Recurring concern

Failure to reliably allocate key workers to mental health service users

First to latest report 12 Feb 2015 — 21 Nov 2022

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
4

What this concern includes

Includes failures of arrangements dedicated to allocating, identifying, maintaining or replacing a key worker for mental health service users, including delayed allocation, absent allocation and failure to ensure the service user or care team knows who the key worker is.

What is not included
  • Excludes named-nurse allocation, social-worker allocation, care-coordinator provision and other roles unless the report explicitly identifies them as a key-worker arrangement.
  • Excludes generic care-planning, risk-assessment, staffing or communication deficiencies where no key-worker allocation failure is identified.
  • Excludes failures in the quality of care or engagement after a key worker has been reliably allocated, unless the allocation or continuity arrangement itself is deficient.
  • Excludes key-worker arrangements for non-mental-health beneficiaries unless the assertion explicitly supports the same mental-health key-worker process.

Reports and published responses 3 reports

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

  1. South Yorkshire (Western)

    AI-generated summary

    Daniel Lee · 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

    Daniel Lee, aged 22, died by hanging at a disused quarry on 16 September 2021, with the intention to end his life; the inquest concluded that his death was suicide. The report identified concerns about superficial risk assessments, the absence of a key worker, communication with the armed forces and family, and uncertainty about risk-based information sharing.

    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 a key worker approach

    Wider context from the report

    “5.1 While acknowledging Daniel’s high level of contact with the IHBBT team, the evidence was that no one was taking responsibility for his care in a ‘key worker’ type role. The large number of people seeing Daniel did not make deep professional relationships with him which would allow his needs and risks to be addressed in a person centred and properly risk sensitive way. The relationships with Daniel were superficial and this infected the risk assessment process. The large number of mental health professionals in contact with Daniel inhibited him establishing deep relationships of trust. 5.2 The risk assessments themselves were therefore superficial, often relying uncritically on self-reporting without meaningfully engaging in suicide risk prevention. The initial risk assessment on first contact on 16.07.21 was flawed in that, despite the presenting context being an attempt at suicide by hanging, the risk assessment was ‘low risk of suicide’. 5.3 Daniel was a serving soldier and there was a failure to meaningfully communicate and engage with his Regiment and the medical staff attached to it. 5.4 Communication with the family was superficial and the evidence was that their perception was that they couldn’t fully share issues and concerns because of perceived barriers in information sharing. This may not have been the team’s intention, but it was the reality felt by the family. This inhibited their engagement with the team in Daniel’s best interests. The evidence of ████████ was that engagement with the family was important because they were the people who knew Daniel best and who would be the first to identify any risks or concerns. 5.5 There was evidence that staff in the team struggled with decision making around information sharing. For example, on 15.09.21, the day before he died, Daniel’s girlfriend called to share concerns about his wellbeing. The person taking the call indicated that Daniel’s lack of knowledge of her referral placed the team in difficulty in sharing the information. In the event, a practitioner saw Daniel for a visit only a few minutes later and correctly identified his need for an urgent psychiatric review. Notwithstanding this, I considered that this was evidence of a failure to understand the basics of risk-based information sharing. 5.6 In summary, therefore, I considered that there was evidence that a failure to address these issues could create a risk of further deaths: • Superficiality of risk assessments • Lack of a key worker approach • Lack of communication with the armed forces, army in this case • Superficiality of communication with the family • Anxiety about appropriate risk sharing ”

    Source location

    Daniel Lee · 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

    Allocate three shared Key Workers using clinical-risk and staff-availability criteria, with regular caseload audits to confirm allocation.

    Verbatim wording from the response

    “As a result of the learning from Mr Lee’s death, how the team allocates a Key Worker has changed to include the following:”

    Source location

    Response from South West Yorkshire Partnership
    Page 3 · response
    Published 25 November 2022

    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

    Introduce a practitioner role focused on liaison with armed forces and veteran services, including visits and Key Worker support where necessary.

    Verbatim wording from the response

    “In December 2022, the IHBBT introduced a practitioner role with a specific focus on ensuring liaison with the armed forces or veteran services where the person has been identified as being involved with these agencies.”

    Source location

    Response from South West Yorkshire Partnership
    Page 5 · response
    Published 25 November 2022

    Open published response

  2. East London

    AI-generated summary

    Sammi Higgins · 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

    Sammi Higgins had mental health conditions and a deteriorating mental state, including voices telling her to harm herself. On 3 February 2018, after presenting to mental health services following an overdose and self-harm and being discharged without weekend mental health support, she ingested a fatal combination of alcohol and tablets. Concerns included the absence of an overarching care plan or key-worker, failures in communicating and implementing a medication change, and lengthy delays in accessing psychotherapy.

    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 assign a key-worker to oversee AABIT service users’ care

    Wider context from the report

    “1. Sammi was cared for under the Access Assessment and Brief Intervention Team (AABIT). She was under the care of this team for almost three years. Her care requirements went beyond "brief intervention". Whilst under the care of this team, Sammi had no overarching care plan. No-one was appointed to oversee Sammi’s care. The evidence at the Inquest revealed that doctors working within the team were not aware of the possibility of service users under the AABIT having an overarching care plan or of service users having a key-worker assigned to them. ”

    Source location

    Sammi Higgins · 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

    Issue clinical staff a reminder to record the named key worker or caseload manager in the designated RIO section.

    Verbatim wording from the response

    “8. Policy/practice update – Compliance with terms of AABIT SOP Action: A reminder will be issued to all clinical staff for the named key worker/caseload manager to be identified in the correct section of RIO clinical record – AAPI section of RIO clinical record. Deadline: 31.01.2020 Lead: ████████, Operational Lead QAABIT”

    Source location

    Response from North East London NHS Foundation Trust
    Page 5 · response
    Published 13 December 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 RIO functionality displaying the named key worker alongside the clinical risk record.

    Verbatim wording from the response

    “10. Policy/practice update – clinical risk management Action: Implement functionality to display the named key worker alongside the clinical risk record (RIO) so that this is immediately visible to the clinician. This will ensure monitoring of action 8 above. Deadline: 28.02.2020 Lead: ████████, RIO Clinical Systems Manager”

    Source location

    Response from North East London NHS Foundation Trust
    Page 5 · response
    Published 13 December 2019

    Open published response

  3. Northamptonshire

    AI-generated summary

    Jane Marie Clark and Isobel Griffin · 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

    Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature risk.

    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

    Delay in allocating a key worker

    Wider context from the report

    “Re Jane Marie Clark 1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented. 2. She did not place any boundaries on the leave for example providing a time by which Jane was to return. 3. Risk assessment documentation generally was poor and appeared perfunctory. Re Isobel Griffin 1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th. 2. The risk assessment was not updated with the events of the 7th. 3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature. 4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family. 5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment. 6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances. 7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk. ”

    Source location

    Jane Marie Clark and Isobel Griffin · 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.

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Data last updated 7 September 2026