First reported 13 Dec 2013•Latest report 24 Nov 2025
Definition
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.
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.
Reports
12
Distinct published reports
Individual concerns
12
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
26
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 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
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.
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.
Responses linked to these concerns
Each 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
Map emergency admission arrangements across adult forensic provider collaboratives, including out-of-hours access.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2025.
Action
Develop a national adult forensic Access Assessment Services specification requiring emergency adult forensic bed admission arrangements, including out-of-hours access.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2025.
Action
Launch and maintain a national database of adult forensic Access Assessment Services with referral and out-of-hours contact information.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 1 December 2025.
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.
Responses linked to these concerns
Each 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.7
Action
Increase the number of funded inpatient mental health beds for the Trust’s population.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Continue improving service flow, aligning operational processes and reducing unnecessary inpatient delays and length of stay.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025.
Action
Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025.
Action
Provide daily escalation and weekly executive oversight of patients awaiting psychiatric admission through collaboration with SABP and the ICB.
Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Maintain regular cross-boundary system calls and agreed escalation arrangements between Epsom General Hospital and mental health providers.
Stated by NHS Southwest London Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025.
Action
Work with the commissioned mental health trust to improve the urgent care pathway, maximise appropriate crisis alternatives, and reduce delays in accessing inpatient beds.
Stated by NHS Southwest London Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025.
Action
Use the assessment outputs to identify pathway gaps, support future commissioning and winter planning, and produce tailored improvement plans for mental healthcare delivery.
Stated by NHS Southwest London Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.
Stated by Epsom and St Helier University Hospitals NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.
Stated by Epsom and St Helier University Hospitals NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Surrey patients’ psychiatric beds are commissioned by Surrey Heartlands ICB from Surrey and Borders Partnership NHS Foundation Trust.
Stated by NHS Southwest London Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.
Stated by Department of Health and Social CareRedirects 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
Responses linked to these concerns
Each 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
Increase timely access to psychiatric hospital beds and provide earlier identification, treatment and support for people in custody who need mental healthcare.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
Action
Address concerns and lessons identified in the HMIP review of delays transferring mentally unwell prisoners.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 February 2024.
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.
Responses linked to these concerns
Each 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
Position
The ICB considers its commissioned mental health bed capacity appropriate because it matches the national median per 100,000 population.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The ICB relies on alternative solutions to mitigate the impact of closed mental health beds.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Closed acute and rehabilitation beds cannot be reinstated because of environmental issues being challenged through the provider’s contract.
Stated by Department of Health and Social CareUnable 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.
Responses linked to these concerns
Each 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
Action
Ensure crisis care and treatment plans specify management escalation, including possible admission where appropriate.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 November 2022.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.
Responses linked to these concerns
Each 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
Action
Determine management arrangements for Section 136 cases.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing policies, clinical discretion and monitoring are considered sufficient safeguards for the exceptional use of Mental Health Act Section 4.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Council and NHS Birmingham and Solihull Integrated Care Board and West Midlands PoliceExisting 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.
Responses linked to these concerns
Each 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
Commission independent system modelling to identify solutions and investment priorities for mental-health demand and capacity.
Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.
Action
Commission an independent review of inpatient journeys to identify alternatives to admission and reduce avoidable discharge delays.
Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.
Action
Support delayed-transfer initiatives through funded Section 117 care packages and escalation calls with providers and social-work teams.
Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.
Action
Provide additional investment to expand commissioned mental-health service capacity and provision.
Stated by NHS Birmingham and Solihull Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 October 2018.
Action
Continue supporting out-of-area NHS and independent hospital admissions when locally commissioned beds are unavailable and admission is necessary.
Stated by NHS Birmingham and Solihull Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2018.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Pin
Get email alerts
Request correction
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.
