Recurring concern

Failure to provide reliable community mental health assessments

First to latest report 20 Apr 2017 — 18 Nov 2025

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
10

What this concern includes

Includes failures of the community mental health assessment process, including missing or inadequate assessment frameworks, failure to complete assessments, and unsafe delays or unavailability of urgent assessments where these concern assessment of a person's mental health needs and required help or treatment.

What is not included
  • Excludes generic documentation, staffing, demand or service-capacity deficiencies unless they are directly tied to failure of the community mental health assessment process.
  • Excludes treatment, placement, referral and crisis-response failures that do not concern the assessment itself.
  • Excludes assessments in unrelated clinical, social-care, legal or public-safety systems.

Reports and published responses 5 reports

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

  1. Staffordshire and Stoke-on-Trent

    AI-generated summary

    Lynsey Ellen Dearden · 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

    Mrs Lynsey Ellen Dearden was found deceased at her home on 11 March 2025. The inquest concluded with a short-form conclusion of suicide; the stated cause of death was asphyxiation, with anxiety and depression recorded in Part II. Concerns included failures to provide allocated Community Psychiatric Nurse appointments and to complete a standard assessment framework, alongside the absence of policies or guidance governing these processes.

    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 complete standard community needs and treatment assessments

    Wider context from the report

    “2. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs Dearden may need in the community. This did not take place, and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this. ”

    Source location

    Lynsey Ellen Dearden · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 policy, guidance or framework governing standard community needs and treatment assessments

    Wider context from the report

    “2. Evidence emerged during the inquest that Mrs Dearden was allocated a Community Psychiatric Nurse, on the 31st December 2024, to facilitate a standard assessment framework, to assess what help and treatment Mrs Dearden may need in the community. This did not take place, and there was no answer as to when this should have taken place, or how this should have been carried out as there is no policy, guidance or framework in place to govern this. ”

    Source location

    Lynsey Ellen Dearden · Prevention of Future Deaths report
    Page 1 · 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

    Issue and operationalize a Practice Note requiring SAF waiting-list contact, key-worker appointment dates, transition timescales, and clarification that SAF is not prerequisite to care.

    Verbatim wording from the response

    “Immediate actions taken: In response to the PFD and our internal review, we have implemented the following: A Practice Note issued highlighting the following,”

    Source location

    Response from North Staffordshire Combined Healthcare NHS Trust
    Page 2 · response
    Published 21 November 2025

    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

    Revise the Trust Care Management Policy to incorporate the new processes, guidance, and audit assurance arrangements.

    Verbatim wording from the response

    “These additional processes and clarifications will be added to the Trust Care Management Policy which is currently under review.”

    Source location

    Response from North Staffordshire Combined Healthcare NHS Trust
    Page 2 · response
    Published 21 November 2025

    Open published response

  2. West Sussex, Brighton and Hove

    AI-generated summary

    Imogen Alice NUNN · 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

    Imogen Alice NUNN was found deceased at her home on 1 January 2023 after leaving a party and being reported as a high-risk missing person; the circumstances text states that she had consumed a substance bought online. The principal concern was the lack of available British Sign Language interpreters for Deaf patients receiving mental health support, particularly for urgent assessments when patients were in crisis.

    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 available British Sign Language interpreters for Deaf patients with mental health difficulties

    Wider context from the report

    “During the course of the Inquest (which has yet to be concluded) I heard evidence that there was a lack of availability of British Sign Language Interpreters able to help support Deaf patients in the community who were being treated with mental health difficulties. This was particularly apparent when mental health staff were seeking an interpreter at short notice for a patient who was in crisis. The lack of interpreters available has meant that urgent assessments are being carried out with no interpreters present. The overall lack of British Sign Language Interpreters has also meant that this Inquest has itself had to be delayed/adjourned for two months due to there being no available Interpreters to interpreter for two deaf witnesses over the two week period of the Inquest. ”

    Source location

    Imogen Alice NUNN · 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

    Hold a stakeholder meeting to brief stakeholders on the plan to publish a refreshed Accessible Information Standard.

    Verbatim wording from the response

    “loss. The AIS was co-designed with stakeholders such as Sign Health and the British Deaf Association. A meeting will be held by NHS England later in May 2025 to brief stakeholders on the plan to publish a refreshed version of the AIS. The revised AIS is expected to ensure that BSL interpreters are suitably qualified, and that their provision is a requirement for families and carers, as well as patients.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 27 March 2025

    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

    Work with the BSL Advisory Board to inform statutory guidance with professional standards and contract-level requirements for interpreter provision.

    Verbatim wording from the response

    “In accordance with the British Sign Language (BSL) Act 2022, the Department for Culture, Media and Sport has established the BSL Advisory Board, which is now tasked with developing statutory guidance. As the UK’s largest voluntary register of communication professionals working with Deaf and Deafblind people, NRCPD considers it incumbent upon us to contribute actively to this work.”

    Source location

    Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
    Page 4 · response
    Published 27 March 2025

    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

    Support NHS England and Integrated Care Boards in designing procurement frameworks aligned with the Procurement Act 2023.

    Verbatim wording from the response

    “NRCPD’s Role in Supporting Procurement Reform”

    Source location

    Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
    Page 9 · response
    Published 27 March 2025

    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

    Support Deaf organisations and sector partners in advocating for system-wide changes enabling practical real-time language provision.

    Verbatim wording from the response

    “• Support national Deaf organisations and sector partners in advocating for system-wide changes, including service models that make real-time language service provision a practical reality.”

    Source location

    Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
    Page 10 · response
    Published 27 March 2025

    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

    Contribute to statutory guidance under the BSL Act by promoting high-quality, regulated interpreting requirements in service specifications and contracts.

    Verbatim wording from the response

    “• Contributing to the development of statutory guidance under the BSL Act”

    Source location

    Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
    Page 9 · response
    Published 27 March 2025

    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

    Promote person-centred procurement models embedding interpreting provision from the outset of care planning.

    Verbatim wording from the response

    “We will commit to:”

    Source location

    Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
    Page 14 · response
    Published 27 March 2025

    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

    Promote interpreter provision as a core communication function within care and safeguarding models.

    Verbatim wording from the response

    “• Promote models in which interpreter provision is recognised as a core communication function and not a peripheral support service, particularly where language access is essential to care and safeguarding.”

    Source location

    Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
    Page 14 · response
    Published 27 March 2025

    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

    Individual NHS Trusts and employers determine staffing levels and workforce composition, including appropriate weekend cover.

    Verbatim wording from the response

    “Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the needs of their patients in order to deliver safe and effective care. I would expect South West London & St George’s Mental Health Trust, and all other NHS Trusts to ensure that their staffing arrangements, including weekend cover, are appropriate, following the tragic death of Ms Nunn.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 27 March 2025

    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

    Integrated Care Boards are responsible for commissioning community mental health services and ensuring adequate BSL interpreter provision.

    Verbatim wording from the response

    “NHS England recognises that the provision of interpreters within community mental health services is important, both to support patients and to ensure that comprehensive mental health assessments take place in a timely manner. Commissioning of community mental health services is the responsibility of Integrated Care Boards (ICBs), and this includes responsibility for ensuring there is adequate provision of BSL interpreters to support deaf patients in the community. Should a Trust or local provider experience challenges in booking interpreters, they would be expected to identify this as a risk and work with their commissioner (ICB) to resolve the issue.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 27 March 2025

    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

    NHS commissioners and procurement leads must require interpreting agencies to adopt continuity-based frameworks and confirm interpreter availability during care planning.

    Verbatim wording from the response

    “To embed this model into practice, NHS commissioners and procurement leads must require interpreting agencies to adopt a continuity-based framework. This includes demonstrating systems for assigning dedicated interpreter teams to long-term care cases, contributing to meeting scheduling logistics (without clinical involvement), and confirming interpreter availability at the planning stage.”

    Source location

    Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
    Page 7 · response
    Published 27 March 2025

    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

    Systemic improvement in interpreter access cannot be achieved by NRCPD alone, requiring coordinated action by multiple organisations and sectors.

    Verbatim wording from the response

    “This is not a challenge NRCPD can meet alone. But we are committed to playing our part, informed by evidence, guided by our registrants, and accountable to the Deaf and Deafblind communities we exist to protect.”

    Source location

    Response from National Register of Communication Professionals working with Deaf and Deafblind people - NRCPD
    Page 10 · response
    Published 27 March 2025

    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

    Commissioning community mental health services, including adequate BSL interpreter provision, is the responsibility of integrated care boards.

    Verbatim wording from the response

    “You raised in your report concerns about the availability of British Sign Language (BSL) interpreters available in the local community. We fully recognise the importance of the provision of interpreters within community mental health services, both to support patients and to ensure that comprehensive mental health assessments take place in a timely manner. Commissioning of community mental health services is the responsibility of integrated care boards, and this includes responsibility for ensuring that there is adequate provision of British Sign Language interpreters to support deaf patients in the community.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 27 March 2025

    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

    NHS trusts and integrated care boards are responsible for making Equality Act reasonable adjustments to ensure accessible services.

    Verbatim wording from the response

    “It is for individual NHS organisations including NHS trusts and integrated care boards to comply with the Equality Act 2010. Under the Equality Act 2010, organisations have a legal duty to make changes in their approach or provision to ensure that services are as accessible to people with disabilities as they are for everybody else. These changes are called reasonable adjustments. The Reasonable Adjustment Flag was developed in the NHS Spine”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 27 March 2025

    Open published response

  3. South London

    AI-generated summary

    Billy James Jenkins · 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

    Billy James Jenkins was found hanging by the neck in a hotel room bathroom on 12 August 2019, following a history of low mood, alcohol and cocaine abuse, suicidal ideation and previous suicide attempts. The concerns included limited information gathering during his mental health assessment, a decision that he did not have a mental health condition without further assessment, inadequate documentation and planning, and possible over-reliance on alcohol and drug use as the explanation for his suicidal ideation. The inquest concluded that he took his own life following an assessment after which he felt helpless because there had been no clear mental state examination and a potential missed opportunity to consider an appropriate referral.

    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

    Over-reliance on alcohol and drug use in assessing suicidal ideation

    Wider context from the report

    “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask. ”

    Source location

    Billy James Jenkins · 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

    Share the root-cause analysis report and investigation learning with the involved team and across the Trust to support reflection by similar teams.

    Verbatim wording from the response

    “Since the death of Mr Jenkins the RCA report has been shared with the team and across the Trust so that similar Teams can reflect on the lessons learnt. The actions arising from the investigation have also been implemented including areas addressed above. Additional learning reflects the need to ensure that all service users who are receiving care and treatment from Oxleas mental health services and also use drugs and or alcohol have equal access to all strands of treatment available to those who are not using substances. Only if there is clear evidence that the use of substances will impact on the ability to clinically benefit from any treatment would a decision be made to withhold treatment and in these instances this would be reviewed regularly with the service user and the team.”

    Source location

    2020-0068-Response-from-Oxleas-NHS-Foundation-Redacted
    Page 3 · response
    Published 27 March 2020

    Open published response

  4. Manchester North

    AI-generated summary

    Mr Gregory Rekowski · 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

    Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.

    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

    Unavailability of an out-of-hours mental-health community response service for face-to-face assessment

    Wider context from the report

    “The Court heard evidence there is no Mental Health Community Response team available to deal with mental health issues out of hours. The only out of hours service is in A&E which would necessitate someone attending there. Evidence was given as to the substantial increase in such issues being reported to GMP. The Court heard how there is now a mental health professional within the GMP control room to assist with the calls received. However the main issues are in attending to conduct face to face assessments. The police are the service who have a power to enter property, unlike other services. Therefore whilst they may not be best placed in respect of the assessment they are often called. Given the issue in respect of resources laid throughout this Inquest the Court would question the lack of this Mental Health provision. ”

    Source location

    Mr Gregory Rekowski · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    CRT cannot respond to all mental-health incidents because demand exceeds its commissioned capacity and requires triage.

    Verbatim wording from the response

    “However, it must be recognised that the most significant limitation on the service is the availability of CRT resources. The volume of incidents where a relevant person has mental health needs exceeds CRT capacity and this burden requires the VSU to act as a filter focusing CRT staff time to providing the commissioned service.”

    Source location

    2018-0411-Response-by-Greater-Manchester-Police
    Page 4 · response
    Published 28 December 2018

    Open published response

  5. City of London

    AI-generated summary

    Charlotte Anne Agnew · 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

    Charlotte Anne Agnew became psychiatrically unwell and expressed suicidal ideation. After referrals to psychiatric services, her care was not effectively transferred, her suicide risk was not sufficiently assessed or managed, and no care plan was put in place; she died on 25 March 2016 after ingesting high levels of alcohol and medication and jumping in front of a London Underground train. The report identified an ongoing risk that similar failures in timely assessment, treatment, care transfer and suicide-risk management could recur.

    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

    Delays in granting urgent psychiatric assessments

    Wider context from the report

    “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were: (1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge. (2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide. (3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge. (4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness. (5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016. I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance. Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise). Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised. In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives. ”

    Source location

    Charlotte Anne Agnew · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

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

Back to top

Data last updated 7 September 2026