Recurring concern

Inadequate integrated care for people with co-occurring physical and mental health needs

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First reported 3 Mar 2014•Latest report 15 Jun 2026

Definition

What this concern includes

Includes deficiencies in facilities, care pathways, coordination or delivery that are specifically intended to provide integrated physical and mental healthcare for the same patient group.

Not included

  • Excludes generic shortages of mental health facilities or placements where co-occurring physical and mental health needs are not identified.
  • Excludes failures concerning substance misuse or other complex needs unless they are explicitly tied to integrated physical and mental healthcare.
  • Excludes generic staffing, training, documentation or communication deficiencies that are not specifically dedicated to this integrated care concern.
Reports
11

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
7

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
NHS England2
Norfolk and Suffolk NHS Foundation Trust2
Royal College of Psychiatrists2
BNF Publications1
British Association Of Dermatologists1
Cwm Taf Morgannwg University Local Health Board1
Hellesdon Hospital1
Mid Yorkshire Teaching NHS Trust1
NHS Hertfordshire and West Essex Integrated Care Board1
Royal College of Physicians1
South London and Maudsley NHS Foundation Trust1
South London Healthcare NHS Trust1
South West Yorkshire Partnership Teaching NHS Foundation Trust1
Sussex Partnership NHS Foundation Trust1

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. Inner South London

    AI-generated summary

    Kirabo Kiwanuka · 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

    Kirabo Kiwanuka, a 28-year-old woman with bipolar disorder, died on 11 June 2011 after developing tachycardia, tachypnoea, pyrexia and markedly raised creatinine kinase during psychiatric treatment. The inquest recorded sudden unexpected death in a patient treated with multiple drugs, while NMS could not be confirmed or excluded as a contributory factor. Concerns included uncertainty about diagnosing and managing NMS, whether patients with physical illness in psychiatric facilities should receive medical review or be transferred, and limited family involvement in treatment decisions.

    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 clarity about the appropriate care setting and staffing model for physically ill psychiatric patients

    Wider context from the report

    “2. There is lack of clarity about whether acutely manic patients in a psychiatric facility with physical illness should receive domiciliary visits from physicians and medical care in the psychiatric facility or be transferred to a medical facility, where psychiatric staff attend and visit. She was not examined by a physician when she developed abnormal vital signs. At the time it appears that there was no facility for a physician from the neighbouring hospital to be called out for a medical opinion, although this is currently being explored by SLAM and KCH and is included in a draft protocol. When are patients best under the care of a medical and when a psychiatric ITU? How are Trusts to know what is the optimal model of care? ”

    Source location

    Kirabo Kiwanuka · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026