First reported 16 Jan 2015•Latest report 23 Jun 2025
Definition
What this concern includes
Includes failures within mental-health services to explore non-attendance or reluctance to engage, make appropriate direct or assertive contact, assess current needs and risks, and avoid discharge until engagement or a safe alternative assessment and follow-up arrangement has been established.
Not included
Excludes ordinary missed appointments where the service undertook appropriate exploration, assertive engagement and safe follow-up or discharge planning.
Excludes general appointment scheduling, referral-access or waiting-time failures that do not concern engagement with a mental-health service user before discharge.
Excludes failures limited to follow-up after a service user has already been safely discharged; those concern post-discharge follow-up rather than pre-discharge engagement.
Excludes generic communication, staffing or training deficiencies unless they directly impair the mental-health engagement and discharge process.
Reports
7
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
14
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.
Cornwall Council2
Department of Health and Social Care2
NHS Cornwall and the Isles of Scilly Integrated Care Board2
49 Marine Avenue Surgery1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Moorbridge1
NHS North East and North Cumbria Integrated Care Board1
Norfolk and Suffolk NHS Foundation Trust1
Northumbria Healthcare NHS Foundation Trust1
Sussex Community NHS Foundation Trust1
Tees, Esk and Wear Valleys NHS Foundation Trust1
NHS trust5
Integrated care board3
English unitary authority2
Ministerial department2
Multi-service care provider1
Pupil referral unit / alternative provision1
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.
Northumberland
Concerns raised2
Lack of scrutiny of reluctance to engage and attend appointments
Failure to provide face-to-face or direct contact before CAMHS discharge
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.
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.8
Action
Review patient invitation and follow-up arrangements, considering additional family and community support to improve adolescent attendance and monitoring.
Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Action
Review, implement and share safeguarding procedures and checklists for children not brought to appointments or monitoring.
Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Develop a Dietetics SOP for managing patients who do not attend or are not brought, subject to Trust-wide agreement on tolerances for very low-weight patients.
Stated by Northumbria Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Action
Update CAMHS non-engagement guidance to address frequent cancellations, low weight or restricted intake, MDT discussion and safeguarding escalation.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Require CAMHS MDT discussion before discharging non-attending young people, including review of measurements, physical assessment needs and wider risks.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Capture the child or young person’s voice during assessment and reassess care plans and risks after cancellations or non-engagement.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Review CAMHS non-attendance and cancellation rates through caseload-management meetings, including checks of risk assessments and care plans.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Develop, implement and cascade an administrative SOP covering Dietetics non-attendance, cancellations, telephone substitutions and discharge without review.
Stated by Northumbria Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Cornwall and Isles of Scilly
Concerns raised1
Discharging referrals without clinical triage of non-response
This report raised 10 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.2
Position
No further difficulties need to be overcome in the referral pathway into secondary mental health services.
Stated by Cornwall CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
The Integrated Care Board is expected to respond to concerns about the specific care provided.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Northumberland and South Northumberland
Concerns raised2
Failure of the care coordinator to establish direct contact and a relationship with the service user before discharge
Insufficient in-person engagement before discharge from the Community Treatment Team
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.
North Northumberland
Concerns raised1
Failure to make in-person contact before discharging mental health patients who do not attend appointments
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.4
Action
Review the Did Not Attend policy to require in-person contact before mental-health discharge.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 November 2022.
Action
Share discharge lessons and face-to-face appointment requirements with service staff and Team Managers.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 November 2022.
Action
Update the service Operational Policy to reflect the revised face-to-face discharge process.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 November 2022.
Action
Request that the revised discharge process be incorporated into the Trust-wide discharge policy.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 November 2022.
Cornwall and Isles of Scilly
Concerns raised1
Failure to use an assertive approach to engage clients referred to mental health services
This report raised 3 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.1
Position
Existing discharge procedures, including multidisciplinary review and notifications to clinicians and patients, are considered a robust response to disengagement.
Stated by Cornwall Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Sussex
Concerns raised1
Failure to provide clinical contact and assessment after repeated service cancellations
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.2
Action
Create and implement a formal SOP governing service-cancelled appointments, including duty-therapist escalation after two cancellations.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 February 2020.
Action
Establish a digital alert process notifying senior therapists when two service appointments are cancelled without clinician contact.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2020.
Norfolk
Concerns raised1
Failure to establish contact and review non-attendance before discharge from mental health team
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.
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Includes failures within mental-health services to explore non-attendance or reluctance to engage, make appropriate direct or assertive contact, assess current needs and risks, and avoid discharge until engagement or a safe alternative assessment and follow-up arrangement has been established.
