Fragmented menopause and mental health care
Lack of joined-up care between menopause and mental health services, insufficient understanding, and inadequate national guidance.
108 items
6 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
100match
#15 - Community Mental Health Services fragmentation persists, requiring sustained investment for integrated support models.
Community Mental Health Services (CMHS) are integral to supporting people with severe mental illness across health, social care, and with their wider social needs. Evidence to this inquiry shows that integrated models of support within multi-disciplinary teams—such as co-located teams and Individual Placement and Support—can improve outcomes and reduce system pressures. However, fragmentation across services persists. Without sustained...
Matched on
terms: care, health, mental
Committee recommendation
100match
#2 - Lack of continuity of care fragments support for people with severe mental illness
Continuity of care is a necessity for people with severe mental illness. It is essential to the delivery of high-quality care. When it is present, it prevents crisis, builds trust, and supports recovery. When it is absent, it fragments support, burdens families, and puts lives at risk. This continuity must be built into the design of mental health...
Matched on
terms: care, health, mental
Committee recommendation
99match
#9 - Fragmented mental health system requires sustained investment and cultural shift for transformative community care.
Delivering real change and achieving parity of esteem in mental health care requires dismantling the current fragmented system and reimagining service design and delivery. The 24/7 Neighbourhood Mental Health Centre 75 pilots seem to be genuinely transformative. The experience from Trieste, and early evidence from Barnsley Street, show that radically different, individualised, community-based care gets results. We also...
Matched on
terms: care, fragmented, health, mental
Committee recommendation
99match
#3 - Current mental health services fail to provide person-centred, holistic care
Service users, their families, carers and loved ones have been clear: high- quality care must be person-centred, responsive to the full range of needs individuals experience, and ensure involvement of their wider networks. Current services too often fall short—focusing narrowly on diagnosis, overlooking physical health, and failing to support people with housing, employment, and social connection. People are...
Matched on
terms: care, health, mental
Committee recommendation
99match
#4 - Perinatal mental health investment remains insufficient and geographically limited to address needs.
Perinatal mental health is as important as physical health, with poor mental health outcomes having potentially significant long-term consequences for both the mother and child. We were struck by how frequently mental health concerns were raised in evidence. Given that the Government’s 54 new investment is available only to the original 75 local authority areas this will struggle...
Matched on
terms: care, health, mental
Committee recommendation
95match
#5 - Set actions to improve perinatal mental health access within Family Hubs for ethnic minority women.
The Government should set out what actions it will take to improve access to perinatal mental health care within Family Hubs, supported by specific targets to improve access for women from ethnic minority backgrounds who have disproportionately poorer mental health outcomes. (Recommendation, Paragraph 33)
Matched on
terms: care, health, mental
Committee recommendation
94match
#49 - Prioritise mental health support for children in care and pilot co-located CAMHS services.
The Department for Education should work with the Department of Health and Social Care to ensure that children in care and care leavers are prioritised for mental health support and improve training for mental health practitioners on the impact of trauma. This could be achieved by setting up co-located mental health services between children’s social care and Child...
Matched on
terms: care, health, mental
PFD report
93match
Philip Denning
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.
Matched on
terms: care, fragmented, health, mental
PFD report
93match
Jonathan Zucker
A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.
Matched on
terms: care, fragmented, health, mental
PFD report
93match
David Buttriss
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.
Matched on
terms: care, fragmented, health, mental
PFD report
93match
Danyon Chesters
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.
Matched on
terms: care, fragmented, health, mental
PFD report
93match
Alice Litman
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.
Matched on
terms: care, health, mental
Committee recommendation
91match
#21 - Commission women's health hubs to include mental health support in core specification in underserved areas
Women’s health hubs situated in areas where access to appropriate mental health services is lacking should be commissioned to include mental health support as part of their core specification.
Matched on
terms: health, mental
Committee recommendation
90match
#8 - Improve NHS website with interactive tools, guidelines, accessibility, and mental health support
To supplement improvements in the provision of information on the NHS website, we recommend the inclusion of an interactive tool which can help women to determine whether they might have a reproductive health condition. We further recommend that information on specific conditions, contains links to the relevant medical guidelines so that patients can make themselves aware of the...
Matched on
terms: care, health, mental
PPO recommendation
90match
The Heads of Healthcare at HMP Manchester and HMP Buckley Hall
The Heads of Healthcare at HMP Manchester and HMP Buckley Hall should ensure that: liaison between prisons takes place when prisoners with a history of severe and enduring mental illness are transferred to Manchester and that the outcome is fully documented in the prisoner’s medical records. All prisoners identified as requiring an urgent mental health assessment are assessed...
Matched on
terms: care, health, mental
PFD report
89match
Nancy Hughes
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.
Matched on
terms: care, health, mental
PFD report
89match
Elizabeth Godwin
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.
Matched on
terms: care, health, mental
PFD report
89match
Lee Swain
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.
Matched on
terms: care, health, mental
PFD report
89match
Jennifer Lewis
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.
Matched on
terms: care, health, mental
PFD report
89match
Toby Nieland
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.
Matched on
terms: care, health, mental
PFD report
89match
Samantha Gould
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.
Matched on
terms: care, health, mental
PFD report
89match
Gareth Williams
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.
Matched on
terms: care, health, mental
PFD report
89match
Kirsty Taylor
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.
Matched on
terms: fragmented, health, mental
PFD report
89match
Shahzadi Khan
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.
Matched on
terms: health, menopause, mental
PFD report
87match
Conrad Colson
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.
Matched on
terms: health, mental
PFD report
87match
Axel Price
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.
Matched on
terms: health, mental
Committee recommendation
87match
#20 - Offer specialist mental health support to individuals with reproductive health conditions from first symptoms through treatment
Individuals with a suspected or diagnosed reproductive health condition should be offered specialist mental health support from when they start to report distressing and/or painful symptoms and throughout diagnosis and treatment. Delays at each step of the process and a lack of treatment options make mental health support all the more essential.
Matched on
terms: health, mental
PPO recommendation
86match
The Head of Healthcare
The Head of Healthcare should conduct an urgent review of the following areas of mental healthcare delivery at Wakefield: ▪ develop a protocol for disseminating transfer handover information, within a centralised email system, not to an individual staff member’s email, to minimise the loss of critical clinical information; ▪ ensure all staff within the mental health team understand...
Matched on
terms: care, health, mental
PFD report
85match
Matthew Dunham
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.
Matched on
terms: care, health, mental
PFD report
85match
Janet Blackman
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.
Matched on
terms: care, health, mental
PFD report
85match
Stephen Morris
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.
Matched on
terms: health, mental
PFD report
85match
Gillian Taylor
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.
Matched on
terms: care, health, mental
PFD report
85match
Margaret Conway
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.
Matched on
terms: care, fragmented, health, mental
PFD report
85match
Reece Lapina-Amarelle
The report identifies a lack of resources and treatment for individuals with serious mental illness and substance misuse issues, as well as insufficient information sharing between mental health services and substance misuse services.
Matched on
terms: health, mental
PFD report
85match
David Walker
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.
Matched on
terms: care, fragmented, health
PPO recommendation
85match
The Head of Healthcare, the lead GP and the lead manager of the mental health service
The Head of Healthcare, the lead GP and the lead manager of the mental health service should: • review the system for the follow up of patients who do not meet the threshold for input from the mental health team but who continue to be referred; and • clarify the GP role and the development of shared care...
Matched on
terms: care, health, mental
Committee recommendation
85match
#46 - NHS England needs national menopause strategy to retain senior staff
NHS England should develop and implement a national menopause strategy focused on the retention of senior staff who may be reducing their hours, leaving management or supervisory roles, or retiring earlier than intended, because of a lack of support around menopause.
Matched on
terms: care, health, menopause
PFD report
81match
Charlotte Bevan and Zaani Malbrouck
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.
Matched on
terms: care, fragmented, health, mental
PFD report
81match
Grant Burns
There was a significant lack of cooperative working and communication between mental health and substance misuse services, which impeded a complete root cause analysis.
Matched on
terms: health, mental
PFD report
81match
Thomas Wedrychowski
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.
Matched on
terms: care, health
PFD report
81match
Jude Lloyd
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.
Matched on
terms: care, mental
PFD report
81match
Gaia Pope-Sutherland
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.
Matched on
terms: health, mental
PFD report
81match
Samuel Morgan
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.
Matched on
terms: health, mental
PFD report
81match
Marlene McCabe
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.
Matched on
terms: health, mental
PFD report
81match
Donna Donnellan
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.
Matched on
terms: health, mental
PFD report
77match
David Price
There is a critical lack of an integrated mental health counselling and detoxification service in Stockport to support individuals treating anxiety alongside alcohol dependency.
Matched on
terms: health, mental
PFD report
77match
George Twiddy
Poor inter-agency communication and unclear responsibilities between mental health services led to delays in providing immediate assistance during a patient's crisis.
Matched on
terms: health, mental
PFD report
77match
Darren Lawrence
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.
Matched on
terms: health, mental
PFD report
77match
Angela Collins
Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health crisis receive insufficient or no support.
Matched on
terms: health, mental
PFD report
77match
Amarnih Lewis-Daniel
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.
Matched on
terms: health, mental