Recurring concern

Failure to provide required daily mental-health team visits

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First reported 1 Jun 2015•Latest report 9 Apr 2019

Definition

What this concern includes

Includes failures to provide required daily visits by mental-health teams, including Home Treatment Teams, where visits are missed, omitted or cannot be delivered to all patients who require them.

Not included

Excludes general mental-health appointment, referral, discharge or follow-up failures where a required daily team visit is not the unsafe condition.
Excludes failures limited to recording reasons for missed visits, escalating visit-capacity problems or communicating within the team when the daily visit provision itself is otherwise reliable.
Excludes non-daily mental-health contacts and routine community-care visits without an explicit mental-health team visiting requirement.
Excludes the broader existing concern concerning unreliable community Home Treatment Team care pathways when the assertion concerns pathway coordination rather than failure to provide required daily visits.

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

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.

NHS Birmingham and Solihull Integrated Care Board1

NHS England1

Norfolk and Suffolk NHS Foundation Trust1

North London 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.

9 Apr2019
Suffolk
Concerns raised1
1. Failure to provide daily visits from the mental health team
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.
Respondent positions 1
1. Position
  Contact frequency is determined flexibly by multidisciplinary assessment and service-user needs, rather than requiring daily mental health team visits.
  Stated by Norfolk and Suffolk NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Anthony Hayward BUCKINGHAM · 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

Anthony Hayward BUCKINGHAM died at home on 13 March 2018 with a metal cable around his neck, after a previous suicide attempt and ongoing suicidal thoughts. The inquest highlighted concerns about the frequency of mental health visits, involvement of his father and practice nurse, a formal mental health assessment, and use of a care facility.

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 provide daily visits from the mental health team
Wider context from the report
“At the Inquest it was highlighted the following could have been done to try and prevent his death 1/ Daily visits from the mental health team 2/ Involvement of the next of kin (his father) 3/ Formal mental health act assessment 4/ Involvement of the practice nurse 5/ Use of Corner house care facility ”
Source location
Anthony Hayward BUCKINGHAM · Prevention of Future Deaths report
Page 1 · 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
Contact frequency is determined flexibly by multidisciplinary assessment and service-user needs, rather than requiring daily mental health team visits.

Verbatim wording from the response
“The Trust's internal investigation identified that Anthony had no contact with mental health services prior to February 2018. Following referral to the Trust he was provided with support by the Home Treatment Team. This team provides short term support for people experiencing acute mental health needs, through visits and telephone calls. From the period 16 February 2018 to 13 March 2018 the team completed seven face to face contacts and seven telephone contacts. The decision as to the frequency of contact is considered by the multi-disciplinary team in conjunction with the service user, based on their presenting needs. The multi-disciplinary team approach assists to ensure all perspectives are considered and the judgement is a shared decision. Through this process contact can be increased and decreased on a flexible basis.”

Source location
2019-0123-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 18 June 2019
Open published response
4 Oct2018
Birmingham and Solihull
Concerns raised1
1. Failure of home treatment teams to visit all patients requiring a visit each day
This report raised 5 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 2
1. Action
  Work with partners to address recruitment and retention challenges so services are appropriately resourced.
  Stated by NHS Birmingham and Solihull Integrated Care BoardStated planned
2. Action
  Provide additional investment to expand commissioned mental-health service capacity and provision.
  Stated by NHS Birmingham and Solihull Integrated Care BoardStated completed
Respondent positions 1
1. Position
  The Clinical Commissioning Group will lead the shared demand analysis needed to assess demand, capacity and funding constraints.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Michael Paul Wheeler · 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

Michael Paul Wheeler died after jumping from a fourth-floor window at his brother’s home on 26 July 2018, following increasing paranoia and bizarre behaviour. The principal concerns were that he was not reviewed by a psychiatrist, had no treatment plan, and had no planned review on 26 July; broader concerns were raised about pressures on mental health services, including the availability of urgent psychiatric reviews and inpatient beds.

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 home treatment teams to visit all patients requiring a visit each day
Wider context from the report
“2. The Coroner is aware, although not from evidence obtained in respect of Mr. Wheeler’s case as the inquest is yet to take place, that inpatient beds within the BSMHFT who are currently operating at 109% capacity and are often not available. Consequently, patients who would otherwise have been offered in-patient treatment, are having to be managed by the HTTs. Partly as a consequence of this but partly due to other pressures the demand on the HTTs is often too great to enable them to visit all patients requiring a visit in any one day. One particular problem in the Birmingham and Solihull area is that the occurrence of psychosis is more than 3 times higher than the national average. It is understood that the Trust is exploring options to expand its HTT service but funding is required. ”
Source location
Michael Paul Wheeler · 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
Work with partners to address recruitment and retention challenges so services are appropriately resourced.

Verbatim wording from the response
“8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.”

Source location
Birmingham-and-Solihull-CCG-Response
Page 9 · response
Published 4 October 2018
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
Provide additional investment to expand commissioned mental-health service capacity and provision.

Verbatim wording from the response
“5.4.8 In 2017/18 providing additional investment in mental health services above the contract value amounting to £4,611,000 for BSMHFT (3.7% increase) and £6,235,000 for FTB (22.6% increase).”

Source location
Birmingham-and-Solihull-CCG-Response
Page 5 · response
Published 4 October 2018
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
The Clinical Commissioning Group will lead the shared demand analysis needed to assess demand, capacity and funding constraints.

Verbatim wording from the response
“Funding alone is not the issue but there is agreement that in order to answer the question of the likely attribution of funding constraint on risk within services, all stakeholders need to be party to a shared demand analysis (with an extended invitation to partners from health and Justice, local authority and schools) and a ‘Suicide prevention strategy’. The Demand analysis will be led by the CCG and the Suicide prevention strategy will be led by the Director of Public Health.”

Source location
NHS-England-Response.pdf
Page 4 · response
Published 4 October 2018
Open published response
1 Jun2015
Inner North London
Concerns raised1
1. Failure to conduct twice-daily crisis team visits in accordance with the care plan
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.
Actions described in response 1
1. Action
  Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.
  Stated by North London NHS Foundation TrustStated completed
AI-generated summary

Mark Patrick DANIELS · 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

Mark Patrick Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. The principal concerns were failures to carry out and record planned visits, communicate within the team and with crisis houses, progress a crisis-house referral promptly, and consider hospital admission despite identified suicide risk and Mr Daniels stating that he did not feel safe at home.

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 conduct twice-daily crisis team visits in accordance with the care plan
Wider context from the report
“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”
Source location
Mark Patrick DANIELS · 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 measures across all Crisis Teams and Crisis Houses to address the identified concerns.

Verbatim wording from the response
“████████ Associate Divisional Director for the Acute division has considered your concerns and put in place a comprehensive action plan to address them – the action plan is appended at the end of this letter. As you can see from the action plan updates, several”

Source location
2015-0208-Response-by-Camden-and-Islington-NHS-Trust
Page 1 · response
Published 1 June 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide daily visits from the mental health team

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of home treatment teams to visit all patients requiring a visit each day

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to conduct twice-daily crisis team visits in accordance with the care plan

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.1

Respondent positions 1

Actions described in response 2

Respondent positions 1

Actions described in response 1