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
Source spread
Where this theme appears
Fragmented menopause and mental health care has been flagged across 6 independent accountability sources:
61 PFD reports
37 committee recs
3 PPO recs
2 IMB reports
4 PHSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
PFD Reports (61) — showing 50 strongest matches
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
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
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.
Response (Department of Health): The Department of Health acknowledges the concerns raised and highlights existing NICE guidance on self-harm and a government suicide prevention strategy. They note that Trusts develop their own transfer protocols …
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.
Response (Bedfordshire Clinical Commissioning Group): Bedfordshire Clinical Commissioning Group is considering support for people with ADHD as part of a procurement of mental health services, due by April 2015. In the interim, they will work …
Responded
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.
Response (MDU Services Limited): The MDU is responding on behalf of a member, arguing that the coroner's report was not based on clear evidence and that the doctor's actions were reasonable in the circumstances.
Overdue
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.
Response: The Health Board has implemented a system where patients have a named care coordinator responsible for maintaining contact and reviewing medication, including a prescribing guideline for review and discontinuation of …
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.
Response (Royal United Hospitals Bath NHS Trust): Royal United Hospitals Bath NHS Foundation Trust (RUH) has implemented additional resource for Mental Health Services and amended the Mental Health Assessment Matrix. All junior doctors, Emergency Nurse Practitioners and …
Response (Wiltshire Council): Wiltshire Council describes planned discussions between Wiltshire Council (WC) and AWP to be held to clarify roles and responsibilities and ensure that a process is followed.
Response (Avon and Wiltshire NHS Trust): Avon and Wiltshire NHS Trust highlights that the Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the CPA process including assessment …
Responded
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.
Response: A consultant perinatal psychiatrist has been tasked to review individual pathway arrangements against NICE guidelines, aiming to agree and implement a Trust-wide pathway. The Trust also plans to prepare and …
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
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.
Response (Welsh Government): Following the report, Welsh Government facilitated a meeting between all Health Boards mental health managers to discuss using Welsh NHS beds whenever possible. They also highlighted the existing requirement for …
Response (Powys Teaching Health Board): Powys Teaching Health Board is working to repatriate Mental Health Services for direct delivery, expecting to treat more patients within Powys and reduce out-of-county placements.
Response (Kent and Medway NHS Trust): Kent and Medway NHS Trust revised its 'Unable to Contact' Protocol, launched it at the Acute Leadership Forum, and cascaded training to CRHT teams. The new Protocol is being piloted …
Responded
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.
Response (Solent NHS Trust): The trust has compiled a spreadsheet of clients identified as being worked with by Adult Mental Health and Substance Misuse Services, which is updated at the Southampton Alcohol Recovery Service …
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.
Response (PSYCH): The Royal College of Psychiatrists will discuss consultant accountability, ownership during transitions, and care involving multiple teams at its Professional Practice and Ethics Committee meeting on November 2, 2017, to …
Response (Department of Health): The Department of Health acknowledges the concerns raised and highlights existing guidance on care planning and continuity of care, including GMC guidance and consensus statements. It notes that the Royal …
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
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.
Response (Susssex Partnership NHS Trust): Sussex Partnership NHS Foundation Trust explains that they were not chosen by Brighton and Hove City Council to continue providing local substance misuse services and encourages the coroner to write …
Response (Brighton Hove City Council): Brighton & Hove City Council's Public Health department, as commissioner for adult and substance misuse in-patient detoxification beds, explains the history of service provision, noting the decision to work with …
Response (Brighton and Hove Clinical Commissioning Group): Brighton and Hove CCG highlights existing measures like a Dual Diagnosis integrated model, co-located DD workers, accommodation with support, and a Rough Sleepers project. Service user feedback is regularly reviewed, …
Overdue
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.
Response (Devon Doctors): Devon Doctors no longer provides out-of-hours services in Cornwall and has passed the report to the new provider. They reviewed the concerns in relation to their Devon services, noting that …
Response (NHS England): NHS England proposes to disseminate a reminder to GPs to safety net urgent mental health referrals, and to consider giving patients written guidance on what to expect and when following …
Response (Cornwall NHS Trust): Cornwall NHS Trust has implemented a new assessment service with designated administrators to manage referrals, and developed new Safety Plans for patients containing crisis information. The Trust is also reviewing …
Responded
Maureen Campbell-Scott
Concerns: A referral was sent to the wrong team and then lost, causing a four-month delay in assessment. There were also delays in delivering clinic letters to the GP, and prescribing did not always follow the psychiatric team's directions.
Response (NELFT): NELFT has been liaising with Fullwell Cross Medical Centre and Redbridge CCG and progress has been made to address concerns and they are reconvening a meeting with primary care colleagues …
Overdue
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.
Response (Hampshire Hospitals NHS Trust): The Trust has a 24-hour referral service and pathway with Inclusion, leaflets about Inclusion Service, a weekly inreach service (now adhoc), regular telephone liaison, referrals to Mental Health Provider and …
Overdue
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.
Response (Harrogate CCG): The CCG will review the primary care referral process for private counselling, look at developing Mental Health & Psychological First Aid within Primary Care and the CCGs, and further develop …
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.
Response (Department of Health and Social Care): The Department of Health and Social Care highlights national initiatives like 'Future in Mind' and the Suicide Prevention Workplan. They also mention plans to set up 24/7 crisis care for …
Response (Calderdale CCG): Calderdale CCG and Calderdale Council have reviewed and revised processes and identified new actions related to CAMHS referrals and communication between professionals, overseen by the multi-agency Open Mind Partnership. Calderdale …
Responded
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.
Response (Department of Health and Social Care): The Department acknowledges the concerns raised and explains the NHS's role in commissioning services and targets for psychological therapies. They reference guidance for therapists on managing client confidentiality and risk, …
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.
Response (Oxleas NHS Trust): The Trust has implemented several changes, including inviting relevant healthcare professionals to CPA meetings, entering all patients' weight and height into the Malnutrition Universal Screening Tool (MUST), and ensuring patients …
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.
Response (Stockport NHS CCG): The CCG and Local Authority will continue promoting services for people with alcohol and substance misuse problems experiencing mental health problems, request regular updates on service promotions, and monitor access, …
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.
Response (Southern Health NHS Foundation Trust): Hampshire County Council (HCC) & Southern Health Foundation Trust (SHFT) will implement a s140 Policy, opportunities to attend inter – agency training, strategic development plans to deliver integrated pathways, mental …
Overdue
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.
Response (Oldham NHS CCG): Oldham CCG is co-ordinating a learning event with Hopwood House Medical Centre and the Oldham Turning Point team to facilitate reflection and agree on actions to improve working relationships.
Response (Turning Point): Turning Point conducted a review of GP communication across its substance misuse services and has implemented improvements including changes to prescriber templates, communication frequency, record keeping, and audit processes. These …
Response (Hopwood House Medical Practice): Hopwood House Medical Practice has implemented a DNA policy to discuss patients who do not attend appointments and is considering referring such patients to a Focus Care worker. The practice …
Responded
Reece Lapina-Amarelle
Concerns: 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.
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges the concerns and notes the NHS England and Improvement response. They commissioned a review of the Mental Health Act and will publish …
Response (NHS England): NHS England expresses condolences and acknowledges the concerns raised, referencing existing initiatives to improve mental health services and digital tools. It notes that the Department of Health and Social Care …
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
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.
Response (Lincolnshire County Council): Lincolnshire County Council plans to implement a working protocol for mental health and substance misuse services, take into account best practice when re-commissioning drug and alcohol services, review dual diagnosis …
Response (We Are With You charity): We Are With You charity has jointly agreed to review Dual Diagnosis pathways, embedded information sharing expectations, and reviewed staff structures to introduce specialist Dual Diagnosis roles. They have also …
Response (Lincolnshire Partnership NHS Foundation Trust): The Trust plans to update training programmes to focus on dual diagnosis, reinforce the role of carers, review the Care Programme Approach, and engage with commissioners to ensure appropriate funding …
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
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.
Response (NHS England): NHS E/I acknowledge a systemic weakness existed and is working with NHS Digital to allow information about local prescription plans to be added to Summary Care Records. They highlight existing …
Response (RPS): The RPS welcomes guidance/standards to ensure the NHS and other providers of care inform community pharmacies of patient safety plans. They highlight their existing guidance and campaigns on patient health …
Response (GPC): The GPhC outlines its role in setting standards for pharmacies and pharmacists, noting that NHS England is better placed to provide information on national medication safety plans. They will share …
Response (CCA): The CCA will discuss the case at the next Community Pharmacy Patient Safety Group meeting to identify learnings and share best practice. They will also work with other organizations (GPhC, …
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
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.
Response (Greater Manchester Mental Health NHS Foundation Trust): Following a Root Cause Analysis Investigation, recommendations were made and implemented to address concerns regarding diabetes monitoring and management. An eLearning training package is in place for CMHT staff regarding …
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.
Response (Droylsden Road Family Practice): The practice has developed a pathway for managing patients with suicidal tendencies and implemented changes to their template. They have also nominated leads for suicide prevention and will start recruiting …
Response (Greater Manchester Mental Health NHS Foundation Trust): The Trust has implemented daily multi-disciplinary zoning meetings in CMHT, attended by HBTT staff twice weekly to improve communication; also, an Assistant Director for Quality has been appointed to address …
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.
Response (North East London NHS Foundation Trust): The Trust has hired agency staff on a semi-permanent basis, approved budget for reduced caseloads, provided training and supervision for staff, and amended the electronic admission checklist to include prompts …
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.
Response (NHS Dorset Integrated Care): NHS Dorset will undertake a review of nursing resources in epilepsy care locally, encompassing primary and secondary care for adults and children, and interaction with other specialities. The Regulation 28 …
Response (BCP Council): BCP Council's AMHP service uses the Mental Health Act 1983 and Code of Practice, monitored through a Quality Assurance Framework, to inform practice. They are actively engaging with Dorset Healthcare …
Response (Dorset Healthcare University NHS Foundation Trust): The Integrated Care Board (ICB) are carrying out an 8 week review of the entire Epilepsy and Neurology service which started on 11 August 2022.
Response (Dorset Council): Dorset Council has completed an internal review of its AMHP pathways and recording systems to ensure adherence to the Mental Health Act Code of Practice, focusing on information sharing. The …
Response (Dorset Healthcare University NHS Foundation Trust): The trust outlines multiple planned actions, including updating policies to address sexual harassment/assaults on inpatient units, reviewing patient observation practices, improving documentation of rationale for observation levels, reviewing guidance on …
Response (Dorset Police): Dorset Police supports sharing learning about life-threatening illnesses with the College of Policing and has offered to support national training. They have implemented changes to the POLSA/LPSM process, directed staff …
Response (College of Policing): The College of Policing believes their current approach to vulnerability training, which focuses on risk management and information gathering, is appropriate. They argue that the complexity and variability of medical …
Response (Department of Health and Social Care): The Trust has introduced a Standard Operating Procedure in May 2022 which covers the provision of information following Mental Health Act assessments.
Response (Dorset Healthcare University NHS Foundation Trust): The Trust has updated its Safeguarding policy to highlight the response needed when an adult discloses they have experienced sexual abuse, with two appendix documents added to the policy setting …
Response (Royal College of Psychiatrists): The Royal College of Psychiatrists acknowledges the lack of effective communication between neurology and mental health services. They highlight workforce issues in neuropsychiatry and support the development of integrated services …
Response (Association of British Neurologists): The Association of British Neurologists will communicate suggested actions to improve communication between psychiatry and neurology teams, such as copying communications to the treating neurologist and informing neurologists of psychiatric …
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.
Response (Aneurin Bevan University Health Board): Aneurin Bevan University Health Board is expanding a service called 'Adferiad' to include people with other medical and long-term conditions, which will be delivered by a multi-disciplinary team including medical, …
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.
Response (Swansea Bay University Health Board): For Swansea based teams, technical changes to enable two-way information sharing between community mental health teams and drug and alcohol services via WCCIS will be completed within 10 working days, …
Responded
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.
Response (South London and Maudsley NHS Foundation Trust): CADAT has updated its discharge policy to explicitly state the expectations of liaison between local teams and how staff are expected to communicate with skin clinics regarding patients seeking aesthetic …
Response (NHS England): NHS England's Clinical Reference Group (CRG) for OCD & BDD intends to convene with stakeholders to consider issues of patients with BDD accessing aesthetic dermatology treatments. They have asked to …
Response (NELFT): NELFT is developing actions including care pathway mapping, updating the risk assessment process, and arranging BDD training for all staff in conjunction with SLAM. A Quality Improvement Project will be …
Response (Aesthetic Dermatology): The clinic updated its BDD policy to include formal screening for BDD using the COPS questionnaire, updated the patient journey policy regarding communication and information sharing, and provided in-depth, mandatory …
Responded
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
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.
Response (Department of Health and Social Care): The Department acknowledges concerns over physical healthcare in mental health settings and compatibility of electronic patient records, noting expectations for the Trust's response and describing the use of shared care …
Overdue
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.
Response (Northern Care Alliance NHS Foundation Trust): The Trust has finalised and ratified the policy 'Management of Medical Emergencies in Adult Patients with Eating Disorders' and shared it with Pennine Care NHS FT. The policy clarifies roles, …
Response (Pennine Care NHS Foundation Trust): The Trust has worked with Northern Care Alliance NHS Foundation Trust to review policies and procedures following the Inquest, to add clarity regarding referral. The learning from this inquest and …
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.
Response (East London NHS Foundation Trust): The Trust is planning to review discharge and de-escalation pathways, work with system partners to review 'Multi-Agency Vulnerable Adult Return Home Interview Practice Guidance', ensure staff attend 'Think Family' training, …
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.
Response (Surrey and Borders Partnership NHS Foundation Trust): The Trust is developing a mandatory training package for all staff on working with people from the transgender community, co-produced with people with lived experience and their families. It is …
Response (NHS England): NHS England acknowledges concerns about the death of Alice Litman and outlines its role as commissioner of gender dysphoria services. They note improvements being made to the NCMD alert system …
Response (Royal College of Genereal Practitioners): The RCGP expresses condolences and describes its existing work to improve care for transgender individuals, including e-learning packages and a transgender policy document. They highlight long waiting lists for specialist …
Response (Travistock and Portman NHS Foundation Trust): The Tavistock and Portman NHS Foundation Trust acknowledges concerns about services for patients on the GIC waiting list. They describe the role of the GIC, noting the HA60 classification, and …
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.
Response (NHS England): NHS England is working to develop new models of integrated primary and community mental health care, including a dedicated community mental health offer for those with diagnoses of ‘personality disorder’ …
Response (Hampshire and Isle of Wight): The ICB has endorsed the creation of a new all-age Trust to oversee community and mental health services across Hampshire and Isle of Wight, expected to go live on 1 …
Response (Southern Health NHS Foundation Trust): Southern Health NHS Foundation Trust, along with other trusts, is working towards establishing a new, single community and mental health provider by 1 April 2024 (Project Fusion). They are continuing …
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.
Response (Essex Partnership University NHS Foundation Trust): Essex Partnership University NHS Foundation Trust has implemented measures to improve handover of care between inpatient and community psychology services, ensure access to clinical systems and robust information sharing, and …
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.
Response (NHS England): NHS England expresses condolences and acknowledges the concerns raised. The response focuses on the NHS pathway of care for adults with gender dysphoria, national policy on mental health services for …
Response (Together UK): Together UK has information sharing agreements with NELFT and ELFT and follows a Standard Operating Procedure for Liaison and Diversion. The agency social worker would have received risk management, information …
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.
Response (Department of Health and Social Care): The Department of Health and Social Care outlines initiatives being implemented in Greater Manchester to address mental health bed shortages and improve awareness of menopause for healthcare staff. NHSGM ICB …
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.
Response (Department of Health and Social Care): The DHSC acknowledges concerns about transitions from children's to adult mental health services and highlights the NHS Long Term Plan's aim for a comprehensive offer for 0-25 year olds. They …
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.
Response (NHS England): NHS England has adopted a new process for Child Death Overview Panels (CDOPs) to alert NHS England following the death of every child or young person identified with gender distress. …
Response (Arden and Greater East Midlands NHS Commissioning Support Unit): The Arden and GEM CSU updated its website in April 2024 to reflect a new supportive offer from NHSE, where all children and young people on the waiting list for …
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.
Response (Cheshire and Wirral Partnership NHS Foundation Trust): The Trust clarifies the function of Cafe 71 and its liaison with the Trust and outlines how GPs are informed of contact with the crisis line, noting that the referral …
Response (Cheshire and Merseyside Integrated Care Board): NHS Cheshire and Merseyside Integrated Care Board will work with CWP and GP colleagues to improve the timeliness and content of correspondence from the Crisis Line.
Response (Spider Project Cafe): The cafe has changed its referral forms to include consent for leaving voicemails and to gather more information about existing support for the individual being referred.
Response (Spider Project 1): Spider Project 1 disputes several points in the coroner's report, clarifying that the deceased never contacted Cafe 71 directly and that the referral from the Crisis Line gave no indication …
Responded
Committee Recommendations (37)
#3 —
Recommendation: It is unacceptable that there are parts of the country where women cannot access the specialist menopause services they need. By 2024, there should be a menopause specialist or specialist service in every Clinical Commissioning Group area. The Menopause Taskforce, …
Gov response: 35. Whilst supporting the ambitions behind this recommendation, the government does not accept this recommendation. 36. It is the government’s ambition, as set out in the Women’s Health Strategy, that all women can access high-quality, …
Under Consideration
#2 —
Recommendation: GPs will be the first port of call for many women who are experiencing perimenopause or menopause. It is vital that women can trust their GPs and that GPs feel confident and well-equipped in diagnosing a condition that affects half …
Gov response: 18. The government accepts this recommendation in part. 19. It is the government’s ambition, as set out in the Women’s Health Strategy, that healthcare professionals in primary care are well informed about the menopause, and …
Partially Accepted
#21 — Commission women's health hubs to include mental health support in core specification in underserved areas
Recommendation: 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.
Gov response: As the report highlights, some reproductive health conditions are not always straightforward to diagnose. Nonetheless, it is not good enough that women with reproductive health conditions often experience a delayed diagnosis, which can lead to …
Under Consideration
#20 — Offer specialist mental health support to individuals with reproductive health conditions from first symptoms through treatment
Recommendation: 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 …
Gov response: We sympathise with anyone who is the victim of rape. Sexual assault referral centres have been co-commissioned by NHS England and police and crime commissioners since 2013. They provide a safe space and dedicated care …
Accepted
#8 — Ensure FGM Support Clinics offer specialist counselling with clear referral pathways
Recommendation: The Government should ensure that all FGM Support Clinics offer specialist counselling support to FGM survivors in appropriate settings, provided by counsellors who are trained in the specific challenges of FGM. There should be clear referral pathways to this counselling …
Gov response: Response: Integrated Care Boards and NHS Trusts commission FGM support clinics which offer a range of services to support women affected by FGM including physical treatment, counselling and further referrals to urology, gynaecology etc. depending …
Not Addressed
#7 — Many FGM survivors lack access to appropriate specialist counselling services
Recommendation: FGM survivors often suffer psychosexual, emotional and mental health complications from undergoing FGM. However, many FGM survivors do not have access to appropriate counselling services, with many FGM services not offering any counselling to FGM survivors and others offering counselling …
Gov response: Response: Integrated Care Boards and NHS Trusts commission FGM support clinics which offer a range of services to support women affected by FGM including physical treatment, counselling and further referrals to urology, gynaecology etc. depending …
Partially Accepted
#9 — High number of care leaver deaths highlights poor transition coordination to adult services.
Recommendation: We asked the Department and other witnesses about the circumstances surrounding a young person recently taking their own life after turning 18 and facing the uncertainty of moving out of the children’s social care system. A situation which the Chief …
Response Pending
#47 — Require Government to detail actions addressing complex health needs of women in custody
Recommendation: The Government should respond to this report setting out what action it is taking to address the complex health and wellbeing needs of the women it currently has in its custody. (Recommendation, Paragraph 212) 88
Gov response: Accept. This Government recognises that there are too many women in prison, many of whom have multiple complex needs. Through the Womens Justice Board, we have set out a clear ambition to reduce the number …
Accepted
#46 — System failing to meet complex health and wellbeing needs of women in prison
Recommendation: Women in prison often have acute and complex health needs, yet the system is failing to meet even their most basic requirements. We acknowledge the Government’s ambition to reduce the population in the female prison estate, and that change is …
Gov response: Accept. This Government recognises that there are too many women in prison, many of whom have multiple complex needs. Through the Womens Justice Board, we have set out a clear ambition to reduce the number …
Accepted
#21 — Expand Section 75 use to enable wider budget pooling, including housing and education services.
Recommendation: The Government should expand the use of Section 75 of the NHS Act 2006 by enabling and encouraging more widespread pooling of budgets between NHS bodies and local authorities. This expansion should support the inclusion of a broader range of …
No Published Response
#15 — Community Mental Health Services fragmentation persists, requiring sustained investment for integrated support models.
Recommendation: 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 …
No Published Response
#9 — Fragmented mental health system requires sustained investment and cultural shift for transformative community care.
Recommendation: 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 …
No Published Response
#3 — Current mental health services fail to provide person-centred, holistic care
Recommendation: 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 …
No Published Response
#2 — Lack of continuity of care fragments support for people with severe mental illness
Recommendation: 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, …
No Published Response
#5 — Set actions to improve perinatal mental health access within Family Hubs for ethnic minority women.
Recommendation: 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 …
Response Pending
#4 — Perinatal mental health investment remains insufficient and geographically limited to address needs.
Recommendation: 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 …
Response Pending
#5 —
Recommendation: We recommend that the Government commits to removing dual prescription charges for oestrogen and progesterone, replacing it with a single charge for all women. We also recommend that the Government works with the NHS and the ‘HRT tsar’ to develop …
Gov response: 47. The government accepts this recommendation in part. 48. As set out in the response to recommendation 4, we are committed to reducing prescription charges for HRT. The implementation of the bespoke HRT PPC will …
Partially Accepted
#16 — Encourage firms to establish menopause policies and support to retain talent.
Recommendation: We recommend that Government continue to encourage firms to recognise the impact of menopause and to establish policies and support for those who are affected to ensure that their experience and talents are not prematurely lost from the industry. (Paragraph …
Gov response: In March 2023, the (then) Minister for Social Mobility, Youth and Progression appointed Helen Tomlinson as the Government’s first Menopause Employment Champion. The Menopause Champion is driving awareness of issues surrounding menopause in the workplace; …
Accepted
#4 — Ensure all FGM survivors access timely, essential support and specialist care nationwide
Recommendation: The Government should ensure that all FGM survivors can access the essential support and care they need in a timely manner. While some variation in service provision may be necessary to reflect local prevalence rates, higher-prevalence areas should offer funded …
Gov response: Response: Integrated Care Boards and NHS Trusts commission FGM support clinics which offer a range of services to support women affected by FGM including physical treatment, counselling and further referrals to urology, gynaecology etc. depending …
Accepted
#46 — Ministerial responsibility split leads to neglect and fragmentation of FE SEND policy.
Recommendation: SEND policy is currently overseen by the Minister for School Standards whilst further education policy lies with the Minister for Skills. This split in ministerial responsibility has led to the neglect of FE SEND policy, as well as inefficiencies, limited …
Gov response: There is no response for this recommendation.
Not Addressed
#13 —
Recommendation: We are also persuaded that a new protected characteristic of menopause should be created, although we acknowledge this will need careful drafting and consultation. The Government should launch a consultation on how to amend the Equality Act to introduce a …
Gov response: 91. The government does not accept this recommendation. 92. The government agrees that it is important that women who suffer substantial and longer-term menopausal effects should be adequately protected from discrimination in the workplace. However, …
Not Accepted
#4 —
Recommendation: We are extremely disappointed that despite a clear Government commitment on a single-cost, annual pre-payment certificate for HRT, almost nine months later that commitment has not been realised. Progress has been further derailed by supply issues. We welcome the Health …
Gov response: 43. The government accepts this recommendation in part. 44. The government is committed to reducing the cost of HRT prescriptions and work is underway with the NHS Business Services Authority to develop a bespoke pre-payment …
Partially Accepted
#1 —
Recommendation: Menopause still carries significant social and cultural stigma, particularly for certain groups, including LGBT+ people and young and ethnic minority women. We are encouraged by the recent shift towards talking about menopause more openly, by the inclusion of menopause in …
Gov response: 1. The government accepts this recommendation in principle. Menopause public health campaign 2. As set out in the Women’s Health Strategy, the government’s ambitions are that everyone is educated about the menopause from an early …
Partially Accepted
#32 — Develop and pilot a specific 'menopause leave' policy with a large public sector employer.
Recommendation: We endorse and support the recommendation by the Women and Equalities Committee that the Government should develop and pilot a specific ‘menopause leave’ policy with a large public sector employer.
Gov response: Since its introduction, Automatic Enrolment has transformed workplace pension saving with participation amongst eligible employees in the private sector increasing from 42% in 2012 to 86% in 2021. It was designed specifically to help groups …
Under Consideration
#15 — Progress in supporting employees affected by menopause requires further action.
Recommendation: Welcome progress has been made in recognising the effect of the menopause and in identifying ways of assisting those affected to overcome the challenges it presents without having to leave their jobs. That progress, as in other areas of this …
Gov response: In March 2023, the (then) Minister for Social Mobility, Youth and Progression appointed Helen Tomlinson as the Government’s first Menopause Employment Champion. The Menopause Champion is driving awareness of issues surrounding menopause in the workplace; …
Accepted
#8 — Improve NHS website with interactive tools, guidelines, accessibility, and mental health support
Recommendation: 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 …
Gov response: The government is committed to ensuring that women receive comprehensive, up-to-date information about diagnostic and treatment options for reproductive health conditions. Healthcare professionals are expected to provide women with detailed information ahead of any surgical …
Accepted
#49 — Prioritise mental health support for children in care and pilot co-located CAMHS services.
Recommendation: 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 …
Gov response: the Department for Health and Social Care to pilot this approach. We recognise the importance of prioritising mental health support for children in care and care leavers. Working with DHSC, NHSE, and MoJ, we are …
Accepted
#46 — NHS England needs national menopause strategy to retain senior staff
Recommendation: 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 …
Gov response: NHSE requires all trusts to follow the UK Ethical Code of Practice when employing international health and care staff, which is clear that applicants must not be required to pay any fees in order to …
Not Addressed
#12 —
Recommendation: The current law does not serve or protect menopausal women. Whilst the law rightly protects women from pregnancy and maternity discrimination, it does not specifically protect menopause. This is anomalous, given all women will experience menopause, whilst not all women …
Gov response: 91. The government does not accept this recommendation. 92. The government agrees that it is important that women who suffer substantial and longer-term menopausal effects should be adequately protected from discrimination in the workplace. However, …
Not Accepted
#7 — Government's 'Get Active' strategy remains inadequate for addressing midlife women's health barriers.
Recommendation: Women in midlife face specific health-related barriers to participation, including but not limited to the symptoms of perimenopause and menopause. These occur after many have experienced barriers at earlier life stages, including in early years and at school during puberty. …
Gov response: Health barriers for girls and women in sport: Government and Sport England responses 11 The Government accepts this recommendation. The Government believes that, through the National Physical Activity Taskforce (NPAT) and Board of Women’s Sport, …
Accepted
#16 —
Recommendation: We are aware that there has been a significant increase in the number of referrals to Gender Identity Development Services in recent years. We strongly believe that improved support is needed to help young people seeking to transition, especially mental …
Gov response: 49. NHSEI is committed to the commissioning of a new service model for adults in the future, building clinical capacity in primary care and sexual health services, to reduce waiting times. DHSC and NHSEI welcome …
Not Addressed
#9 —
Recommendation: Menopause symptoms can have a significant and sometimes debilitating impact on women at work. The Government should work with a large public sector employer 48 Menopause and the workplace with a strong public profile to develop and pilot a specific …
Gov response: The government does not accept this recommendation. Within the Civil Service, we are focusing our efforts on developing and promoting good practice and adoption across the Civil Service. As set out in our response to …
Not Accepted
#8 —
Recommendation: We recommend that the Government, in consultation with the Menopause Ambassador, produces model menopause policies to assist employers. The model policies should cover, as a minimum: how to request reasonable adjustments and other support; advice on flexible working; sick leave …
Gov response: Whilst supporting the ambition, the government does not accept this recommendation, as we do not believe a model menopause policy is necessary at this moment. The government agrees with the Committee that there is much …
Not Accepted
#7 —
Recommendation: The Government has a key strategic role in helping businesses and should lead the way in developing and disseminating good practice. The Government should appoint a Menopause Ambassador to work with stakeholders from business (including small to medium enterprises), unions, …
Gov response: 57. The government accepts this recommendation in principle. 58. This recommendation is in line with the recent government response18 to the independent menopause and the workplace report19 commissioned by the then Minister for Employment through …
Accepted
#6 —
Recommendation: Menopause is a workplace issue. There is a legal, economic, and social imperative to address the needs of menopausal employees. We are not persuaded that a legal requirement for every workplace to have a menopause policy would embed meaningful change. …
Gov response: 62. Whilst supporting the ambition, the government does not accept this recommendation, as we do not believe a model menopause policy is necessary at this moment. The government agrees with the Committee that there is …
Not Accepted
#11 —
Recommendation: Wellbeing of Women’s period symptom checker should be added to the NHS app. The Government should work with Wellbeing of Women to determine whether conditions in addition to heavy bleeding and pain, such as irregular bleeding, depression and anxiety, might …
Response Pending
#10 —
Recommendation: We congratulate Wellbeing of Women on developing and rolling out its period symptom checker. It is an excellent tool, which has the potential to be a major breakthrough in improving awareness and understanding of menstrual health problems and speeding up …
Response Pending
PPO Death in Custody Recommendations (3)
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, …
The Heads of Healthcare at HMP Manchester and HMP Buckley …
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 …
The Head of Healthcare, the lead GP and the lead …
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 …
IMB Annual Reports (2)
Warren Hill (2023)
HMP Warren Hill, a Category C adult male prison with an operational capacity of 267, maintained a safe environment despite some low-level bullying. The Board noted improved use of safety interventions (CSIPs, ACCTs) and zero deaths in custody. Key challenges included persistent issues with food provision, the suspension of the ROTL pilot, and delays in progression caused by Secretary of State interventions. The IMB made recommendations regarding food quality, estate investment, digital skills for resettlement, and urges review of the ROTL suspension.
PRISON
Key concerns
Thorn Cross (2023)
HMP/YOI Thorn Cross is a Category D open prison that maintains a very safe environment with extremely low violence levels and effective drug reduction strategies. Relationships between staff and prisoners are generally positive, fostering a rehabilitative culture. While healthcare provision is deemed excellent and rehabilitation efforts are at the heart of the prison's operations, concerns remain regarding low transfer rates for long-sentence prisoners, property transfer issues, and limitations in internet and mobile phone access for prisoners.
PRISON
Key concerns
PHSO Casework Decisions (4)
P-004551 — A practice in the Leeds area
Ms J complains the Practice did not appropriately treat her perimenopause symptoms and disregarded her concerns based on normal blood test results. She complains the Practice did not prescribe her hormone replacement therapy (HRT) and did not advise her of its HRT prescription policy.
NHS in England
Dec 2025
P-004580 — A practice in the Richmond upon Thames area
Ms M complains about the care and treatment she received from her GP Practice for perimenopausal symptoms.
NHS in England
Jan 2026
P-003984 — A practice in the City of Nottingham area
Ms P complains a GP Surgery in Nottingham refused to provide her HRT prescription and did not inform her before it reduced her prescription. She also complains it did not communicate with other organisations to support her prescription.
NHS in England
Sep 2025
P-004575 — Dorset Healthcare University NHS Foundation Trust
Mr I complains the Trust failed to return his voicemail, provided no ADHD care or treatment after his private diagnosis and did not inform him his dialectical behaviour therapy (DBT) referral had gone to the wrong place or he was being transferred to another service.
NHS in England
Jan 2026