Recurring concern

Failure to ensure timely Lead Practitioner appointment for mental health patients

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First reported 21 Nov 2019•Latest report 15 Mar 2021

Definition

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.

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.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2019–2021

First to latest report issue date

Stated actions
2

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.

Sussex Partnership NHS Foundation Trust2

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. Brighton and Hove

    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

  2. West Sussex

    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
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Data last updated 7 September 2026