Recurring concern

Inadequate signposting to mental health assistance and support

First to latest report 17 Oct 2022 — 7 Apr 2026

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

What this concern includes

Includes failures of arrangements to provide, maintain or use clear mental-health-support signposting, including signs, crisis-service information, eligibility information and protocols for directing people in crisis or distress to appropriate agencies and services.

What is not included
  • Excludes suicide-specific signage and suicide-prevention information where that narrower hazard-specific concern is the supported boundary.
  • Excludes failures of mental health assessment, treatment, crisis response or service capacity after a person has been appropriately signposted.
  • Excludes generic communication, information-sharing or public-signage deficiencies without a material mental-health-assistance signposting purpose.
  • Excludes neutral descriptions of mental health services or support where no failure to provide usable signposting is identified.

Reports and published responses 5 reports

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

  1. Warwickshire

    AI-generated summary

    Matilda Rose Davis · 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

    Matilda was found deceased at her home shortly after an urgent safeguarding visit concerning her mental health and the welfare of her children. The inquest identified concerns that suicide prevention training was not mandatory for frontline practitioners, that she was not asked directly about suicidal ideation, and that she was not signposted to crisis support services.

    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 signpost people with possible suicidal thoughts to crisis support services

    Wider context from the report

    “Evidence heard during the inquest confirmed that suicide prevention training is not mandatory for frontline practitioners and staff within Warwickshire Children’s Services. The social worker and support worker who visited Matilda had not received suicide prevention training, although such training was available within the organisation. In the absence of mandatory suicide prevention training, Matilda was not asked directly about suicidal ideation during the visit, where reference was made to suicidal thoughts within the referral context. It was also noted that she was not signposted to crisis support services at that time. The non-mandatory nature of suicide prevention training may give rise to variability in practice when practitioners are required to explore, record, or respond to indications of possible self harm or suicidal thoughts. ”

    Source location

    Matilda Rose Davis · 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

    Establish a refreshed central suicide prevention intranet resource hub supporting access to guidance, training materials and support pathways.

    Verbatim wording from the response

    “Delivery will be through the updated 2024 e-learning programme, ensuring content is aligned with current best practice in suicide prevention, supported by a single, accessible intranet resource hub which signposts to additional resources and pathways for support (including Dear Life). A refreshed and regularly reviewed suicide prevention intranet page will act as the central resource hub, building on the existing WCC Suicide Prevention page and ensuring consistent access to guidance and training materials, as well as signposting resources.”

    Source location

    Response from Warwickshire County Council
    Page 2 · response
    Published 13 April 2026

    Open published response

  2. Manchester South

    AI-generated summary

    Andrew John Hughes · 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

    Andrew John Hughes was found deceased at his home after concerns about his wellbeing and unsuccessful attempts to contact him. The inquest concluded that he died by suicide, with the medical cause recorded as hanging. The principal concern was a lack of clarity about how people raising urgent mental-health concerns could be directed to mental-health services and what emergency response those services could provide.

    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 clear arrangements for signposting and contacting emergency mental health services and clarifying their expected response

    Wider context from the report

    “The inquest heard evidence that across Greater Manchester there is a system known as Right Care Right Person (RCRP). This is a system that has been adopted by Greater Manchester along with many other parts of England. The inquest was told that adoption of the system was overseen by the Office of the Deputy Mayor for Greater Manchester. The aim according to the evidence heard was to identify which agency was most appropriate to respond to concerns raised such as in the case of Mr Hughes. In this case Greater Manchester Police declined to attend and indicated it was a health matter and therefore a matter for the Ambulance Service. The evidence was that this was an incident that involved concerns around his mental health and the risks that his mental health presented to his wellbeing. It would, the inquest was told have been more appropriate for mental health services to have become involved rather than the ambulance service. It was however unclear from the evidence how that would have been facilitated. There was no clarity as to what arrangements existed for a concerned family to be signposted by GMP to mental health services or how mental health services could be contacted in such an emergency situation as presented in this case or what response could have been expected. This was because it was unclear what provision there was in Greater Manchester for Mental Health Services to deal with these emergency situations. ”

    Source location

    Andrew John Hughes · 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

    Improve identification of mental health needs, accuracy of signposting, and decision-making accountability during contact handling.

    Verbatim wording from the response

    “Since the implementation of the Right Care, Right Person model in September 2024, Greater Manchester Police has undertaken targeted review and improvement activity. This work has identified that, in a small number of cases, including the circumstances relevant to Mr Hughes, mental health-related contact was not consistently identified, and callers were not always accurately signposted to the most appropriate support.”

    Source location

    2026-0099 - Response from Greater Manchester Police
    Page 2 · response
    Published 23 February 2026

    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

    Operate an agreed process for GMP call handlers to transfer or signpost people with mental-health welfare concerns to NHS 111 option 2.

    Verbatim wording from the response

    “It is not known whether signposting to mental health services, on the day in question, would have been able to prevent Andrew’s death as this did not take place. However, I can confirm that we do have an agreed process, developed in partnership with Greater Manchester Police (GMP) for police call handlers to transfer and signpost people for whom there is a mental health concern for welfare. This is via NHS 111 option 2 which in GM is staffed by trained mental health professionals who provide triage and assessment over the phone for people experiencing mental health crisis. We have established a dedicated mental health team based in Northwest Ambulance Service (NWAS) Emergency Operations Centre that provides 24/7 support and tactical advice to ambulance and ambulance teams ‘at scene’. It is not clear from your report whether GMP contacted the team for tactical advice in this incident.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 23 February 2026

    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

    Urgent mental health intervention is the responsibility of health-based resources and clinical partners, rather than policing.

    Verbatim wording from the response

    “However, the concern raised in the matter you describe did not identify a requirement for an emergency mental health response. It indicated the need for an urgent, rather than emergency, intervention. This distinction is significant. Urgent mental health support falls below the threshold for police attendance and, within Greater Manchester as it is nationally, this is the responsibility of health-based resources and clinical partners. Callers will be supported to access those services directly.”

    Source location

    2026-0099 - Response from Greater Manchester Police
    Page 1 · response
    Published 23 February 2026

    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

    Operational implementation of RCRP, including protocols and emergency arrangements, is the Chief Constable’s responsibility; related Regulation 28 notices should be directed there.

    Verbatim wording from the response

    “Responsibility for the operational management of the policing role in the RCRP system in Greater Manchester rests with the Chief Constable of Greater Manchester Police. This is in accordance with the principle of operational independence, as set out in the Policing Protocol Order 2023. Under this Order, the direction and control of police operations are vested solely in the Chief Constable, ensuring that I, as Deputy Mayor, am excluded from day-to-day decision-making or protocol implementation.”

    Source location

    Response from Deputy Mayor of Greater Manchester
    Page 2 · response
    Published 23 February 2026

    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

    Mental health services provide crisis, not emergency, responses; the concern incorrectly treats them as responsible for 999 emergencies.

    Verbatim wording from the response

    “In your report you state that ‘it was unclear what provision there was in Greater Manchester for mental health services to deal with these emergency situations’. It should be stressed that mental health services are commissioned by NHS GM to deliver a crisis mental health response, and not an emergency response, which is provided by 999 services. Based on the circumstances of the death, this report of concern required an emergency response and as mental health services were not contacted immediately prior to Andrew’s death, they could not have known about the immediate risk to life.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 23 February 2026

    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

    999 services, rather than commissioned mental health services, are responsible for emergency responses requiring immediate intervention.

    Verbatim wording from the response

    “We have reviewed the circumstances of the death included in your report and understand that immediately prior to Andrew’s death, mental health services were not contacted. It is our understanding from your report that 999 services were contacted as Andrew required an emergency response. Mental health services commissioning by NHS in Greater Manchester would not provide a 999-emergency response, nor would they have the means to contact someone who is not responding to phone calls or be able to force entry to a property when there is a concern for an individual’s safety.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 23 February 2026

    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

    Commissioned mental health services cannot provide 999 emergency responses, contact nonresponsive individuals, or force entry to protect someone at risk.

    Verbatim wording from the response

    “We have reviewed the circumstances of the death included in your report and understand that immediately prior to Andrew’s death, mental health services were not contacted. It is our understanding from your report that 999 services were contacted as Andrew required an emergency response. Mental health services commissioning by NHS in Greater Manchester would not provide a 999-emergency response, nor would they have the means to contact someone who is not responding to phone calls or be able to force entry to a property when there is a concern for an individual’s safety.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 23 February 2026

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    Sophie Ann Louise Cotton · 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

    Sophie Ann Louise Cotton had a long history of mental health problems and previous suicide attempts. On 6 January 2025, after she failed to attend important family contact and could not be contacted, four calls were made to the police requesting a welfare check; shortly afterwards, her family found her hanging by a ligature at home. The principal concerns were refusals or delays in police attendance under the “Right Care, Right Person” procedure, including where callers expressed a real and immediate risk to life and where mental health services could not enter locked premises.

    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 account for mental health crisis team inability to enter locked premises when directing callers to mental health services

    Wider context from the report

    “(2) During the 16:44 call the “Right Care, Right Person” advice to contact mental health services appears to have disregarded the fact that the mental health crisis team do not have the power to enter locked premises and so would require police attendance to facilitate entry to the premises. ”

    Source location

    Sophie Ann Louise Cotton · 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

    Monitor and work with partners on powers of entry so agencies understand legal parameters and available options.

    Verbatim wording from the response

    “Ongoing monitoring and work is being undertaken with partners with regards to powers of entry to ensure all partners are aware of the legal parameters in which all agencies operate, including for all agencies to understand the specific legal powers available to them, and to ensure all options are being considered.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 29 May 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

    Collate concerns raised, review them against the toolkit and guidance, and amend the toolkit where necessary.

    Verbatim wording from the response

    “The College collates all information in respect of concerns that are raised, and reviews these against the toolkit and guidance provided to forces. The toolkit is subject to ongoing review and where necessary amendments will be made. The College continues to encourage forces to follow the guidance within their development of RCRP and provides ongoing support and advice to forces.”

    Source location

    Response from College of Policing
    Page 3 · response
    Published 29 May 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

    Continue reviewing toolkit content and provide forces with tools, training and support to implement and deliver Right Care, Right Person.

    Verbatim wording from the response

    “The concerns raised will also be communicated with all forces within the national tactical delivery Board, where learning can be shared. The College continually reviews the content of the toolkit guidance to ensure forces are provided with the tools, training, and support to effectively implement and deliver RCRP.”

    Source location

    Response from College of Policing
    Page 3 · response
    Published 29 May 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

    A review found no significant failings in the use or implementation of the Right Care Right Person policy.

    Verbatim wording from the response

    “A thorough review has since taken place and although it has not highlighted any significant failings in the use of, and implementation of the ‘Right Care Right Person’ (RCRP) policy, the review of the incident(s) has resulted in two specific points of organisational learning and recommendations to be implemented and progressed. Durham Constabulary has also consulted with the national mental health co-ordinator to ensure the response is aligned to national practice.”

    Source location

    Response from Durham Police and Crime Commissioner
    Page 1 · response
    Published 29 May 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

    Operational decisions and responses under Right Care, Right Person are the responsibility of individual police forces, including Durham Constabulary.

    Verbatim wording from the response

    “In relation to the operational elements and decision-making processes, we have been in contact with Durham Constabulary and understand that a full response to these points is being provided.”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 29 May 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

    Police cannot enter a person’s home for a welfare check where assessed risk does not reach the threshold of risk to life and limb.

    Verbatim wording from the response

    “The College RCRP guidance reaffirms the position as set out within the case of Syed v DPP [2010] EWHC 81 (Admin) in relation to the powers of entry available to the police. The toolkit states ‘There is no specific power of entry to carry out a concern for welfare check…’”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 29 May 2025

    Open published response

  4. South Yorkshire (Eastern)

    AI-generated summary

    Carol Ann Guest · 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

    Carol Ann Guest died by suicide after hanging herself at home on 24 March 2024, before a planned consultant visit could be arranged following an urgent mental health referral. The principal concerns were inadequate crisis support for patients over 65, delays in sending and responding to the urgent referral, and the provision of a crisis number that was not available to people over 65.

    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 crisis-service information that accurately reflects age eligibility

    Wider context from the report

    “During the course of the evidence from both family and medical witnesses it became clear that there were no adequate systems in place for providing crisis support to patients over the age of 65. The family were very concerned and very frustrated by the futile attempts they made to secure psychiatric input and support when they could see a rapidly deteriorating picture. There was no explanation as to why individuals in crisis who were 65 or under had access to the crisis service but once a person is over 65 that service is no longer available to them. It is not clear whether access to such services would have altered the outcome but the current structure and services available in my view denied Ms Guest with the opportunity of obtaining specialist assessment support at a much earlier stage. A further concern was that the GP surgery provides patients with the crisis number seemingly without appreciating that this would only be available to those who were 65 or under. Furthermore, the family's evidence was that when they called 101 seeking medical input and support for Ms Guest, they were told they would be referred to the crisis team but as soon as Ms Guest's age was mentioned they halted that process and said that they would not be able to refer her after all because of her age. ”

    Source location

    Carol Ann Guest · 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

    Disseminate revised crisis pathways, referral routes and advice arrangements to staff, primary care, NHS111, communities, carers and patients.

    Verbatim wording from the response

    “We will set out our revised arrangements in writing for those providing the services, but also for local GPs. We will also ensure that, during November, relevant primary care leadership meetings are advised of the changes. That is because we suspect that, over a period of years, pathway changes have been made, and practices have varied knowledge of them. The arrangements will also be clarified in our triage-SPA and to NHS111. This work will be complete before the end of November. In putting this change into place, we will also clarify for local practices, the best routes through which themselves to seek advice, and how to make referrals including urgent referrals. Importantly this will be shared with our communities, carers and patients through all our communication channels.”

    Source location

    Response from Rotherham Doncaster and South Humber NHS Foundation Trust
    Page 2 · response
    Published 17 September 2024

    Open published response

  5. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Seth Curtis Palminder · 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

    Seth Curtis Palminder died instantly on 6 February 2022 after falling from a road bridge and being struck by southbound vehicles. The report states that he had recently been discharged from mental health care, had taken overdoses of prescribed medication, and impulsively jumped from the bridge intending to take his own life. Concerns included inadequate bridge safety measures, a lack of means to summon help or access mental health support, insufficient CCTV monitoring, and repeated previous crisis incidents and fatalities at the location.

    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 signposting to mental health assistance and support

    Wider context from the report

    “2. At the incident location there are no means of summonsing help or calling for help should a person be in crisis and require assistance. There are no signs or signposting for mental health assistance or support (such as Samaritans). ”

    Source location

    Seth Curtis Palminder · 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

    Install four Samaritans crisis signs on the bridge parapets.

    Verbatim wording from the response

    “In September 2022, we installed four Samaritans “Crisis” signs on the inner faces of the parapets over both carriageways of the A3████████ road below. This features the short 6-digit number anyone in crisis can call from any phone 24 hours a day to reach a trained Samaritans volunteer.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 20 October 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

    Add the location to the South East Network Needs list for future funding prioritisation.

    Verbatim wording from the response

    “We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 20 October 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

    Apply for future funding for a study into preventing future suicide events at the location.

    Verbatim wording from the response

    “We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 20 October 2022

    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

    National Highways, as bridge asset owner, must essentially consider the required action, while the County Council can collaborate on potential solutions.

    Verbatim wording from the response

    “The bridge at ████████ over the A3(████████) is owned, managed, and maintained by National Highways and forms part of the Strategic Road Network. This would apply to all the overbridges along the A3(████████) corridor, regardless of their primary usage. The ████████ bridge carries a public bridleway which is managed by the County Council’s Countryside Service, as a right-of-way, and they have confirmed that it is mainly used by pedestrians and cyclists.”

    Source location

    Response from Hampshire County Council
    Page 1 · response
    Published 20 October 2022

    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

    Further measures, including CCTV or physical barriers, depend on a funded study establishing their suitability and securing future funding.

    Verbatim wording from the response

    “We will add this structure to our South East region “Network Needs” list of locations that are put forward to bid for future public funds. In this case, we will seek funding for a study into the prevention of future potential suicide events at this location. The proposed study would enable us to analyse the potential risks, the prioritisation of this structure against the structures across the South East region and the Strategic Road Network (“SRN”) to help us determine if there are appropriate mitigating measures that could be taken forward. Measures that may be considered as part of the study are physical barriers, CCTV monitoring, increased signage to organisations offering support and interventions such as immediate telephone access to mental health groups.”

    Source location

    Response from National Highways
    Page 2 · response
    Published 20 October 2022

    Open published response

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