicate that admission should be considered or provided, including failure to admit despite patient or family requests where admission is clinically indicated.
What is not included
Excludes general hospital-admission delays or bed-capacity shortages unless the assertion specifically concerns a clinically indicated psychiatric admission decision or provision.
Excludes failures in psychiatric assessment, treatment, observation, discharge or follow-up where psychiatric admission is not the deficient control.
Excludes refusals or non-admission decisions where the report does not identify that psychiatric admission was clinically indicated.
Excludes failures confined to referral or crisis-team access when the unsafe condition is not failure to offer or provide psychiatric admission.
Trends
Reports over time
Reports mentioning this concern, 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 Care5
NHS England5
NHS Birmingham and Solihull Integrated Care Board2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Care Quality Commission1
Epsom Hospital1
Greater Manchester Mental Health NHS Foundation Trust1
Health and Care Professions Council1
Health Services Safety Investigations Body1
NHS Greater Manchester Integrated Care Board1
NHS South West London Integrated Care Board1
Norfolk and Suffolk NHS Foundation Trust1
North London NHS Foundation Trust1
NHS trust8
Executive non-departmental public body6
Ministerial department5
Integrated care board4
Education sector body1
English metropolitan district council1
Health and care professional regulator1
Health and social care service regulator1
Healthcare site1
Police force1
Private limited company1
Reports and published responses 12 reports
See individual reports that have raised this concern, and the actions taken in response
Surrey
Concerns raised1
Requirement for pre-planning before secure mental health unit admission
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
NHS England
Map emergency admission arrangements across adult forensic provider collaboratives, including out-of-hours access.
NHS England
Develop a national adult forensic Access Assessment Services specification requiring emergency adult forensic bed admission arrangements, including out-of-hours access.
NHS England
Launch and maintain a national database of adult forensic Access Assessment Services with referral and out-of-hours contact information.
Surrey
Concerns raised1
Lack of psychiatric hospital beds resulting in prolonged emergency department detention
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care
Epsom and St Helier University Hospitals NHS Trust
NHS Southwest London Integrated Care Board
Surrey and Borders Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Surrey and Borders Partnership NHS Foundation Trust
Increase the number of funded inpatient mental health beds for the Trust’s population.
Surrey and Borders Partnership NHS Foundation Trust
Continue improving service flow, aligning operational processes and reducing unnecessary inpatient delays and length of stay.
Surrey and Borders Partnership NHS Foundation Trust
Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
Epsom and St Helier University Hospitals NHS Trust
Provide daily escalation and weekly executive oversight of patients awaiting psychiatric admission through collaboration with SABP and the ICB.
NHS Southwest London Integrated Care Board
Maintain regular cross-boundary system calls and agreed escalation arrangements between Epsom General Hospital and mental health providers.
NHS Southwest London Integrated Care Board
Work with the commissioned mental health trust to improve the urgent care pathway, maximise appropriate crisis alternatives, and reduce delays in accessing inpatient beds.
NHS Southwest London Integrated Care Board
Use the assessment outputs to identify pathway gaps, support future commissioning and winter planning, and produce tailored improvement plans for mental healthcare delivery.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Epsom and St Helier University Hospitals NHS Trust
Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.
Outside remitThe respondent said that this matter was outside its role or authority.
Epsom and St Helier University Hospitals NHS Trust
Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS Southwest London Integrated Care Board
Surrey patients’ psychiatric beds are commissioned by Surrey Heartlands ICB from Surrey and Borders Partnership NHS Foundation Trust.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Unavailability of suitable psychiatric hospital bed spaces in a timely way
Linked response
NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
NHS England
Increase timely access to psychiatric hospital beds and provide earlier identification, treatment and support for people in custody who need mental healthcare.
NHS England
Address concerns and lessons identified in the HMIP review of delays transferring mentally unwell prisoners.
Cornwall and Isles of Scilly
Concerns raised1
Unavailability of hospital beds for informal admission
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
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.3
Department of Health and Social Care
The ICB considers its commissioned mental health bed capacity appropriate because it matches the national median per 100,000 population.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Department of Health and Social Care
The ICB relies on alternative solutions to mitigate the impact of closed mental health beds.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department of Health and Social Care
Closed acute and rehabilitation beds cannot be reinstated because of environmental issues being challenged through the provider’s contract.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Avon
Concerns raised1
Failure to admit a patient when admission is requested and clinically indicated
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Avon and Wiltshire Mental Health Partnership NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Avon and Wiltshire Mental Health Partnership NHS Trust
Ensure crisis care and treatment plans specify management escalation, including possible admission where appropriate.
Inner West London
Concerns raised1
Failure to consider appropriate admission
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised1
Failure to offer hospital admission when indicated
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised1
Failure to use section 4 for urgent cases
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Birmingham and Solihull Mental Health NHS Foundation Trust
Birmingham City Council
NHS Birmingham and Solihull Integrated Care Board
West Midlands Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands Police
Determine management arrangements for Section 136 cases.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands Police
Existing policies, clinical discretion and monitoring are considered sufficient safeguards for the exceptional use of Mental Health Act Section 4.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised1
Unavailability of inpatient mental health beds for patients requiring inpatient treatment
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS Birmingham and Solihull Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
NHS Birmingham and Solihull Integrated Care Board
Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
NHS Birmingham and Solihull Integrated Care Board
Commission an independent review of inpatient journeys to identify alternatives to admission and reduce avoidable discharge delays.
NHS Birmingham and Solihull Integrated Care Board
Support delayed-transfer initiatives through funded Section 117 care packages and escalation calls with providers and social-work teams.
NHS Birmingham and Solihull Integrated Care Board
Provide additional investment to expand commissioned mental-health service capacity and provision.
NHS Birmingham and Solihull Integrated Care Board
Continue supporting out-of-area NHS and independent hospital admissions when locally commissioned beds are unavailable and admission is necessary.
London Greater (East)
Concerns raised1
Failure to admit patients whose presentation requires hospital admission following psychiatric referral
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.