Recurring concern

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

First to latest report 3 Mar 2014 — 15 Jun 2026

Reports that mention this concern
11
Times this concern has been raised
12
Stated actions linked to this concern
7

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.

What is 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 and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026