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Data updated 7 September 2026
Concerns 305
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Insufficient mental health service capacity for timely patient care
40 reports 46 recipients
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Insufficient police training for safe recognition and response to mental-health and behaviour-related medical crises
30 reports 48 recipients
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Failure to reliably follow up identified mental-health safety concerns
17 reports 36 recipients
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Failure to ensure frontline personnel recognise mental-health indicators
13 reports 30 recipients
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Excessive waiting times for NHS mental health services
33 reports 29 recipients
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Inadequate university mental-health support systems for students
8 reports 16 recipients
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Inadequate mental health risk assessment
118 reports 116 recipients
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Failure to move people in mental health crisis promptly from A&E to appropriate mental-health care
4 reports 3 recipients
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Failure to integrate mental health services across care settings
33 reports 59 recipients
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Failure to provide timely continuing mental health reviews and follow-up
47 reports 74 recipients
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Failure to provide indicated psychological interventions in mental health care
19 reports 21 recipients
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Unreliable mental health referral pathways
110 reports 141 recipients
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Unreliable coordination of mental health crisis responses
22 reports 41 recipients
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Unreliable specialist mental health support in hospital care
8 reports 12 recipients
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Failure to recognise physical illness in mental health patients
6 reports 6 recipients
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Failure to involve families and carers in mental health care planning and decisions
26 reports 34 recipients
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Inadequate mental health assessment before care decisions
12 reports 29 recipients
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Failure to assess and respond to mental-health risks arising during child protection and care proceedings
3 reports 13 recipients
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Unreliable access to specialist mental health treatment for serious mental illness
14 reports 27 recipients
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Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pending
18 reports 34 recipients
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Insufficient age-appropriate mental health provision for young people transitioning to adulthood
8 reports 13 recipients
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Unsafe discharge, closure or withdrawal of mental health services
17 reports 27 recipients
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Failure to ensure safe accommodation after discharge from mental health care
5 reports 6 recipients
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Failure to recognise and respond to deteriorating mental health in service users
28 reports 47 recipients
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Insufficient multi-disciplinary coordination in mental health care
22 reports 34 recipients
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Unreliable recording of safety-critical mental health information
51 reports 66 recipients
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Unreliable mental-health patient leave arrangements
22 reports 36 recipients
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Failure to reliably identify and support students with emerging mental-health needs
4 reports 10 recipients
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Inadequate competence in mental health assessment
9 reports 21 recipients
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Unsafe coordination and continuity during mental health service transfers
26 reports 48 recipients
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Failure to ensure physical healthcare staff can safely care for patients with significant mental health needs
2 reports 4 recipients
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Inadequate 24-hour mental health crisis support
14 reports 23 recipients
Reports 2,023
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Joy Burgess · Prevention of Future Deaths report
Circumstances of the death …died from multiple injuries sustained as a consequence of ████████. Ms Burgess had a long history of complex mental health difficulties and had been under the Community Mental Health Team. In addition to being prescribed medication, Ms…
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Daniel HALL · Prevention of Future Deaths report
Circumstances of the death …Daniel received confirmation on 17 and 22 October 2019 that his name had been placed on a waiting list to see a Mental Health Adviser. Due to ill-health and absences of the University’s three Mental Health Advisers, there were ~200…
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Jason Ricardo White · Prevention of Future Deaths report
Circumstances of the death Jason Ricardo White developed mental health symptoms in April 2024 which were essentially depression and psychotic episodes. Mr White engaged with both his…
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Siwan Llio SMITH · Prevention of Future Deaths report
Circumstances of the death …had a long-standing history of anxiety and depression which was exacerbated during the Covid 19 pandemic. Siwan’s mental health deteriorated and she started to have suicidal thoughts. Siwan did not have ongoing support from either primary or…
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Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report
Circumstances of the death Matty had struggled with their mental health throughout their adult life, but it wasn’t until 2019 that Matty was finally diagnosed with Autism, ADHD and…
Recipients 51
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National Confidential Inquiry into Suicide and Safety in Mental Health
University research centre
1 report Latest 18 Mar 2022
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Community Mental Health Services for Older People, Llandough Hospital
Sub-organisation
1 report Latest 17 Dec 2013
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Community Mental Health Recovery Services (Surrey and Borders Partnership)
Healthcare site
1 report Latest 15 Sep 2015
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Department of Community Mental Health, Woolwich Station Medical Centre
Healthcare site
1 report Latest 19 Nov 2020
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Trafford Improving Access to Psychological Therapies Service
Healthcare site
1 report Latest 4 Sep 2013
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Greater Manchester Health and Social Care Partnership
Health-system partnership
32 reports Latest 4 Nov 2022
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Mental Health Act assessors
1 report Latest 25 Oct 2016
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