First reported 11 Jul 2017•Latest report 12 Jan 2026
Definition
What this concern includes
Includes failures by mental-health assessment, treatment or related care services to contact, receive, listen to, understand or meaningfully consider safety-relevant information and concerns from a patient's family or friends, including failures to provide an accessible route for families to communicate concerns.
Not included
Excludes family or carer involvement in care planning, discharge or treatment decisions when the specific concern is participation in the decision process rather than communication and listening about the patient's safety; that narrower concern has its own parent.
Excludes generic patient, family or inter-agency communication failures without a mental-health-care context.
Excludes failures to act on family information after it was reliably received and understood when the communication and listening process itself was adequate.
Excludes ordinary complaints or dissatisfaction without safety-relevant information about the patient's mental health, risks, deterioration or care.
Excludes communication with patients, professionals or agencies where family or friends are not the relevant source or recipient.
Reports
11
Distinct published reports
Individual concerns
11
A report can raise multiple concerns
Date range
2017–2026
First to latest report issue date
Stated actions
27
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.
Hampshire and Isle of Wight Healthcare NHS Foundation Trust3
Department of Health and Social Care2
NHS England2
Essex Partnership University NHS Foundation Trust1
HCRG Care Services Ltd1
HM Prison and Probation Service1
Legal Services Lincolnshire1
Leicestershire Partnership NHS Trust1
Livewell Southwest1
LPFT Legal Services1
Ministry of Justice1
NHS Hampshire and Isle of Wight Integrated Care Board1
NHS South Yorkshire Integrated Care Board1
North East London NHS Foundation Trust1
Recipient name withheld1
NHS trust7
Ministerial department3
Executive non-departmental public body2
Integrated care board2
Community interest company1
Executive agency1
Healthcare site1
Local authority service1
Private limited company1
Sub-organisation1
Type not available1
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.
Essex
Concerns raised1
Failure to communicate with families and gather collateral information
This report raised 13 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.
Hampshire, Portsmouth and Southampton
Concerns raised1
Failure to demonstrate professional curiosity and obtain relevant information from family members
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Work with involved teams to improve professional curiosity when caring for patients.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Hampshire, Portsmouth and Southampton
Concerns raised1
Failure to effectively communicate with and listen to families and friends of mental health patients
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Introduce the Triangle of Care framework and updated co-produced training across Isle of Wight and legacy Solent teams.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2025.
Action
Maintain an organisation-wide ESTHER ambassador network and provide ESTHER coaching courses.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
Action
Provide Carers Champions in teams and honorary champions across the Trust.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
Action
Implement the Carer Information Plan in the electronic patient record with consent, privacy and family-centred information fields.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
Action
Expand carer feedback routes and fund or support carer groups, reporting feedback through governance groups.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
Action
Commission and complete an independent audit of arrangements for involving and listening to carers.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
Action
Commission and complete an independent audit of arrangements for involving and listening to families and carers.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
Action
Improve the Triangle of Care initiative to support family and carer involvement.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
East London
Concerns raised1
Failure to maintain meaningful family contact about concerning loss of contact
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review and finalise the Missed Appointments Policy with stronger guidance for disengagement, unsuccessful contact and escalation of concerns.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025.
Hampshire, Portsmouth and Southampton
Concerns raised1
Failure to communicate effectively with and listen meaningfully to families of patients with mental health difficulties
This report raised 7 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Action
Deliver Triangle of Care training to staff and include it in Healthcare Support Worker induction.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
Action
Progress Triangle of Care accreditation from Star 2 toward Star 3.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
Action
Introduce Esther Improvement Coaches to reinforce person-centred carer and family engagement.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 December 2023.
Action
Employ carer leads, honorary carer leads and dedicated Carer Support Workers across the Trust.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
Action
Provide carer information and support through booklets, a public website and community-based Carers and Patient Support Hubs.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
Action
Expand feedback routes through carer groups, forums, storytelling events, surveys and a funded BAME carers group.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
Action
Develop and run an expanded Family Connections programme for families of people with complex emotional needs, including neurodiversity.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
Action
Maintain an ongoing focus on improving engagement with families and carers using learning from this case.
Stated by NHS Hampshire and Isle of Wight Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
South Yorkshire (Western)
Concerns raised1
Superficiality of communication with the family
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.
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
Action
Use home-visit progress-note prompts and caseload audits to ensure regular family and carer feedback, involvement and offers of carer assessments.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 25 November 2022.
Lincolnshire
Concerns raised1
Failure to consider primary evidence from families alongside patients’ accounts when assessing masked mental illness
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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.3
Action
Complete mandatory suicide and risk training for AMHPs, emphasising assessment of all case factors including family views.
Stated by Lincolnshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 October 2022.
Action
Review policies to consider adding and strengthening references to masking where appropriate.
Stated by Lincolnshire County CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 October 2022.
Action
Present masking at the next AMHP Forum to disseminate the coroner’s concerns and explore discussion and good-practice issues with AMHPs.
Stated by Lincolnshire County CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Masking was not relevant to this case because the AMHPs did not see the deceased.
Stated by Lincolnshire County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
A separate masking policy is not currently considered necessary because statutory guidance, mandatory training and competency controls address the issue.
Stated by Lincolnshire County CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Lack of national guidance on engaging the families of mental health patients
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.
Manchester West
Concerns raised1
Failure to communicate relevant information between mental health care professionals and patients’ close relatives
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Work with professional bodies to agree and publish a consensus statement on information sharing and suicide prevention.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Plymouth, Torbay and South Devon
Concerns raised1
Failure to involve and inform families in psychiatric care
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.
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Includes failures by mental-health assessment, treatment or related care services to contact, receive, listen to, understand or meaningfully consider safety-relevant information and concerns from a patient's family or friends, including failures to provide an accessible route for families to communicate concerns.
