First reported 18 Aug 2014•Latest report 17 Oct 2024
Definition
What this concern includes
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.
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.
Reports
5
Distinct published reports
Individual concerns
5
A report can raise multiple concerns
Date range
2014–2024
First to latest report issue date
Stated actions
17
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.
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
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.
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.
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
Emphasise face-to-face assessment opportunities for new mental health presentations in shared case learning.
Stated by gtd healthcareStated plannedThe respondent said that this action was planned when they made their response on 17 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Routine two-week mental health reviews may be conducted by telephone because face-to-face consultation is not considered necessary for that limited purpose.
Stated by gtd healthcareExisting 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.
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.10
Action
Review and refresh helpline workers’ roles, referral escalation, training, supervision, monitoring and audit arrangements.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Agree a standard operating procedure governing helpline referrals to the Crisis Team.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Ensure helpline workers and their team leader understand the referral standard operating procedure.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Introduce additional monitoring and audits to check compliance with the referral procedure and address variance promptly.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Agree a competency framework covering staff confidence in handling calls and escalating risk.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Update the Recovery Worker competency assessment to strengthen competence in call management, systems use, and risk and safety escalation.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Review local UK Mental Health Triage Scale guidance and establish a more robust process for escalating call-transfer difficulties.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Review and disseminate the Urgent Access line Standard Operating Procedure to relevant staff through email, supervision, and team meetings.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Introduce a digital telephony system that records calls and enables regular audit of call activity.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Introduce monthly sampling and auditing of telephone recordings to assess SOP compliance and provide training or remedial action where needed.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
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.
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.4
Action
Share suicide and self-harm documentation and assessment learning with all Frimley GP practices through bulletins, meetings, clinical leads and prescribing updates.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Deliver a recorded virtual training session on mental health assessment and documentation, then distribute the recording to all practices.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Send PHQ9 and GAD7 questionnaires before consultations and record their scores directly in EMIS Web.
Stated by Farnham Park Health Group and Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Create and circulate an Accurix template directing clinicians to GAD and PHQ9 resources for detecting anxiety and symptoms.
Stated by Farnham Park Health Group and Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 19 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
Existing clinical guidance, professional standards, revalidation and training arrangements are considered sufficient to support appropriate prescribing and diagnosis.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
The response disputes that secondary mental health referral was indicated, stating that the patient did not meet referral criteria and remained low risk.
Stated by Farnham Park Health Group and Recipient name withheldDisputes 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.
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.
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.
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.2
Action
Complete supervised observation, evaluation and competency development for telephone assessment practice.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 August 2014.
Action
Conduct periodic quality checks of crisis-team assessments and provide targeted staff feedback.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 August 2014.
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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.
