Includes failures of telephone-based mental health assessment, including inadequate questioning, insufficient exploration of symptoms, inappropriate reliance on telephone review or failure to identify the assessor's role or qualifications when these impair the safety of the assessment.
What is not included
Excludes general telephone triage or call-handling failures that are not specifically concerned with mental health assessment.
Excludes failures of face-to-face mental health assessment where telephone assessment is not the identified control.
Excludes generic training, communication or staffing deficiencies unless they directly make a telephone mental health assessment inadequate.
Excludes failures limited to subsequent referral, treatment, admission or follow-up when the telephone assessment itself was adequate.
Trends
Reports over time
Reports mentioning this concern, 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.
Department of Health and Social Care3
Care Quality Commission1
Farnham Park Health Group1
General Medical Council1
Greater Manchester Health and Social Care Partnership1
gtd healthcare1
NHS England1
NHS Frimley Integrated Care Board1
Nottinghamshire Healthcare NHS Foundation Trust1
Tees, Esk and Wear Valleys NHS Foundation Trust1
Turning Point1
Ministerial department3
NHS trust2
Executive non-departmental public body1
Health and care professional regulator1
Health and social care service regulator1
Healthcare site1
Health-system partnership1
Independent healthcare provider1
Integrated care board1
Registered provider of social housing1
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
Manchester South
Concerns raised1
Greater difficulty assessing mental health by telephone than face to face
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
gtd healthcare
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
gtd healthcare
Emphasise face-to-face assessment opportunities for new mental health presentations in shared case learning.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
gtd healthcare
Routine two-week mental health reviews may be conducted by telephone because face-to-face consultation is not considered necessary for that limited purpose.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Nottinghamshire
Concerns raised1
Failure to ensure specialist mental health assessment of patients triaged by telephone workers
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Nottinghamshire Healthcare NHS Foundation Trust
Turning Point
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10
Turning Point
Review and refresh helpline workers’ roles, referral escalation, training, supervision, monitoring and audit arrangements.
Turning Point
Agree a standard operating procedure governing helpline referrals to the Crisis Team.
Turning Point
Ensure helpline workers and their team leader understand the referral standard operating procedure.
Turning Point
Introduce additional monitoring and audits to check compliance with the referral procedure and address variance promptly.
Turning Point
Agree a competency framework covering staff confidence in handling calls and escalating risk.
Nottinghamshire Healthcare NHS Foundation Trust
Update the Recovery Worker competency assessment to strengthen competence in call management, systems use, and risk and safety escalation.
Nottinghamshire Healthcare NHS Foundation Trust
Review local UK Mental Health Triage Scale guidance and establish a more robust process for escalating call-transfer difficulties.
Nottinghamshire Healthcare NHS Foundation Trust
Review and disseminate the Urgent Access line Standard Operating Procedure to relevant staff through email, supervision, and team meetings.
Nottinghamshire Healthcare NHS Foundation Trust
Introduce a digital telephony system that records calls and enables regular audit of call activity.
Nottinghamshire Healthcare NHS Foundation Trust
Introduce monthly sampling and auditing of telephone recordings to assess SOP compliance and provide training or remedial action where needed.
Surrey
Concerns raised1
Failure to undertake mental health assessment and identify need for further or secondary mental health support
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
Department of Health and Social Care
Farnham Park Health Group
General Medical Council
NHS Frimley ICB
Recipient name withheld
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
NHS Frimley ICB
Share suicide and self-harm documentation and assessment learning with all Frimley GP practices through bulletins, meetings, clinical leads and prescribing updates.
NHS Frimley ICB
Deliver a recorded virtual training session on mental health assessment and documentation, then distribute the recording to all practices.
Farnham Park Health Group and Recipient name withheld
Send PHQ9 and GAD7 questionnaires before consultations and record their scores directly in EMIS Web.
Farnham Park Health Group and Recipient name withheld
Create and circulate an Accurix template directing clinicians to GAD and PHQ9 resources for detecting anxiety and symptoms.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Care Quality Commission
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Care Quality Commission
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Care Quality Commission
Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Outside remitThe respondent said that this matter was outside its role or authority.
Department of Health and Social Care
Existing clinical guidance, professional standards, revalidation and training arrangements are considered sufficient to support appropriate prescribing and diagnosis.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
General Medical Council
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
General Medical Council
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
No action considered necessaryThe respondent said that no further action was needed.
Farnham Park Health Group and Recipient name withheld
The response disputes that secondary mental health referral was indicated, stating that the patient did not meet referral criteria and remained low risk.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Telephone-only GP assessments of mental health risk and need
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised1
Lack of training and understanding for appropriate telephone assessment
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Tees, Esk and Wear Valleys NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Tees, Esk and Wear Valleys NHS Foundation Trust
Complete supervised observation, evaluation and competency development for telephone assessment practice.
Tees, Esk and Wear Valleys NHS Foundation Trust
Conduct periodic quality checks of crisis-team assessments and provide targeted staff feedback.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.