Fragmented menopause and mental health care
61 items
1 source
Lack of joined-up care between menopause and mental health services, insufficient understanding, and inadequate national guidance.
Cross-Source Insight
Fragmented menopause and mental health care has been flagged across 1 independent accountability source:
61 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (61)
Oliver Robinson
Concerns: A consultant with inadequate expertise prescribed medicinal cannabis based on incomplete information, without consulting existing psychiatrists, obstructing the patient's appropriate psychiatric and addiction care.
Response: Curaleaf Clinic has implemented several changes following an internal investigation, including requiring specialist consultants prescribing cannabis-based medicinal products to provide evidence of competencies across all clinical practice areas. They also …
Responded
Wendy Eyles
Concerns: No protocol exists for managing patients under both NHS and private psychiatry, leading to critical medication changes not being communicated, creating confusion and patient safety risks.
Overdue
Declan Carr
Concerns: Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
Response: NHS England confirmed that a national pathway for transferring non-clinical healthcare information, including psycho-social support, between prisons was implemented on 24 November 2025. They also conducted an audit confirming 100% …
Responded
Sarah Healey
Concerns: Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with physical issues led to fragmented care. Over-reliance on remote appointments may fail vulnerable individuals.
Response: The Department of Health and Social Care notes there are no plans to develop a national policy on mandatory face-to-face appointments. They are working with NHS England on new Personalised …
Responded
Angela Thompson
Concerns: A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, creates risks for continuity of care.
Response: HM Prison and Probation Service highlights the establishment of Regional Health & Justice Teams and regular multidisciplinary meetings to improve integrated health services and support transitions. It also notes the …
Response: HMPPS has established Regional Health & Justice Teams and a central Deaths Under Supervision Team to improve integrated health services and liaison for prison leavers. Learning from this case will …
Responded
Victoria Taylor
Concerns: Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex needs.
Overdue
Alexi Susiluoto
Concerns: Separate mental health and substance misuse services, compounded by patient homelessness, create significant confusion and gaps in care for individuals with dual diagnoses.
Overdue
Sean Heath
Concerns: Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.
Responded
Leighton Dickens
Concerns: Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support and unimplemented alternative services.
Responded
Lee Purkis
Concerns: A critical Mental Health Treatment Requirement was not transferred or communicated between Trusts, highlighting a systemic failure in MHTR administration and probation oversight.
Responded
Michelle Moore
Concerns: There was a lack of joined-up care between menopause and mental health treatment, compounded by a poor understanding of their link and an absence of national guidance or training.
Responded
Evie Davies
Concerns: A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments and poor information sharing.
Responded
Jason Pulman
Concerns: Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and CAMHS being unaware of new national support offers, risking patient safety.
Responded
Axel Price
Concerns: A national lack of clear guidance and multi-agency understanding for vulnerable young people transitioning from child to adult mental health services leads to inadequate support and patients falling through service gaps.
Responded
Shahzadi Khan
Concerns: National mental health bed shortages led to out-of-area placements with poor communication and discharge planning. There was also a lack of awareness regarding menopause as a factor in mental health deterioration.
Responded
Amarnih Lewis-Daniel
Concerns: Extremely long waiting lists for Gender Identity Clinics, coupled with a severe lack of local support and specialist knowledge in mental health services, and unclear responsibilities for patient welfare, are intensifying distress.
Responded
Katharine Fox
Concerns: A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer systems, resulted in substantial wait times and impaired continuity of care.
Responded
Alice Litman
Concerns: Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient mental healthcare provision for those awaiting gender-affirming treatment.
Responded
Angela Collins
Concerns: Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health crisis receive insufficient or no support.
Responded
Donna Donnellan
Concerns: A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role and appropriate referral pathways to specialist eating disorder services.
Responded
Kirsty Taylor
Concerns: Fragmented mental and physical health services lack seamless connectivity for neurodivergent patients, particularly those with ADHD. Additionally, communication with families of mental health patients remains ineffective, and the Personality Disorder Pathway development is too slow.
Responded
Corinne Haslam
Concerns: Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment guidance for ward staff pose significant patient safety risks.
Overdue
Marlene McCabe
Concerns: Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, and a risk of misdiagnosis or delayed assessment due to assumptions about substance misuse.
Overdue
Conrad Colson
Concerns: There was a lack of liaison and information sharing between specialist and step-down mental health services, particularly regarding discharge risks and Body Dysmorphic Disorder (BDD) treatment. Training on BDD and its associated risks, including aesthetic dermatology, is insufficient, compounded by a lack of national BDD resources.
Responded
Samuel Morgan
Concerns: A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly for complex dual diagnosis cases. This poses a significant risk that critical patient safety information will be lost between agencies.
Responded
Gareth Williams
Concerns: The deceased fell between two non-communicating care teams (mental health and ENT), leading to insufficient support and an inability to resolve his complex health problems.
Responded
Gaia Pope-Sutherland
Concerns: Poor communication between neurology and mental health teams, under-resourced epilepsy services, and inadequate police training on epilepsy and complex mental health conditions pose significant risks.
Responded
David Walker
Concerns: Frequent changes in care coordinators and the failure to obtain critical collateral information from other healthcare trusts on admission resulted in a fragmented understanding of the patient's risks.
Responded
Darren Lawrence
Concerns: Inadequate communication and follow-up between mental health teams and the GP led to a patient disengaging and not receiving crucial medication. The Trust's internal investigation was also flawed and incomplete.
Responded
Jude Lloyd
Concerns: Inadequate care planning and communication between inpatient, CMHT, and GP services led to unmanaged diabetes and missed mental capacity assessments. The Trust's internal investigation was also flawed and incomplete.
Responded
Fadhia Seguleh
Concerns: Mental health professionals operated in silos without information sharing protocols. Pandemic-related telephone assessments and unsupported solo A&E visits hindered comprehensive risk assessment and family involvement.
Overdue
Samantha Gould
Concerns: There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.
Responded
Sarah Smith
Concerns: Mental health clinicians failed to consider or routinely monitor the significant impact of hormonal changes as a contributory factor to depression in peri-menopausal women.
Overdue
Toby Nieland
Concerns: Agencies failed to engage with family concerns for a patient with complex dual diagnosis. There was inadequate care coordination, poor evaluation of relapse signs, and a lack of assertive community outreach for his advanced addiction and mental health needs.
Responded
Thomas Wedrychowski
Concerns: Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing between primary and secondary care providers.
Overdue
Reece Lapina-Amarelle
Concerns: There's a systemic failure to provide integrated treatment for co-occurring serious mental illness and substance misuse, hampered by poor information sharing and an outdated Mental Health Act.
Responded
Beverley Shaw
Concerns: Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete medical record transfers between substance misuse services also posed risks.
Responded
David Price
Concerns: There is a critical lack of an integrated mental health counselling and detoxification service in Stockport to support individuals treating anxiety alongside alcohol dependency.
Responded
Jennifer Lewis
Concerns: There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate care for the patient's overall needs.
Responded
George Twiddy
Concerns: Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during a patient's crisis.
Overdue
Danyon Chesters
Concerns: Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between professionals, and private therapists not reviewing medication, impacting the deceased's treatment.
Responded
Ursula Keogh
Concerns: Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary Psychology Team, highlighted poor communication between health and education professionals.
Responded
Robin McEwan
Concerns: Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients were identified.
Responded
Nigel Malloy
Concerns: There was a critical lack of information sharing and coordinated treatment planning between the Alcohol Liaison service and other support services for a patient with severe alcohol dependence and repeated admissions.
Responded
Maureen Campbell-Scott
Concerns: Systemic failures in mental health referral and communication between GP and mental health trust led to significant delays in patient assessment and medication management.
Responded
David Buttriss
Concerns: Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in mental health crisis pathways across multiple agencies hindered effective care.
Responded
Thomas Wall
Concerns: The lack of local in-patient detox facilities and long waiting lists are unacceptable. A more collaborative approach for dual diagnosis patients is critically needed, as current separation of care increases risk.
Responded
Jonathan Zucker
Concerns: A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.
Responded
Lee Swain
Concerns: A lack of coordinated procedures for transferring mental health patients between NHS Trusts, exacerbated by exiting a Care Programme Approach, resulted in delayed intervention and ineffective information exchange.
Overdue
Margaret Conway
Concerns: Systemic separation of mental and physical health services led to challenging patient transfers and fragmented care for individuals with co-occurring serious mental and physical health problems. Closer integration and shared resources are needed.
Overdue
Grant Burns
Concerns: There was a significant lack of cooperative working and communication between mental health and substance misuse services, which impeded a complete root cause analysis.
Responded
Gillian Taylor
Concerns: A lack of acute mental health facilities in Powys forces patients to be moved far from home, causing discontinuity of care and negatively impacting patient engagement, thus increasing self-harm and suicide risk.
Responded
Philip Denning
Concerns: Fragmented services for patients with co-occurring substance misuse and mental health issues, a lack of information sharing, and primary care's misunderstanding of available help pose significant risks.
Overdue
Charlotte Bevan and Zaani Malbrouck
Concerns: There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
Responded
Elizabeth Godwin
Concerns: Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, and a lack of audit trails for patient transfers.
Responded
Nancy Hughes
Concerns: No systematic medication review occurred as per medical practice, and a lack of cohesion between mental health and general medical treatment meant vulnerable patients' mental health information was disregarded in their physical care.
Pending
Stephen Morris
Concerns: Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, up-to-date patient history, compromising risk assessment and response.
Overdue
Aaron Vranas
Concerns: Fragmented care for patients with co-occurring psychiatric illness and ADHD due to treatment at geographically separate hospitals creates significant management difficulties.
Responded
Samiyo Farah
Concerns: Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric referrals from A&E.
Overdue
Janet Blackman
Concerns: Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated care delivery for both physical and mental health.
Overdue
Matthew Dunham
Concerns: Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination among professionals.
Overdue