Recurring concern
Unreliable coordination of mental health crisis responses
- Reports that mention this concern
- 22
- Times this concern has been raised
- 24
- Stated actions linked to this concern
- 37
What this concern includes
Includes failures of the mental health crisis-response process involving coordination, role clarity, shared situational awareness, operational direction, staff readiness or timely recognition and response when these deficiencies directly affect coordinated crisis care.
What is not included
- Excludes generic inter-agency, multidisciplinary or organisational coordination failures not specifically tied to a mental health crisis response.
- Excludes failures limited to routine mental health care, referral access, discharge, follow-up or ongoing care coordination outside a crisis response.
- Excludes generic staff training, staffing or communication deficiencies unless they directly impair coordination or operational readiness during a mental health crisis.
- Excludes failures concerning the availability or capacity of crisis services where no coordination or operational-response deficiency is identified.
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.
Reports and published responses 22 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Absence of national guidance for frontline emergency crews dealing with time-critical mental health situations
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
NHS England is responsible for addressing concerns about national guidance for frontline emergency crews and will respond directly.
-
Concerns raised1
Failure of mental health professionals to work collaboratively to find a safe crisis-care solution
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- West London NHS 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.3
-
West London NHS Trust
Implement a borough-based mental-health service structure to support integrated, less fragmented care.
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West London NHS Trust
Bring Ealing Psychiatry Liaison and crisis teams under a single senior manager.
-
Department of Health and Social Care
Transform mental health services into community-based mental health centres bringing crisis services and short-stay beds together.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
West London NHS Trust is handling the specific local issues arising from Kallum’s death and responding separately to the report.
-
Concerns raised1
Failure to explain anticipated police assistance
This report raised 9 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
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Tees, Esk and Wear Valleys NHS Foundation Trust
Present the case to the Trust Urgent Care Board to address learning from the incident.
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Tees, Esk and Wear Valleys NHS Foundation Trust
Share incident learning across Trust clinical networks and the Organisational Learning Group to reinforce clear communication about contacting police.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Tees, Esk and Wear Valleys NHS Foundation Trust
Police advice was correct because violence and aggression required an emergency response with police powers, rather than Crisis Team intervention alone.
-
Concerns raised1
Failure to notify the mental health team when a person has contacted the café71 service
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Cheshire and Wirral Partnership NHS Foundation Trust
- Spider Project Café71
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
-
Cheshire and Wirral Partnership NHS Foundation Trust
Remind crisis line staff to include contact information in referrals and complete warm call transfers where possible.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Cheshire and Wirral Partnership NHS Foundation Trust
Existing procedures require Café 71 to contact relevant mental-health teams, attend professionals’ meetings and notify the Trust after three failed contact attempts.
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Spider Project Café71
Cafe 71 disputes that EJD contacted it, that it was a crisis line, or that referral information indicated immediate risk.
-
Spider Project Café71
The NHS Crisis Line, which received the call, was responsible for notifying the mental health team.
-
Concerns raised1
Lack of contact details for neighbouring psychiatric liaison and crisis mental health teams
Linked response
- NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS England
Existing NHS Service Finder and website directories provide professionals with current neighbouring mental health service contact details and referral information.
-
Concerns raised1
Lack of structured, clinically informed training for staff identifying and interacting with people in mental health crisis
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to establish the changed risk and immediacy of serious or fatal harm when a patient escapes from a secure mental health ward
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Essex Partnership University NHS Foundation Trust
- Essex Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Essex Partnership University NHS Foundation Trust
Create and disseminate an SBARD aide-mémoire guiding staff escalation to police for patients absent from authorised leave or absconded, including Mental Health Act status and risk information.
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Essex Partnership University NHS Foundation Trust
Audit missing-person calls with Essex Police to assess the aide-mémoire’s effectiveness and establish and share further learning.
-
Essex Police
Share national guidance on restricted patients who abscond with Essex Police and relevant external agencies.
-
Concerns raised1
Lack of shared understanding of neighbourhood team patient-contact response times
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- East London 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.1
-
East London NHS Foundation Trust
Require Serious Incident reviewers to consider integrated working practices between different services during quality assurance.
-
Concerns raised1
Failure of ambulance, police and health services to coordinate and share mental-health crisis intervention resources
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Merseyside Police
- North West Ambulance Service NHS 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.1
-
Merseyside Police
Review and assess NWAS interoperability models and relevant best practice when establishing and evaluating the mental-health triage service.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
North West Ambulance Service NHS Trust
A shared mental health response vehicle is not appropriate because ambulance and police services face different demands, calls, triage and dispatch processes.
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North West Ambulance Service NHS Trust
Mental health response vehicles are health-led, with their scope and operating model agreed through a regional steering group involving ICBs and mental health trusts.
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Merseyside Police
Existing separate police and NWAS cars are considered more effective than joint operability for Merseyside communities.
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Concerns raised1
Failure to assign responsibility for risk management and crisis referral
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sussex Partnership 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.1
-
Sussex Partnership NHS Foundation Trust
Review daily-meeting documentation and audit clinical records to verify recording of identified risk, actions and responsible staff.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Sussex Partnership NHS Foundation Trust
Ongoing audits of red-zone risk recording and crisis referral arrangements were considered sufficient, so no additional action was required.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026