Recurring concern

Failure to ensure timely Lead Practitioner appointment for mental health patients

First to latest report 21 Nov 2019 — 15 Mar 2021

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 2

What this concern includes

Includes failures of the dedicated Lead Practitioner appointment and continuity process in mental health care, including failure to appoint urgently, failure to appoint on transfer between services, and comparable delays that leave patients without the required Lead Practitioner.

What is not included

Excludes failures concerning care coordinators, social workers or other roles unless the report specifically identifies the Lead Practitioner appointment process.
Excludes generic mental-health staffing, follow-up, communication or care-coordination deficiencies where failure to appoint or maintain a Lead Practitioner is not the unsafe condition.
Excludes deficiencies in the wider Care Programme Approach that do not concern appointment or continuity of the Lead Practitioner.
Excludes failures occurring after a Lead Practitioner has been appointed unless they directly concern the reliability of that appointment or continuity arrangement.

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

Reports about this concern sent to each recipient.

Sussex Partnership NHS Foundation Trust2

Reports and published responses 2 reports

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

15 Mar2021
Brighton and Hove
Concerns raised1
1. Failure to appoint a Lead Practitioner when urgently needed
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.
AI-generated summary

Timothy Julian STEELE · 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

Timothy Julian STEELE was a 28-year-old man with a lifelong history of low mood, depression and suicidal ideation, who made multiple suicide attempts during 2020 and died at his home in Brighton on 10 August 2020. The report identified concerns that his referral was lost, that he was not followed up because of inefficient processes and failure to appoint a Lead Practitioner promptly, and that the Care Programme Approach was not followed. It also identified a fragmented approach to policies across different areas of Sussex.

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
Failure to appoint a Lead Practitioner when urgently needed
Wider context from the report
“(1) Mr. Steele was lost to ATS follow up apparently due to inefficient processes and a failure to appreciate the urgent need to appoint a Lead Practitioner for him. In particular the focus and delivery of the Care Programme Approach (CPA) as set out in national guidance “Refocusing the CPA- Policy and Positive Practical Guidance” does not appear to have been followed. ”
Source location
Timothy Julian STEELE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Nov2019
West Sussex
Concerns raised1
1. Failure to appoint a Lead Practitioner when transferring patients between the CRHTT and ATS
Linked response

Sussex Partnership NHS Foundation Trust
Stated actions 2
1. Sussex Partnership NHS Foundation Trust
  Implement a transfer process for allocating Lead Practitioners and providing interim treatment, support, contact details and follow-up plans when immediate allocation is unavailable.
2. Sussex Partnership NHS Foundation Trust
  Monitor weekly patients transferred between teams who remain without an allocated Lead Practitioner.
Respondent positions 2
1. Sussex Partnership NHS Foundation Trust
  There is no delay in patients receiving treatment when transferred between the CRHTT and ATS.
  Disputes the concern
1. Sussex Partnership NHS Foundation Trust
  Existing monitoring and Duty Worker arrangements are sufficient while a Lead Practitioner is identified after transfer.
  Existing arrangements considered sufficient
AI-generated summary

George Edward Rogers · 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

George Edward Rogers had a diagnosis of body dysmorphic disorder and died on 28 August 2018 after causing a fatal laceration to his chest. Following his transfer between care teams, a Lead Practitioner was not appointed promptly, resulting in a period without treatment or ongoing risk assessment. The principal concern was that such transfer arrangements could delay treatment and leave patients unmonitored.

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
Failure to appoint a Lead Practitioner when transferring patients between the CRHTT and ATS
Wider context from the report
“1. When transferring patients between the CRHTT and ATS there is not always a Lead Practitioner appointed on transfer which may (a) delay patients receiving treatment and (b) mean that patients may not be monitored pending the appointment. ”
Source location
George Edward Rogers · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a transfer process for allocating Lead Practitioners and providing interim treatment, support, contact details and follow-up plans when immediate allocation is unavailable.

Verbatim wording from the response
“The process for allocation of a Lead Practitioner is as follows; the CRHTT attends the weekly Multi-Professional ATS meeting (ATS - sometimes referred to as a Community Mental Health Team) to provide an update on each case and to request allocation, if needed, of a Lead Practitioner.”

Source location
Response from Sussex Partnership NHS Foundation Trust
Page 1 · response
Published 27 November 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Monitor weekly patients transferred between teams who remain without an allocated Lead Practitioner.

Verbatim wording from the response
“Any patient not allocated a Lead Practitioner is monitored by the Team Leader on a weekly basis.”

Source location
Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 27 November 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
There is no delay in patients receiving treatment when transferred between the CRHTT and ATS.

Verbatim wording from the response
“I hope that the content of this letter and its enclosures addresses your concerns and provides you with assurance that there is no delay in a patient receiving access to treatment on transfer between CRHTT and the ATS, that there is a process in place to monitor patients who have been transferred and are receiving support with the Duty Worker whilst a Lead Practitioner is identified. However, if any further clarification is required or I can assist further in any way then please do not hesitate to contact me.”

Source location
Response from Sussex Partnership NHS Foundation Trust
Page 2 · response
Published 27 November 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing monitoring and Duty Worker arrangements are sufficient while a Lead Practitioner is identified after transfer.

Verbatim wording from the response
“If the patient is already known to the team, the Lead Practitioner (ATS) will remain involved and work with the CRHTT throughout the episode of care. If the person is unknown to the ATS, the CRHTT and ATS will work together to plan onward care and support. Where a Lead Practitioner cannot be provided immediately by the ATS, an initial appointment will be offered within 7 days of transfer from the CRHTT and follow-up plans will be agreed. This may include care and support being offered by the ATS Duty Worker (a senior registered professional) who the patient will be able to contact for support. This support includes face to face contact on the same day if necessary and attendance at the ATS if”

Source location
Response from Sussex Partnership NHS Foundation Trust
Page 1 · response
Published 27 November 2019
Open published response