Search PFD Monitor

Unsafe application of Mental Health Act detention safeguards to informal patients 5 7 6 Feb 2026 Unreliable multidisciplinary and interagency care planning for mental-health relapse 2 4 25 Feb 2022 Inadequate safety planning for acute mental-health deterioration and suicide risk 8 8 27 May 2026 Inadequate psychiatrist review of mental health admission and discharge decisions 5 7 1 Aug 2025 Unreliable observation of patients in specialist mental health units 18 22 1 Apr 2026 Unreliable shared terminology for mental-health emergency responses 2 6 12 Jun 2023 Failure to provide the NHS 111 mental health crisis triage service 2 1 29 Sep 2023 Unreliable community mental-health response to urgent GP concerns 5 10 14 May 2024 Unreliable operational liaison between police and mental health services for safety-critical risk management 12 26 5 Mar 2026 Failure to reliably apply PSI 64/2011 mental-health risk guidance 3 2 1 Aug 2024 Unsafe emergency department care environments for people in mental health crisis 8 12 28 Oct 2025 Failure to provide effective consultant psychiatrist oversight in mental health care 13 24 4 Feb 2026 Unreliable care-coordinator provision and cover for mental health service users 21 27 18 May 2026 Failure to actively engage mental health service users before discharge 7 11 23 Jun 2025 NHS smoke-free policy inadequately protects safety in mental health hospitals 2 3 22 Nov 2024 Out-of-area mental health placements failing to provide effective continuity of care and support 10 13 18 Oct 2024 Unreliable completion of mental health assessments when patients leave or disengage 2 3 25 Aug 2022 Unreliable lawful decision-making for mental health patient detention and return 10 15 28 Oct 2025 Failure to reliably allocate key workers to mental health service users 3 5 21 Nov 2022 Incomplete recording of legally relevant relative details in mental-health records 3 4 29 May 2025 Failure to manage sleep deprivation risks to mental health and suicide 2 5 27 Jun 2022 Unreliable medication supervision and escalation for mental health patients 3 3 8 Feb 2026 Failure to reliably communicate with and listen to families of mental health patients 11 17 12 Jan 2026 Failure to commission care for people with overlapping mental-health and complex needs 2 4 6 May 2026 Unreliable sharing of information about absent mental-health patients with police 5 14 6 Feb 2026