Recurring concern

Failure to provide continuous access to appropriate mental health care

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First reported 3 Feb 2015•Latest report 12 Dec 2019

Definition

What this concern includes

Includes failures in mental health service access, assessment or acceptance arrangements that exclude or leave people without care because their presentation does not fit a psychiatric label, service remit or boundary between mental health organisations, including gaps between OSW and CMHT thresholds.

Not included

Excludes generic mental health waiting-time, staffing or treatment-quality concerns where no service-boundary or diagnostic-acceptance gap is identified.
Excludes failures within a specific mental health referral, crisis, home-treatment or discharge pathway when that named pathway is the material unsafe condition.
Excludes cases where a person was appropriately assessed and offered suitable mental health care, but later treatment or follow-up was inadequate.
Excludes generic gaps in services for overlapping mental-health and complex needs unless the assertion specifically identifies exclusion or lack of access caused by diagnostic or organisational thresholds.

Reports: 3
Individual concerns: 3
Date range: 2015–2019
Stated actions: 6

Reports 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.

Department of Health and Social Care1

NHS Cornwall and the Isles of Scilly Integrated Care Board1

NHS South Yorkshire Integrated Care Board1

Norfolk and Suffolk NHS Foundation Trust1

Sheffield Children's Hospital1

Sheffield Health Partnership University 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.

12 Dec2019
Norfolk
Concerns raised1
1. Failure to accept patients whose mental state does not fit a psychiatric label
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.
AI-generated summary

Peter Frosdick · 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

Peter Frosdick, who had cirrhosis and was experiencing paranoid thinking, extreme anxiety and irrational behaviour, died by hanging in his garage. The concerns raised included that his mental health was not adequately assessed beyond his alcohol dependence, that home treatment or hospital admission was not offered or explored, and that teams appeared unfamiliar with each other’s referral criteria and dismissed his GP’s concerns.

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 accept patients whose mental state does not fit a psychiatric label
Wider context from the report
“(2) His mental state was not classed as a psychiatric illness and since he did not fit neatly under a label he was not taken on. When seen by the Crisis Home Resolution Treatment Team, home treatment was not offered or explored. His mother states that hospital admission was not offered and a referral to Wellbeing Services should have been made but wasn't. ”
Source location
Peter Frosdick · Prevention of Future Deaths report
Page 1 · concerns
Open source report
3 Apr2019
South Yorkshire (Western)
Concerns raised1
1. Lack of urgent mental health service provision for 16- and 17-year-olds
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 6
1. Action
  Complete and approve the business case for the CAMHS Home Intensive Treatment Team.
  Stated by NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation TrustStated completed
2. Action
  Reconfigure the existing Sheffield Treatment and Recovery Service into a CAMHS Home Intensive Treatment Team for young people up to age 18.
  Stated by NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation TrustStated in progress
3. Action
  Recruit nursing staff for the new CAMHS Home Intensive Treatment Team.
  Stated by NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation TrustStated in progress
1. Action
  Establish a Mental Health Liaison Team supporting 0–18-year-olds attending designated emergency departments, with out-of-hours cover.
  Stated by NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation TrustStated planned
2. Action
  Implement the temporary care pathway change agreed with Sheffield Health and Social Care NHS Foundation Trust.
  Stated by NHS South Yorkshire Integrated Care Board and Sheffield Children'S NHS Foundation TrustStated completed
3. Action
  Implement jointly approved policy arrangements providing out-of-hours emergency home treatment to eligible 16- and 17-year-olds requiring crisis intervention.
  Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation TrustStated completed
AI-generated summary

Aryan Akhgar · 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

Aryan Akhgar, aged 17, died on 6 March 2018 after hanging himself with the intent to take his own life. The report identified a gap in urgent mental health services for 16- and 17-year-olds in Sheffield: although an urgent response was recommended on 9 January 2018, the first visit by mental health professionals did not occur until 15 January 2018. The report also raised concern that funding for additional CAMHS resources was not guaranteed.

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 urgent mental health service provision for 16- and 17-year-olds
Wider context from the report
“5.1 A gap in services was identified for 16 and 17 years old’s with urgent mental health issues, such as Aryan had. On 9th January 2018, Aryan was assessed as requiring urgent mental health input, commencing the next day. This was not available as a service for under 18’s in Sheffield and so a referral to Adult Mental Health Services was made in order to obtain this. The adult service refused to take the referral because Aryan was still a child. This gap in the provision between the two services meant that Aryan did not receive the urgent mental health input which he required and there is a risk that other under 18’s in his situation might also suffer the same problem. ”
Source location
Aryan Akhgar · 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
Complete and approve the business case for the CAMHS Home Intensive Treatment Team.

Verbatim wording from the response
“At the time of writing, the business case for the HITT team has been completed and was approved by the CCG on 7th May 2019, with a plan to begin a phased implementation from the autumn 2019. The service will be evaluated to ensure that it meets the needs of the young people who are its service users.”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
Page 2 · response
Published 9 June 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
Reconfigure the existing Sheffield Treatment and Recovery Service into a CAMHS Home Intensive Treatment Team for young people up to age 18.

Verbatim wording from the response
“Sheffield Children’s NHS Foundation Trust and NHS Sheffield Clinical Commissioning Group have been working collaboratively to develop a robust long term solution to the issues you have highlighted. The two organisations have considered the potential models and have agreed the most appropriate way forward to be through the reconfiguration of the existing Sheffield Treatment and Recovery (STAR) Service into a CAMHS Home Intensive Treatment Team (HITT).”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
Page 1 · response
Published 9 June 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
Recruit nursing staff for the new CAMHS Home Intensive Treatment Team.

Verbatim wording from the response
“The CCG and the Trust recognise that there is urgency to the situation and are working closely to ensure that there is no delay to its implementation noting also the temporary change in pathway agreed between Sheffield Children’s NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has already begun to recruit nursing staff to the new service in anticipation of its formal commissioning.”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
Page 2 · response
Published 9 June 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
Establish a Mental Health Liaison Team supporting 0–18-year-olds attending designated emergency departments, with out-of-hours cover.

Verbatim wording from the response
“This new team will be responsible for children and young people up to the age of 18 years and will be aligned with, and where appropriate, undertake, joint working with the Home Intensive Treatment Services provided by Sheffield Health and Social Care NHS Foundation Trust. In addition the Mental Health Liaison Team will support 0-18 year olds attending either Sheffield Children’s or the Northern General Hospital’s Emergency Departments. Access to the HITT will be within 24 hours when required whilst the Liaison Team will operate to meet the demands through the Emergency Departments with an on call rota in place for out of hours.”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
Page 2 · response
Published 9 June 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
Implement the temporary care pathway change agreed with Sheffield Health and Social Care NHS Foundation Trust.

Verbatim wording from the response
“The CCG and the Trust recognise that there is urgency to the situation and are working closely to ensure that there is no delay to its implementation noting also the temporary change in pathway agreed between Sheffield Children’s NHS Foundation Trust and Sheffield Health and Social Care NHS Foundation Trust. Furthermore, the Trust has already begun to recruit nursing staff to the new service in anticipation of its formal commissioning.”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-CCG
Page 2 · response
Published 9 June 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
Implement jointly approved policy arrangements providing out-of-hours emergency home treatment to eligible 16- and 17-year-olds requiring crisis intervention.

Verbatim wording from the response
“1. An addendum to the Transitions Policy has been jointly approved by both Trusts that ensures that emergency home treatment will be provided to 16/17 year olds by Sheffield Health and Social Care’s adult services, should they require crisis intervention out of hours and where they are not known to Child and Adolescent Mental Health Services which mirrors that already present for those known to the Services. This was implemented with effect from January 2019.”

Source location
2019-0115-Response-by-Sheffield-Childrens-NHS-Trust
Page 2 · response
Published 9 June 2019
Open published response
3 Feb2015
Cornwall
Concerns raised1
1. Failure of OSW and CMHT treatment thresholds to provide continuous service coverage
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Shannon Kimberley Gee · 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

Shannon Kimberley Gee, aged 16, died as the result of an Accident. The report raised concerns about gaps between mental health services, delays of weeks in resolving disputes over responsibility for treatment, and difficulties transferring medical notes and records.

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 of OSW and CMHT treatment thresholds to provide continuous service coverage
Wider context from the report
“The situation now is improved from when ████████ encountered the delay in treatment to her but, on the evidence should ████████ a delay of ‘weeks’ in resolving clinical disputes as to which organisation should treat a patient is still worrying. Ideally, there should be a seamless union between the two organisations. The fact that there is not appears to be a consequence of the maximum threshold for treatment by OSW being lower than the minimum threshold for acceptance on to the CMHT workload. Put another way, it is entirely conceivable that both OSW and CMHT may be correct in applying their respective rules as to whether a patient needs to be taken on where that patient’s presenting complaints falls between the two organisations’ rules. That may require formal guidance to resolve hence directing this letter to the Secretary in addition to the Commissioners. The difficulties set out concerning the transfer of medical notes and records appear more difficult to justify. ”
Source location
Shannon Kimberley Gee · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to accept patients whose mental state does not fit a psychiatric label

Concerns raised1

Lack of urgent mental health service provision for 16- and 17-year-olds

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.6

Concerns raised1

Failure of OSW and CMHT treatment thresholds to provide continuous service coverage

Actions described in response 6