Recurring concern

Inadequate trauma-informed mental health services for people affected by trauma and domestic abuse

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First reported 30 Apr 2021•Latest report 5 Sep 2025

Definition

What this concern includes

Includes deficiencies in the provision, accessibility, design, coordination or delivery of mental health counselling, treatment pathways or related support specifically intended to address trauma or the mental-health effects of violence or domestic abuse, including failures to offer or consider appropriate trauma treatment and services that are not trauma-informed.

Not included

  • Excludes generic mental health service shortages or waiting times where trauma, violence or domestic abuse is not a material qualifier.
  • Excludes alcohol or substance-misuse treatment deficiencies unless the report also identifies a trauma-specific or domestic-abuse-specific mental health service concern.
  • Excludes generic counselling or wellbeing provision for students or other groups where no trauma, violence or domestic-abuse-specific need is identified.
  • Excludes failures limited to recognising coercive-control behaviours, domestic-abuse protection, victim contact or safeguarding arrangements when the deficient mental-health service provision is not itself identified.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2021–2025

First to latest report issue date

Stated actions
9

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 Care2
Devon & Cornwall Police1
Greater Manchester Mental Health NHS Foundation Trust1
Ministry of Justice1
Network Rail1
Police and Crime Commissioner for Devon and Cornwall1
Tees, Esk and Wear Valleys NHS Foundation Trust1

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.

  1. North Yorkshire and York

    AI-generated summary

    Victoria Anne TAYLOR · 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

    Victoria Anne Taylor’s mental health deteriorated between May and October 2024, involving suicidal ideation, self-harm and binge drinking. She was reported missing on 1 October 2024, and her body was recovered from the River Derwent on 22 October 2024. The principal concerns were that mental health services did not offer a treatment pathway addressing reported childhood trauma, provided limited safety planning, and did not suggest or convene a multi-agency approach despite knowing that several agencies were involved.

    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 offer or consider trauma treatment pathways through secondary mental health services

    Wider context from the report

    “Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams. Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma. Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her. The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service. The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been offered to Ms Taylor and rejected by her. Instead, it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future. There was no rationale included in the second assessment for naming this service, and no explanation of what it might provide or why this could not be offered on the NHS via the CMHT. When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again. Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor. ”

    Source location

    Victoria Anne TAYLOR · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Tamsin Ann Dolamore · 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

    Tamsin Ann Dolamore died aged 24 after falling from a railway bridge onto railway lines on 8 January 2018; the inquest recorded an Open Conclusion and the medical cause of death as effects of multiple injuries. The substantive concerns included delays in appointing a Sexual Offence Liaison Officer, delays and gaps in mental-health and support services, and insufficient police resources causing delays in progressing rape and serious sexual assault complaints.

    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 extend long-term therapy and recovery provision to domestic abuse and child sexual abuse

    Wider context from the report

    “There are some steps being taken towards the provision of a more joined-up approach through a pენinsula sexual violence pathfinder [funded by NHSE] which brings together commissioners and services across Devon, Cornwall, Plymouth and Torbay to pilot new approaches to longer- term recovery support for those impacted by sexual violence. Locally, a joined- up service called Safer Futures [a partnership between First Light and Barnardos] has been commissioned by Safer Cornwall which includes Cornwall Council, the Integrated Care Board, NHSE and others. I am concerned that the provision of long-term therapy and recovery for the survivors of rape and sexual violence, which should be extended to include domestic abuse and child sexual abuse, needs to be formalised and provided with a guaranteed level of funding. You may wish to consider if this should be on a statutory basis. No one should have to wait half a year for help after being assaulted. ”

    Source location

    Tamsin Ann Dolamore · Prevention of Future Deaths report
    Page 3 · 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 statutory duty for Police and Crime Commissioners, Integrated Care Boards and local authorities to collaborate when commissioning specified victim support services.

    Verbatim wording from the response

    “As you note, the Victims and Prisoners Bill is currently going through Parliament. To respond to your recommendation on introducing statutory funding, the Bill is not the right vehicle to set out how future funding may be directed. This is determined by HM Treasury as part of the Spending Review who decide departmental expenditure limits and set out a plan for how public money will be spent over a multi-year period, in line with government priorities.”

    Source location

    Response from Ministry of Justice
    Page 2 · response
    Published 19 May 2023

    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

    Commission longer-term sexual-violence recovery therapy and group support through Safer Futures.

    Verbatim wording from the response

    “In addition, Commissioners across Cornwall Council, NHSE and the Integrated Care Board (ICB) have pooled the limited resources available for longer term recovery services for those impacted by sexual violence and have commissioned the local Domestic Abuse and Sexual Violence service, Safer Futures, to provide therapy and group support for adults and children who have been impacted by sexual assault and violence.”

    Source location

    Response from Cornwall Council
    Page 2 · response
    Published 19 May 2023

    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

    Invest in Jigsaw as an in-house therapeutic counselling programme for children, young people and families reporting sexual abuse.

    Verbatim wording from the response

    “The Council has made a significant investment in Jigsaw, a therapeutic programme for children, young people and families who have reported sexual abuse. Jigsaw is the primary in house therapeutic counselling service offering a psychology-based person-centred counselling to children and their carers, however support reflects the immediate needs of children and their carers and recognises and supports pre-existing therapeutic relationships. Support may therefore be sourced from either Jigsaw or a wide range of other therapeutic providers in Cornwall including Clear Therapy, targeted youth work from our locality Early Help teams, Dreadnought, CAMHS, and Independent Sexual Violence Advocates.”

    Source location

    Response from Cornwall Council
    Page 4 · response
    Published 19 May 2023

    Open published response

  3. Manchester South

    AI-generated summary

    Kate Hedges · 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

    Kate Hedges died at Gatley Station on 27 November 2020 as a consequence of injuries sustained in an event that is redacted in the supplied text. The concerns included separate computerised record-keeping systems that could mean staff lacked relevant information for risk assessments and care plans, and an alleged failure to follow safeguarding policy. The report also raised concerns that mental health services were not consistently trauma-informed and that the ward environment could be distressing and difficult for people who had experienced trauma.

    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 consistently trauma-informed mental health services to people who have experienced trauma

    Wider context from the report

    “1. The court heard evidence to the effect that Ms Hedges often found the environment of a (mixed-sex) mental health ward distressing and difficult, both as a result of her illness and the ongoing effects of traumatic experiences endured at various stages of her life. It is a matter of concern that modern mental health service design and provision is not consistently or sufficiently trauma-informed, with services being delivered to people such as Ms Hedges who have experienced trauma in a way which is likely to cause a patient to feel unsafe and excluded, thus undermining goals for treatment. ”

    Source location

    Kate Hedges · Prevention of Future Deaths report
    Page 3 · 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

    Replace mental health estate dormitories with single, ensuite bedrooms through a multi-year capital programme.

    Verbatim wording from the response

    “We have committed over £400m for a multi-year capital programme to replace dormitories in the mental health estate with single, ensuite bedrooms by 2023/24. By 2024/25, over 1200 beds in mental health dormitories across more than 50 sites will be replaced with single, en suite rooms. Although this may impact bed availability temporarily, it will support patients by improving their care, safety and sense of dignity.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 5 May 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

    Develop a business case to split Bronte Ward into two smaller single-sex wards.

    Verbatim wording from the response

    “Bronte Ward is currently a mixed sex ward and is progressing the development of a business case for splitting the ward into two smaller single sex wards.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 5 May 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

    Prepare a co-produced trauma-informed-care statement of intent and commitment to action for Trust Board sign-up and website publication.

    Verbatim wording from the response

    “In addition, we would like to let you know of some of the work GMMH is currently developing in relation to a trust wide approach to improving the knowledge of trauma informed care and a commitment to trauma informed care actions. This work is being completed within a quality improvement (QI) collaborative framework with associated task and finish groups. The work currently falls into three clusters:”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 5 May 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

    Harmonise trauma-informed-care training, set standards and identify appropriate training levels for different audience groups.

    Verbatim wording from the response

    “In addition, we would like to let you know of some of the work GMMH is currently developing in relation to a trust wide approach to improving the knowledge of trauma informed care and a commitment to trauma informed care actions. This work is being completed within a quality improvement (QI) collaborative framework with associated task and finish groups. The work currently falls into three clusters:”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 5 May 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

    Relaunch the trauma-informed-care quality improvement collaborative for a further year and conduct a wide recruitment campaign.

    Verbatim wording from the response

    “• The current QI collaborative will end with a celebration event in September. Actions that have been shown to affect an improvement in care will be written up in a format that makes them replicable. These resources will then be stored in an electronic hub where they can easily be accessed by care staff and other resources can be added once approved, this may be shared with GM partners. The QI collaborative will then be relaunched for another year long cycle with a wide recruitment campaign to ensure as widespread participation as possible.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 5 May 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

    Staff followed safeguarding processes after the reported sexual harassment, although the team acknowledged that transfer to a single-sex ward should have been considered.

    Verbatim wording from the response

    “Ms Hedges reported at the multi-disciplinary meeting held on 20th October 2020 that she was being sexually harassed by a male patient on the ward and was considering reporting this to the police. On reviewing Ms Hedges’ clinical record staff were aware of this and had followed Trust safeguarding processes by recording the discussions and putting plans in place with Ms Hedges to address on 18th October 2020. In this instance the male patient was due to be discharged from the ward, this was progressed, and Ms Hedges agreed to be supported by staff with increased observations. Transfer of Ms Hedges to another ward did not happen because Ms Hedges was having leave from the ward and was planning for discharge and the fact the male”

    Source location

    Response from Greater Manchester Mental Health
    Page 2 · response
    Published 5 May 2022

    Open published response

  4. Manchester South

    AI-generated summary

    Joanna Leven · 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

    Joanna Leven was found dead at home on 26 March 2020 after self-induced asphyxia, following a deterioration in her mental health after her dog became seriously unwell and was euthanised. The report identified concerns about the absence of a comprehensive mental health assessment, variable access to therapeutic pathways and trauma-focused services, and the risk of information being lost between hospital and mental health liaison records systems.

    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

    Gaps in statutory provision of trauma-, violence- and domestic-abuse-specific counselling and mental health services

    Wider context from the report

    “2) Evidence was heard in court to the effect that there are gaps in provision by statutory agencies of counselling and other mental health services specifically tailored for victims of trauma, violence and domestic abuse. In Stockport, specialist services of this nature fall to be provided by a registered charity with only short-term funding in place, a position which is understood to be replicated elsewhere in the country; ”

    Source location

    Joanna Leven · Prevention of Future Deaths report
    Page 3 · 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

    Provide £40 million in 2021/22 to strengthen specialist support services for victims of rape and domestic abuse, including community services and adviser recruitment.

    Verbatim wording from the response

    “We continue to take steps nationally to ensure that victims of abuse and domestic abuse have timely access to care and support. As laid out in the recovery action plan, the Government is providing £40million in 2021/22 to boost specialist support services for victims of rape and domestic abuse. This includes: over £20million for local community-based sexual violence and domestic abuse services, to help reduce the amount of time survivors wait for support; £16million to recruit more independent sexual violence and domestic abuse advisers; and £2million for smaller, specialist organisations that help ethnic minority, LGBT or disabled victims.”

    Source location

    2021-0126-Response-from-Dept.-of-Health-Social-Care_Published
    Page 2 · response
    Published 4 May 2021

    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

    Local clinical commissioning groups are responsible for decisions about commissioning mental health services for local populations.

    Verbatim wording from the response

    “In relation to commissioning mental health services for victims of trauma, violence and domestic abuse, local clinical commissioning groups are responsible for decisions about commissioning services to meet the needs of their local populations. Services may be provided by a range of organisations, including NHS and private providers, and providers in the voluntary, community and social enterprises.”

    Source location

    2021-0126-Response-from-Dept.-of-Health-Social-Care_Published
    Page 2 · response
    Published 4 May 2021

    Open published response
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Data last updated 7 September 2026