Mental health access for alcohol addiction
Significant barriers to timely mental health support for patients with alcohol addiction due to service and awareness gaps.
800 items
13 sources
2 inquiries
Source spread
Where this theme appears
Mental health access for alcohol addiction has been flagged across 13 independent accountability sources:
3 inquiry recs
274 PFD reports
117 committee recs
14 CQC actions
34 PPO recs
4 IOPC recs
212 IMB reports
81 IMB recs
7 Article 2 learning points
8 detention investigation recs
19 PHSO decisions
26 LGO/SPSO 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.
Inquiry Recommendations (3)
SP56 — Mental health assessment powers for isolated children
Recommendation: Phase 2 should consider whether further legislative change is required to allow mental health clinicians to assess children and young people who are isolated from professional support and may pose a risk of violence, particularly where powers under the Mental …
Response Pending
SP55 — Community mental health services for violence-fixated children
Recommendation: Phase 2 should consider the ability of community and forensic mental health services to deliver clinical interventions to mitigate the risk from violence fixated children and young people.
Response Pending
16 — Independent review of use of force on mentally ill detainees
Recommendation: The Home Office must urgently commission an independent review (with the power to make recommendations) of use of force on detained people with mental ill health within immigration removal centres. The review must consider: how, when and whether to use …
Gov response: The government stated it is working with HMPPS, NHS England and DHSC to develop new operational standards for use of force on detained people with mental ill health.
Accepted in Part
No update 2+ yrs
PFD Reports (274) — showing 50 strongest matches
Robert Day
Concerns: Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, risking patient lives.
Overdue
Cynthia Fretwell
Concerns: The GP practice had an ineffective system for telephone referrals, lacking timely consultation, proper assessment of patient mental capacity for refusing treatment, and clear communication between staff and doctors.
Response (Hama Medical Centre): Hama Medical Centre has updated its Mental Capacity Act 2005 policy and updated its Telephone Consultation Protocol, in addition to discussing the Mental Capacity Act during medical meetings. They have …
Responded
Andrew Cairns, Rachael Slack and Auden Slack
Concerns: Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of a recent mental health assessment; an existing information-sharing policy was also undisclosed.
Overdue
Michael O’Sullivan
Concerns: The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating GP, psychiatrist, and clinical psychologist, leading to decisions without comprehensive medical input.
Response (Department for Work and Pensions): DWP acknowledges concerns and will issue a reminder to staff about guidance related to suicidal ideation. They also state that they will continue to monitor their policies around assessment of …
Responded
David Chatburn
Concerns: The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.
Response (Department of Health): The Department of Health acknowledges the concerns raised regarding the patient's care and referral process, and notes that patients with a mental health condition have the same legal rights as …
Overdue
Philip Dean
Concerns: Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed professional assessments for severely unwell patients.
Response: South West London and St George's NHS Trust has revised serious incident procedures so that initial findings from concise investigations are reviewed after ten working days to consider escalating to …
Overdue
Samarjit Singh
Concerns: The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and declined referrals for mothers with severe postnatal depression.
Response (Wirral Clinical Commissioning Group): NHS Wirral CCG established a working group to review the perinatal mental health pathway. They are revising the Liaison Psychiatry service specification to include dedicated consultant psychiatrist time and requiring …
Response (Department of Health): The Department of Health acknowledges the coroner's concerns regarding perinatal mental health services in the Wirral and Liverpool. They state that commissioning of local services is the responsibility of Clinical …
Overdue
Sol Hadhasseh
Concerns: A mental health Trust's reliance on a delayed GP referral, rather than a direct Trust-to-Trust transfer, for a patient with complex needs highlighted a systemic flaw in patient transfer procedures between Trusts.
Overdue
Sadik Miah
Concerns: Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for urgent non-emergency medical opinions, creates ongoing patient safety risks.
Overdue
Jake Hardy
Concerns: Vulnerable young persons with complex needs face increased self-harm and suicide risks in Youth Offender Institutions due to staff lacking adequate training and understanding.
Overdue
Graham Darby
Concerns: A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.
Overdue
Ann Wells
Overdue
Brian Dalrymple
Concerns: The report identifies a lack of awareness among detention staff regarding indicators of mental health issues, a failure to act on recorded observations, inadequate medical visits to segregated detainees, and the absence of a comprehensive clinical record system.
Response (The GEO Group UK Ltd): GEO Group states that as the contract for Harmondsworth IRC passed to Mitie, they cannot take action regarding working practices there. However, they will consider lessons learned from the inquest …
Overdue
Christopher Ajayi
Concerns: A vulnerable patient with complex mental and physical health needs was discharged into unsupported accommodation without a care package or necessary medical oversight, highlighting severe failures in discharge planning and care coordination.
Responded
Anthony Huggan
Concerns: The lack of a suitable out-of-hours service for drug addiction placed an undue burden on emergency services, with insufficient timely follow-up for patients who self-discharged after overdoses.
Response (Bury Council): The council provides contextual information about commissioned substance misuse services and describes the services available, but does not outline specific changes in response to the concerns.
Responded
David Greenfield
Concerns: Staff lacked expertise in managing co-occurring drug and alcohol problems, internal reviews overlooked external research, and admission procedures for alcohol detox patients omitted drug screening, hindering proper risk assessment.
Response (Priory Group): The Priory Group audited the competencies of medical staff in specialist wards and provided additional training where needed. They are ensuring a full baseline physical health assessment is in place …
Responded
John Ioannou
Concerns: There is a lack of clear guidance for General Practitioners when patients fail to collect essential mental health medication, potentially compromising treatment continuity and patient well-being.
Response (Department of Health): The Department of Health acknowledges the concerns about GPs monitoring medication collection for mental health patients, but cites practical and ethical challenges to implementing such a system. NHS England advises …
Responded
Ronald Gittens
Concerns: Issues identified include the transfer of acute psychiatric patients when no bed is available and the use of Crisis Resolution Home Treatment Teams as a barrier to inpatient bed access.
Response (Department of Health): The Department of Health acknowledges the concerns regarding mental health patient transfers and CRHTTs, but states responsibility lies with the local NHS. They highlight the Crisis Care Concordat and local …
Overdue
Andrew Farrow
Concerns: A patient with suicidal ideation who requested admission could not be accommodated due to a lack of available beds at the mental health hospital.
Response (Avon and Wiltshire NHS Trust): Avon and Wiltshire NHS Trust explains its process for managing bed pressures and out-of-area placements, stating decisions are risk-based. They also note their surprise at receiving a PFD report for …
Overdue
Michael George
Concerns: Senior management may have attached insufficient importance to previous PFD reports regarding the physical healthcare of mentally ill patients, and there was a lack of domiciliary visits from consultant physicians to mental health wards.
Response (South London and Maudsley NHS Trust): South London and Maudsley NHS Trust outlines planned improvements to policies, audits, and risk management related to physical health monitoring for patients on anti-psychotics, including actions related to diabetes screening …
Responded
Anne Wilson
Concerns: Changes in police welfare check policy were not communicated to ambulance services, and police staff lacked training on managing mental health requests, leading to critical information not being acted upon or shared with the requesting GP.
Response (London Ambulance Service NHS Trust): A Control Services Bulletin will be issued by the end of September 2015 about the MPS welfare checks policy to mitigate the risk of a call to a vulnerable patient …
Overdue
James Adams
Concerns: A severe shortage of acute psychiatric beds in Cornwall forces inappropriate detention in police cells or distant out-of-county transfers, causing patient deterioration and misallocating valuable consultant time.
Response (NHS England): • Colchester Hospital University NHS Foundation Trust worked with the Clinical Commissioning Group (CCG) to develop a pathway for local implementation of guidance for thromboprohylaxis in ambulatory patients requiring temporary …
Response (James Adams): • The working relationship between Devon and Cornwall Police and the local Mental Health Services has been improved, and a Memorandum of Understanding has been drawn up. • Kernow CCG …
Responded
David Baddeley
Concerns: Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and medication needs being repeatedly missed.
Response: Practices will be reminded to screen new patients for serious psychiatric illness and ensure diagnoses are recorded, highlighted, and correctly coded when patients transfer to another practice; from June 2016, …
Responded
Colin Williams
Concerns: A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.
Overdue
Chentoori Chanthirakumar
Concerns: Communication failures, including an email rather than a face-to-face meeting about academic re-take, and mental health staff misinterpreting confidentiality, prevented effective support for a distressed student.
Overdue
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
Elsie Tindle
Concerns: The insufficient number of Second Opinion Appointed Doctors (SOADs) leads to delays, causing practitioners to default to urgent powers for ECT, risking the bypass of crucial safeguards and inappropriate treatment.
Response (Department of Health): The Department of Health acknowledges CQC's administrative error and the SOAD shortage. CQC has undertaken a 100% comparison check and implemented process reminders and daily checks to mitigate errors, and …
Responded
Shalane Blackwood
Concerns: The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear decision-making tools and staff awareness for physical symptoms alongside mental health issues.
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
Simon Klineberg
Concerns: Concerns include insufficient psychiatric bed availability, inadequate resourcing for home treatment teams, and significant waiting lists for psychological therapy, especially for high-risk patients.
Overdue
Steven Trudgill
Concerns: HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was not implemented.
Overdue
Christina O’Brien
Concerns: Limited community respite care options for mentally ill individuals, with the withdrawal of beneficial facilities like "Dove House" without alternative provision, preventing comprehensive support for their distress.
Overdue
Patricia Cleghorn
Concerns: The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside a failure to conduct a formal risk assessment despite repeated threats of overdose.
Response (NHS England): NHS England highlights the establishment of an adult mental health programme taking a whole system approach and reiterates the national ambition of reducing suicides, with Clinical Commissioning Groups expected to …
Response (Department of Health): The Department of Health acknowledges the concerns raised, refers to the government's mandate for accessible and high-quality crisis services, and notes that the availability of mental health beds is a …
Response (Birmingham and Solihull NHS Trust): The Senior Nurse for Professional Standards issued a formal practice alert regarding risk assessments, and a Clinical Risk Management Group has been established. The Head of Pharmacy will review the …
Response (CQC): The CQC is requiring the Trust to clarify the role of non-registered staff in the crisis team. The CQC will formally review the actions put in place by the Trust …
Responded
Rohan Fitzsimons
Concerns: Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals taking their own lives while awaiting necessary detention.
Response (Avon and Wiltshire NHS Trust): The Trust has reviewed and simplified its joint protocol for the Management of Missing Persons and Absent Without Leave, consulting with clinicians and police. A standard template to record relevant …
Overdue
Victoria Halliday
Concerns: A lack of local female psychiatric intensive care beds, ineffective community psychiatric nursing, and inadequate community support for complex patients left individuals unsupported. Care Programme Approach and NICE guidelines were not followed.
Response (Leicestershire Partnership NHS Trust): Leicestershire Partnership NHS Trust is working with commissioners to procure a local, medium to long-term solution for female Psychiatric Intensive Care Unit (PICU) placements. They are also developing an integrated …
Response (East Leicestershire and Rutland Clinical Commissioning Group): East Leicestershire and Rutland CCG are in discussion with potential provider organisations and regional commissioning colleagues to provide a wider range of options for female PICU beds and are developing …
Response (Department of Health): The Department of Health acknowledges the concerns raised about the availability of psychiatric intensive care beds and the quality of care planning, noting that CCGs commission psychiatric intensive care beds …
Responded
Jaroslaw Rogala
Concerns: Patients with addiction are at risk of suicide due to a lack of in-patient facilities for care and supervision during crises.
Response (Greater Manchester Police): • Greater Manchester Police (GMP) is investing in technology to replace existing systems with one user experience to improve information management and sharing. • Mobile technology is being distributed to …
Overdue
Emma Timbrell
Concerns: Patients with suicidal ideation were given a non-free out-of-hours crisis number, creating a financial barrier to accessing urgent mental health support for those with limited means.
Overdue
Robert Lloyd
Concerns: Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective video links and decreased engagement for island residents.
Response (The Health Centre): The Health Centre met with the Drug and Alcohol Action Team, will host a new Addaction worker every 2 weeks, and has provided training for pharmacists to identify those at …
Response (Drug Alcohol Action Team): The DAAT conducted a needs assessment with the Isles of Scilly, put in place a joint improvement plan with Addaction, trained GPs and pharmacy staff, and plans to offer training …
Overdue
David Knight
Concerns: National bed shortages led to out-of-county mental health placement, resulting in inadequate risk assessment for S17 leave, poor communication, and lack of family involvement.
Response (Department of Health): The Department of Health is working towards eliminating clinically unnecessary out of area placements for adult acute mental health care by 2020/21 and reducing significantly delayed transfers of care and …
Response (NHS England): NHS England's adult mental health programme is taking a whole system approach including developing access and quality standards for acute mental health care, reducing out of area placements and developing …
Responded
Wendy Telfer
Concerns: Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage of psychiatric beds also caused critical delays in patient transfer, contributing to preventable deaths.
Response (Northern Eastern and Western Devon NHS Trust): The CCG is monitoring timely discharge performance data, the DPT contract review meeting also monitors the rates of delayed discharges from mental health wards through data reported to NEW Devon …
Response (Royal Devon and Exeter NHS Trust): The Trust describes mental health training delivered, including specific programmes with Devon Partnership Trust (DPT). It argues that in this case, staff sought and followed specialist advice from the DPT …
Response (Devon Partnership NHS Trust): The Trust undertook a Root Cause Analysis investigation with the Royal Devon and Exeter NHS Foundation Trust (RD&E), the actions from which are completed and part of regular management supervision. …
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
Thomas Green
Concerns: A referral to Adult General Psychiatry for an inpatient was not considered or actioned, resulting in no psychiatric follow-up or treatment plan for complex PTSD upon discharge; a commissioning gap exists for complex PTSD services.
Response (Tameside and Glossop CCG NHS Trust): Tameside and Glossop CCG will clarify the Individual Funding Request process by 1/6/17, review and establish clear pathways into MH support for people with complex needs within four months, and …
Overdue
Annabel Lewis
Concerns: Mental health services failed to adequately assess risk, record crucial details, or proactively engage with a vulnerable young person and her parents after an initial declined appointment.
Overdue
Lyndsey Holt
Concerns: Methadone was prescribed unsafely over the phone without a face-to-face consultation, leading to a lack of critical patient information and an inappropriate large supply for a methadone-naive individual.
Overdue
Abigail Baynham
Concerns: The report notes that when Ms Baynham left hospital, there was no referral made back to the Mental Health Liaison Service which may have triggered a further assessment.
Overdue
Melvin James
Concerns: The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions or provide formal referral and aftercare to local mental health services.
Overdue
Brandon Singh Rayat
Concerns: There is a critical lack of long-term mental health care provision for children in Leicestershire who cannot attend hospital due to anxiety, with the crisis team unable to fill this gap.
Response (Leicestershire and Rutland NHS CCG): The CCG acknowledges the need to update the CAMHs outpatient and community service specification to reflect new services implemented, such as alignment of CAHMs to the liaison service and the …
Response (Department of Health): The Department acknowledges the concerns around mental health provision for children in Leicestershire and highlights ongoing national work to transform children and young people's mental health services, supported by additional …
Responded
Jonathan Meaney
Concerns: Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately addressed, resulted in the patient's premature release without proper consultation or confirmed follow-up care.
Response: The Royal Free London NHS Foundation Trust notes that the concerns relate to Camden & Islington NHS Foundation Trust (CANDI)'s Mental Health Liaison service, and that CANDI is undertaking a …
Response: Camden and Islington NHS Foundation Trust outlines several actions taken and planned: Clinicians involved have been prevented from working at this level of expertise until the SIR review is complete. …
Responded
David Sewell
Concerns: There was a lack of a robust system to ensure mental health patients, especially those with psychotic episodes, were seen and re-engaged, leading to discharge without adequate follow-up after an initial appointment failure.
Response: The University Health Board has reviewed the case and circumstances. They will ensure reception staff are aware if an appointment is with the Mental Health Team and direct accordingly and …
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.
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
Committee Recommendations (117) — showing 50 strongest matches
#30 — Reduce visibility of security guards in Jobcentres, ensuring a more welcoming entry experience.
Recommendation: Jobseekers are not criminals and shouldn’t be greeted at Jobcentres by security guards. DWP should make security guards much less visible in Jobcentres, with a more welcoming presence when people enter. (Recommendation, Paragraph 133)
Gov response: Partially accept DWP recognises the importance of a supportive and welcoming environment for our customers, however we also need to strike the right balance to ensure safety for customers and colleagues. This approach does not …
Partially Accepted
#27 — Jobcentre environments often lack accessibility and welcome, undermining efforts to support claimants.
Recommendation: Jobcentres are not places that people want to go to. They are often run-down and lack basic facilities, including accessibility features. An intimidating security presence can create additional barriers for some. It will be important that when people walk through …
Gov response: Accept Through capital investment, DWP is committed to transforming our Jobcentre spaces so that our physical infrastructure is adaptable and responsive to the needs of our customers, colleagues, and local and national partners. The Workplace …
Accepted
#26 — Introduce Jobcentre outreach work as a core service, taking support into local communities.
Recommendation: DWP needs to break Jobcentres out of their four walls. It should make outreach work, with staff taking Jobcentre services into the community and to locations that people trust, a core part of the new service. DWP should include larger-scale …
Gov response: Accept DWP recognises the value of working collaboratively within communities, operating from a range of locations, to deliver timely, tailored support to customers. We are developing and testing a Flexible Delivery Network model to address …
Accepted
#24 — Jobcentres require deeper integration with voluntary and community sectors to address complex employment barriers.
Recommendation: Many people who use Jobcentres have multiple and complex needs, which can act as barriers to them securing employment. Too often, issues that prevent people from finding jobs go unaddressed. Jobcentres and Jobcentre staff will not be able to address …
Gov response: Partially accept DWP recognises the invaluable part played by the voluntary and community sector in supporting customers alongside DWP and agrees that forming a more coherent view of the current position is useful. As part …
Partially Accepted
#21 — Ensure NHS provides culturally competent therapy and fund tailored support for Muslim communities.
Recommendation: The Government should set out steps to ensure that the NHS can provide religiously and culturally competent, trauma-informed, and accessible therapy for those in need, including Muslim communities. 52 The Government should also fund local support services tailored to the …
Gov response: 56. NHS staff should feel safe at work in an environment free of racism and discrimination. Every NHS organisation has a duty to protect staff from racism, sexism and religious hatred and will have their …
No Published Response
#20 — Ensure refreshed Women's Health Strategy addresses poor outcomes for Muslim women's healthcare.
Recommendation: Tackling disparities in women’s healthcare is a key focus of the Women’s Health Strategy. The Government is due to refresh the strategy in the coming months. The Government should ensure that addressing poor outcomes faced by Muslim women, including in …
Gov response: 56. NHS staff should feel safe at work in an environment free of racism and discrimination. Every NHS organisation has a duty to protect staff from racism, sexism and religious hatred and will have their …
No Published Response
#18 — Muslim women in frontline services endure anti-Muslim abuse and face mental health barriers.
Recommendation: It is deeply saddening that Muslim women working in frontline services such as healthcare settings are having to endure anti-Muslim abuse while performing their duties in helping others. Reports of a lack of support from colleagues and employers are also …
Gov response: 56. NHS staff should feel safe at work in an environment free of racism and discrimination. Every NHS organisation has a duty to protect staff from racism, sexism and religious hatred and will have their …
No Published Response
#1 — Severity gap reveals unacceptable failing in timely access to mental health care
Recommendation: Timely access to mental health care is not just a matter of convenience— it is a matter of safety, dignity, and equity. Delays in care can lead to preventable crises, greater distress, poorer outcomes, and higher costs to the system. …
No Published Response
#14 —
Recommendation: Covid-19 has had a significant impact on the mental health of the whole nation. New and expectant parents have especially been put under tremendous strain during what is already an incredibly challenging time in their lives. It is extremely likely …
Gov response: The Government places great value on individuals who come forward to take on the challenging but rewarding role of being an adoptive parent. We also understand how crucial it is that these parents have time …
Accepted
#18 — Co-occurring mental health and alcohol problems frequently result in denial of vital treatment.
Recommendation: Dame Carol, Sir Ian, Ms Taylor and Ms Wiseman all raised concerns about the relationship between mental ill health and alcohol. Sir Ian told us that an estimated 70% of people entering treatment for alcohol dependency have co-occurring mental health …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2025 4.2 Increasing the numbers of dependent alcohol and drug users in treatment is a key aim of the additional drug strategy investment. …
Accepted
#8 —
Recommendation: Financial pressures are affecting provision for students. They have caused some colleges to narrow their curriculum and reduce the length of courses. Some FE colleges have significantly reduced enrichment activities for students, such as careers advice and employability activities, and …
Gov response: 7.1 The government agrees with the Committee’s recommendation. Target implementation date: August 2021 7.2 The department will be conducting a survey looking at the experiences of Further Education learners during the COVID-19 pandemic outbreak for …
Under Consideration
#7 —
Recommendation: Students are losing out as colleges cut mental health and other support services in response to financial pressures. The Department’s funding for colleges fell by 20% in real terms over the six years from 2013/14 to 2018/19, and the ESFA …
Gov response: 7.1 The government agrees with the Committee’s recommendation. Target implementation date: August 2021 7.2 The department will be conducting a survey looking at the experiences of Further Education learners during the COVID-19 pandemic outbreak for …
Under Consideration
#102 —
Recommendation: We recommend that the UK Government and Scottish Government work together either to put mental health resources like counselling in place in remote rural communities, or to ensure that mental health resources can be easily accessed in rural communities when …
Gov response: The UK Government has noted the Committee’s recommendation in relation to advertising avenues to mental health support for the shooting community and also the points made about the particular challenges faced by rural communities traumatised …
Accepted
#11 —
Recommendation: Finally, we heard from the Gun Control Network that “[t]he primary weakness in the regulatory system is how the licensing process is conducted”.29 The organisation stated that “the following may have contributed”30 to “failures in the process”31: “Inadequate guidance resulting …
Gov response: The UK Government has looked at the recommendations from the Committee alongside Prevention of Future Deaths reports issued by the Senior Coroner for Plymouth, Torbay and South Devon on 8 March 2023, following the inquest …
Under Consideration
#13 — Rural communities face inaccessible NHS mental health services due to centralisation, transport, and connectivity
Recommendation: We conclude that NHS mental health services are often not fairly accessible for rural communities, with centralised services creating barriers to access, compounded by poor rural transport and weak digital connectivity.
Gov response: Unleashing Rural Opportunities, published by the Government in June 2023, sets out a range of actions being taken across government in support of rural areas including work to improve access to transport, digital connectivity, and …
Accepted
#19 — A lack of in-patient and residential alcohol treatment creates significant access barriers.
Recommendation: Sir Ian and Ms Wiseman spoke of the cost effectiveness of in-patient and residential treatment services. We heard examples of how the lack of in-patient and residential services in some areas of the country meant patients were left either bouncing …
Gov response: 1.5 NHS England has worked to reduce alcohol-related ill health by targeting the secondary care inpatient population through a number of measures. This includes funding the development of specialist alcohol care teams in 25% of …
Accepted
#16 — Stigma surrounding alcohol dependency, especially with drug users, prevents people seeking treatment.
Recommendation: Even once people accept they may have a problem, issues with stigma can prevent them from accessing help. For example, we heard that people often feel a sense of shame at being unable to “drink responsibly”.36 Dame Carol described the …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2025 4.2 Increasing the numbers of dependent alcohol and drug users in treatment is a key aim of the additional drug strategy investment. …
Accepted
#9 — Government fails to halve detentions of autistic people; numbers in mental health settings rise.
Recommendation: The Government has fallen short on its commitment to halve the number of people with a learning disability and autistic people inappropriately detained in mental health hospitals. Promises to bring forward a new Mental Health Bill to help address this …
Response Pending
#31 — Community programmes significantly increase Muslim women's participation in social activity and support mental well-being.
Recommendation: Community programmes such as Muslim Girls Fence are an important means of increasing Muslim women and girls’ participation in social and physical activity and supporting mental health. They allow Muslim women to be their authentic selves without fear of judgement, …
Gov response: The Government recognises the importance of community-led initiatives in fostering social cohesion and bringing people together. By supporting locally driven programmes we aim to strengthen community connection and cohesion to build resilience. These initiatives play …
No Published Response
#169 — High prison population and overcrowding exacerbate drug demand by limiting purposeful activity and support.
Recommendation: The high prison population and overcrowding lead to a lack of purposeful activity and poor mental health support which exacerbate the existing drivers of drug demand. Efforts to reduce demand are therefore made more challenging and complex. This undermines any …
Gov response: Safety within our prisons remains a key priority and we are committed to upholding the highest standards of protection to prevent staff exposure to drugs. To ensure this, we have a National Risk Assessment and …
Accepted
#29 — Embed specialist practical and mental health support for families of drug users.
Recommendation: We recommend that local authorities use the funding allocated under the 10-Year Drugs Strategy to embed specialist practical and mental health support within drug treatment and support services for the families and the loved ones of people who use, or …
Gov response: The Government accepts these recommendations. The Drug Strategy acknowledges the invaluable role that families and carers play in supporting people in treatment and recovery, and states that services should ensure that family members and carers …
Accepted
#31 —
Recommendation: We recommend that the Bill include provisions to place a core duty on ICSs to have regard to public health and mental health; and to include in ICSs’ public health duties, a requirement to develop strategies to ensure the prevention …
No Published Response
#29 —
Recommendation: In terms of the impact of the UK Government interventions, and collaboration between the two Governments, we were told by Karen Watt, Chief Executive of the Scottish Funding Council, that: 66 HMG, UK Government to fund international Covid-19 studies in …
Not Addressed
#36 —
Recommendation: As the Scottish Government told us: “The purpose of firearms licensing regulation is to protect public safety”.106 It is important for public safety that people can raise concerns about individuals who own, or are applying to own, firearms - for …
Gov response: The UK Government has noted the Committee’s recommendation around creating a new reporting service where members of the public can register concerns about certificate holders. We are seeking views on this in the accompanying consultation …
Under Consideration
#11 —
Recommendation: Discussing mental health, the Department did tell us about a number of initiatives arising from a joint Department for Work & Pensions and Department of Health & Social Care unit which looks to target some of the mental health challenges …
Gov response: 6. PAC conclusion: Many claimants have complex barriers that prevent them from finding work, and some of these barriers may be better addressed through other means than an employment support scheme such as Restart. 6. …
Not Addressed
#27 —
Recommendation: Training curricula required to obtain a licence to perform non- surgical cosmetic procedures should include mandatory modules on informed consent and psychological screening, with a specific focus on identifying Body Dysmorphic Disorder and other vulnerabilities. (Recommendation, Paragraph 105)
Response Pending
#26 —
Recommendation: There appears to be a gap in safeguarding mental health in the cosmetic procedures sector. The absence of mandatory psychological screening prior to procedures, combined with evidence of inadequate consultations, increases the risk of harm, particularly for vulnerable individuals such …
Response Pending
#28 — Establish DEFRA working group to explore leave and support options for rural workers.
Recommendation: Although it will be challenging for the Government to address this given such occupations can involve lone workers in often isolated rural locations, we recommend that DEFRA sets up a working group to: a) explore options to establish or expand …
Gov response: Government works closely with the veterinary profession, including the Royal College of Veterinary Surgeons (RCVS) and the British Veterinary Association (BVA). Defra officials regularly engage with both these organisations as well as the wider profession. …
Accepted
#27 — Address occupational demands and cultural barriers preventing rural workers taking time away.
Recommendation: The Government should look at how to respond to the occupational demands placed on farmers, agricultural and veterinary workers and any cultural barriers that: prevent these workers from taking time away from work, are detrimental for mental health without opportunity …
Gov response: Government works closely with the veterinary profession, including the Royal College of Veterinary Surgeons (RCVS) and the British Veterinary Association (BVA). Defra officials regularly engage with both these organisations as well as the wider profession. …
Accepted
#19 — Identify farming and veterinary mental health as priorities and develop specific NHS staff training.
Recommendation: It is very important for the farming and veterinary communities to feel that their circumstances are understood by NHS staff when seeking to access, or receiving, support (otherwise this may work against help-seeking behaviours). Charities with specialist-knowledge can gain people’s …
Gov response: The government recognises the critical importance of good mental health and wellbeing to the agricultural and veterinary communities and notes with concern the evidence contained in the report. Defra’s Farming and Countryside Programme works with …
Not Accepted
#18 — Consult on proposals to expand preventative mental health support for rural children and young people.
Recommendation: Child and Adolescent Mental Health Services (CAMHS) have been under intense pressure for many years, but a lack of alternative rural social infrastructure and a fall in support for youth services means CAMHS is often the “only show in town”. …
Gov response: The government recognises the importance of early preventative support in schools and local communities for supporting children and young people to have good mental health and wellbeing and prevent poor mental wellbeing from developing into …
Not Accepted
#15 — Open up NHS access for rural veterinary community, supporting flexible appointments and appropriate digital provision.
Recommendation: The NHS also needs to open-up access to the rural veterinary community to reflect restrictions on their ability to attend appointments, and support people who need to Rural Mental Health 79 continue practising. Better digital provision could improve service access …
Gov response: Government works closely with the veterinary profession, including the Royal College of Veterinary Surgeons (RCVS) and the British Veterinary Association (BVA). Defra officials regularly engage with both these organisations as well as the wider profession. …
Not Accepted
#14 — Improve rural mental health service access through mobile provision, community involvement, and stigma reduction
Recommendation: Locally the NHS must focus on providing rural communities with good access to services in terms of location and/or via mobile or outreach services, through effective consultation and co-design, and bring the voluntary and community sector into the delivery landscape …
Gov response: DHSC fully recognises the importance of ensuring that NHS mental health services are accessible for rural communities. Work is already underway to support integrated care systems (ICSs) in providing rural communities with access to mental …
Accepted
#7 — Create clear objectives and actions for agricultural and veterinary workers in national suicide prevention strategy
Recommendation: We are very concerned by the evidence indicating that agricultural and veterinary workers have a higher-than-average suicide rate compared to the rest of the population. Although more accurate information is needed, a clear enough picture Rural Mental Health 77 was …
Gov response: The new Suicide prevention strategy for England: 2023 to 2028 was published on 11 September 2023. This strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates, improve support for …
Accepted
#6 — Joined-up public health approach essential for preventing suicide among agricultural and veterinary workers
Recommendation: Adopting a more joined-up approach to public health focused on early intervention could make a positive contribution to preventing suicide amongst agricultural and veterinary workers. It would need to ‘wrap-around’ people at potential risk, incorporating the NHS, other key public …
Gov response: The new Suicide prevention strategy for England: 2023 to 2028 was published on 11 September 2023. This strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates, improve support for …
Not Addressed
#5 — Require DEFRA to establish a clear and active role in national suicide prevention strategy
Recommendation: DEFRA should be an active stakeholder in any national suicide prevention strategy, as the Department is responsible for populations and occupational groups arguably at higher-than-average risk of poor mental health and death by suicide. However, DEFRA does not appear to …
Gov response: The new Suicide prevention strategy for England: 2023 to 2028 was published on 11 September 2023. This strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates, improve support for …
Not Addressed
#4 — Addressing risks and stressors for farming and veterinary workers represents an immediate priority.
Recommendation: In particular, the long list of risks and stressors affecting the farming community and veterinary workers is perhaps the immediate priority, not least because there are real opportunities for substantial gains in this area with significant levers for change in …
Gov response: The new Suicide prevention strategy for England: 2023 to 2028 was published on 11 September 2023. This strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates, improve support for …
Accepted
#17 — Health services are failing to adequately identify and refer alcohol-dependent individuals for treatment.
Recommendation: Most people entering treatment for alcohol dependency in England self-refer. In 2021– 22, only 23% of referrals were from health services.40 Our expert witnesses thought much more could be done to identify people early and direct them towards treatment. Ms …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2025 4.2 Increasing the numbers of dependent alcohol and drug users in treatment is a key aim of the additional drug strategy investment. …
Accepted
#15 — Low public awareness and poor NHS identification hinder access to effective alcohol treatment.
Recommendation: When we asked Ms Wiseman what was preventing people from accessing treatment, she explained that there was a big issue with people being able to accept that they have a problem in the first place. We heard that drinking alcohol …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2025 4.2 Increasing the numbers of dependent alcohol and drug users in treatment is a key aim of the additional drug strategy investment. …
Accepted
#4 — Address barriers to alcohol treatment access and improve integrated care for co-occurring conditions
Recommendation: We are concerned that a high proportion of people with alcohol dependency are not in treatment and that there are unnecessary barriers to people in need of treatment. Treatment services for alcohol dependency are commissioned by local authorities. They show …
Gov response: The government agrees with the Committee’s recommendation. of the additional drug strategy investment. The department is providing a range of support to all local authorities for identifying and addressing barriers to engagement with treatment, including …
Accepted
#33 — Amend Bail Act 1976 by March 2022 to end remands for protection or welfare.
Recommendation: The Government should bring forward legislation by 31 March 2022 to amend the Bail Act 1976 so that it is unlawful to remand anyone to custody simply for their own protection or welfare. (Paragraph 104) 32 Mental health in prison
Gov response: The Government needs to fully consider all of the impacts of repealing this power in order to ensure its removal would not result in any vulnerable defendants coming to harm. We are therefore currently reviewing …
Under Consideration
#32 — Remanding individuals for protection under Bail Act 1976 is wrong in principle.
Recommendation: The Courts use the provisions in the Bail Act 1976 to remand people to prison for their own protection or welfare only because proper alternatives in the community are not available. We are concerned about the lack of safeguards under …
Gov response: The Government needs to fully consider all of the impacts of repealing this power in order to ensure its removal would not result in any vulnerable defendants coming to harm. We are therefore currently reviewing …
Under Consideration
#31 — Establish viable alternatives to eliminate prison as a place of safety by March 2022.
Recommendation: The Government must, as a matter of urgency, see through its proposal to establish viable alternatives so that prisons are no longer used as a place of safety under the Mental Health Act 1983. We recommend that the Department of …
Gov response: The Government agreed that we should end the use of prison as a place of safety for individuals with severe mental health issues in the Mental Health Act White Paper and committed to legislating at …
Under Consideration
#30 — Welcome proposal to end prison as ‘place of safety’ requires investment in alternatives.
Recommendation: We welcome the proposal in the Mental Health Act Reform white paper to end the use of prison as a ‘place of safety’ and the recognition that this must be supported by investment in alternatives. Problems with access to emergency …
Gov response: The Government agreed that we should end the use of prison as a place of safety for individuals with severe mental health issues in the Mental Health Act White Paper and committed to legislating at …
Under Consideration
#29 — Learning from RECONNECT pathfinders and partnership pilots needs swift acceleration and publication.
Recommendation: The NHS should learn early lessons swiftly from its RECONNECT pathfinder projects and accelerate roll-out of the most important features across all prisons in the interim between now and 2024 when it intends to have completed the full roll-out. Similarly, …
Gov response: The MoJ and HMPPS welcomes the continued roll-out of NHS England and NHS Improvement’s RECONNECT, a care after custody service, which is supporting prison leavers to remain engaged with the right treatment upon resettlement through …
Partially Accepted
#28 — NHS RECONNECT programme remains in infancy, failing to ensure continuity of care.
Recommendation: Despite longstanding difficulties arranging continuity of healthcare for prisoners on their release, the NHS RECONNECT programme, which is meant to resolve these problems, is in its infancy. In the meantime, prisoners who have been receiving treatment in prison for mental …
Gov response: The MoJ and HMPPS welcomes the continued roll-out of NHS England and NHS Improvement’s RECONNECT, a care after custody service, which is supporting prison leavers to remain engaged with the right treatment upon resettlement through …
Accepted
#27 — Persistent challenges arranging mental health treatment packages for parole-eligible prisoners identified.
Recommendation: NHS England should liaise with the Parole Board to identify local areas where there are problems arranging mental health treatment packages for prisoners under consideration for parole. NHS England should then work with the new NHS Integrated Care Systems and …
Gov response: In the recent White Paper, Working Together to Improve Health and Social Care for All,15 the Government set out its ambition for every part of England to be covered by an Integrated Care System. NHS …
Accepted
#26 — Systematic mental health assessment lacking for parole-eligible prisoners before application.
Recommendation: Prison healthcare providers should systematically assess the mental health of prisoners 30 Mental health in prison coming up for parole and make sure that any needing support and treatment have it in good time before they make an application.
Gov response: The mental health of a prisoner is monitored throughout their sentence, not just around the time of their parole. However, HMPPS has work in train to improve how prisoners with mental health issues are supported …
Accepted
#25 — Undiagnosed mental illness and poor community support cause parole decision delays for prisoners.
Recommendation: Some parole decisions are delayed because prisoners applying for parole have undiagnosed mental illness that limit their participation in the parole application process. There are further delays due to insufficient co-operation from community mental health teams in arranging packages of …
Gov response: The mental health of a prisoner is monitored throughout their sentence, not just around the time of their parole. However, HMPPS has work in train to improve how prisoners with mental health issues are supported …
Accepted
#22 — Publish monthly data on prisoners awaiting mental health inpatient transfers, including waiting times.
Recommendation: HMPPS and the NHS should gather and publish monthly information for every establishment (without naming establishments to protect patient confidentiality) on the number of prisoners awaiting transfers to inpatient care for mental illness and for how long they have been …
Gov response: In June 2021 NHS England and NHS Improvement published Transfer and Remission Guidance setting out a 28-day timeframe for transfers from prison to hospital and in April 2021 developed a data input portal. This enables …
Partially Accepted
CQC Inspection Actions (14)
Waverley
Principles of the mental capacity act were not being followed when supporting people with decision making.
Must Do
Benthorn Lodge
The registered person was not meeting the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).
Must Do
The Peter Gidney Neurodisability Centre
People were being deprived of their liberty as the conditions attached to these were not being met, reviewed or renewed as needed.
Must Do
South Network
Best interest meetings and DoLSiDS assessments and application had not been made. Regulation 11 (3)
Must Do
No. 3
The provider should have processes to oversee staff’s understanding and application of the Mental Capacity Act.
Should Do
Mr & Mrs T Grimshaw - 1 Taylor Avenue
The service was not acting sufficiently within the principles of the Mental Capacity Act 2005. Decisions taken in the best interests of people, including managing finances, were not documented and kept under review.
Must Do
Kare Support Services Ltd
We recommend the registered person seeks advice and guidance from a reputable source about MCA legal framework, and their responsibilities to ensure people could express their views and be involved in decision making.
Should Do
Quality Care Management Limited
The registered provider must ensure the Mental Capacity Act 2005 and associated code of practice is followed on all occasions where a person lacks mental capacity to make an informed decision.
Must Do
Kingsley Nursing Home
The registered manager and provider failed to 2. submit Deprivation of Liberty Safeguards (DoLS) authorisation applications that were relevant to the restrictions being made to people's mobility. This is a continued breach of Regulation 13 (5) (7b)
Must Do
Benthorn Lodge
The provider must ensure that consent to care and treatment is always sought in line with legislation and current guidance, that people's capacity to make their own specific decisions is assessed, and that best interest meetings take place when specific …
Must Do
Park Grange Care Home
The care plans did not contain decision specific mental capacity assessment or best interest decisions.
Must Do
Chy Byghan Residential Home
The provider must ensure people who use services are protected against the risks associated with unclear consent procedures in relation to the Mental Capacity Act (2005) and associated Deprivation of Liberty guidelines.
Must Do
St Paul's Lodge
The registered person did not act within the provision of the Mental Capacity Act 2005.
Must Do
Fairmount Residential Care Home
The provider consider the Mental Capacity Act 2005 Code of Practice and the Deprivation of Liberty Safeguards Code of Practice and review their current practices in regards to dealing with issues around people’s mental capacity assessments, in line with these …
Should Do
PPO Death in Custody Recommendations (34)
Manx Care
Manx Care should undertake a systemic population health needs assessment across Isle of Man Prison to determine the prevalence of mental health conditions and need.
The Department of Health and Social Care and Manx Care
The Department of Health and Social Care and Manx Care should review the current provision of mental health services at Isle of Man Prison and provide a dedicated mental health service, which is sufficiently resourced to meet the needs of …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that a dual diagnosis team is established to ensure prisoners with related mental health and substance misuse issues are managed appropriately.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that the mental health team assesses all prisoners on the day of their arrival.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that prison staff know when and how to refer prisoners to the mental health team, including for prisoners experiencing auditory hallucinations and being managed under ACCT procedures.
The Head of Healthcare
The Head of Healthcare should ensure that: • prisoners are assessed by a GP when primary mental health services are required; • if a patient stops engaging with any mental health provider in the prison, this is discussed with the …
The Head of Healthcare and the Mental Health Team Manager
The Head of Healthcare and the Mental Health Team Manager should ensure that: • mental health referrals are actioned and recorded, and assessments take place with appropriate urgency. • ACCT procedures are not used to substitute urgent mental health assessments.
The Head of Healthcare
The Head of Healthcare should ensure that those who are on a waiting list for therapy have access to mental health support in the interim if there is a risk of suicide and self-harm.
The Head of Healthcare
The Head of Healthcare should ensure that psychiatric and psychological assessments: • take place within a specific timeframe; and • are not cancelled unless there are justified and documented reasons.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who are referred to the mental health team by reception staff have a face-to-face triage assessment.
The Head of Healthcare
The Head of Healthcare should ensure that any new information received by the mental health team from the liaison and diversion services after a prisoner has arrived at Wandsworth must inform a review of the level of risk and plan …
The Head of Healthcare (HMP Northumberland)
The Head of Healthcare should review the mental health referral management process at HMP Northumberland to ensure that: initial health screens are thorough so that outstanding mental health assessments are actioned immediately; and the triage and assessment of prisoners after …
The Head of Healthcare and the manager of the integrated …
The Head of Healthcare and the manager of the integrated mental health team should ensure that prisoners with mental health issues have appropriate reviews and care plans which are recorded and implemented.
The Governor, Head of Healthcare and Service Manager for Change, …
The Governor, Head of Healthcare and Service Manager for Change, Grow, Live should work together to ensure that referral processes to the service are clear and established and that all staff understand when and how to refer a prisoner to …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that there is a communication plan in place between OMU and the mental health team so that referrals to the PIPE programme are progressed and prisoners are updated about the status of …
The Head of Healthcare and the Mental Health Services Manager
ensure their operational policy on repeated referrals to the mental health in-reach team includes guidance on repeated self-referrals;
The Head of Healthcare (HMP Forest Bank)
The Head of Healthcare should ensure that pathways are in place to provide effective support and referral for prisoners under the care of the mental health team who might be released from court.
Head of Knowsley and St Helens Probation Delivery Unit
The Head of Knowsley and St Helens Probation Delivery Unit should ensure all COMs understand their responsibilities within release planning and are aware of the need to complete relevant referrals for prisoners with mental health needs.
The Head of Healthcare
The Head of Healthcare should review the procedures in place for assessing the mental health needs of prisoners who have requested mental health support.
The Head of Healthcare
Staff consider whether a prisoner’s neurodiversity presents a barrier to them self-referring to services such as IAPT and psychosocial substance misuse support.
The Head of Healthcare
The Head of Healthcare should review the quality and compliance with policy of reception and secondary health screens in the previous 12 months, ensure that prisoners are referred to the mental health team when appropriate, and identify any improvements required.
The Head of Healthcare
The Head of Healthcare should ensure that mental health services meet the needs of prisoners by: implementing a referral system that results in a timely, face-to-face assessment using all relevant information for appropriate continuity of care and follow-up; ensuring that …
The Head of Healthcare
The Head of Healthcare should ensure that: when a prisoner needs clinical observations, these are completed; and staff refer prisoners appropriately to the mental health team.
The Head of Healthcare
The Head of Healthcare should ensure that a formal mental capacity assessment is promptly completed and fully documented when there are concerns that a prisoner has declined medical advice or treatment.
The Head of Healthcare
The Head of Healthcare should ensure that staff refer newly arrived prisoners who are taking antipsychotic medication to the mental health team for assessment.
The NHS Commissioner
The NHS Commissioner should undertake a review of mental health referrals and assessments at HMP Leeds to assure themselves that prisoners are being assessed in a timely and appropriate manner.
The Head of Healthcare
The Head of Healthcare should review the priority system for prisoners who need urgent access to a psychiatrist and ensure that those with complex needs and ongoing self-harming behaviour are given appropriate priority.
The Head of Healthcare
The Head of Healthcare should ensure that the mental health team act on referrals appropriately, ensuring that patients are seen independently by the mental health team to complete mental health assessments and risk assessments.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners referred for a mental health assessment are offered an individual assessment, separate to the ACCT process.
The Head of Healthcare at HMP Cardiff
The Head of Healthcare at HMP Cardiff should ensure that decisions on mental health referrals are based on a full assessment of a prisoner’s current mental health and circumstances.
The NHS Commissioner for Northeast and Yorkshire Region
The NHS Commissioner for Northeast and Yorkshire Region should write to the Ombudsman, setting out how they intend to improve mental health care at Wakefield, within twelve weeks of receiving our initial report.
The Head of Healthcare, the Integrated Drug Treatment Service (IDTS) …
The Head of Healthcare, the Integrated Drug Treatment Service (IDTS) and The Forward Trust should together ensure that: All Forward Trust workers record their interactions with prisoners on both SystmOne and Nebula; Prisoners are informed if there are delays in …
The Head of Healthcare
The Head of Healthcare should ensure that PCLDS staff forward mental health assessments and any other pertinent information about a prisoner’s risk to the mental health team’s central mailbox.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff: review prisoners’ starting antidepressants in line with Royal College of General Practitioners’ guidance; record actions and decisions about a prisoner’s ongoing care in their medical record and check that the entries …
IOPC Learning Recommendations (4)
Recommendations - Cambridgeshire Constabulary, January 2021
The IOPC recommends that Cambridgeshire Constabulary provides additional guidance to assist officers when making judgements about use of s136 and whether any associated offences are serious. This should cover situations where pursuit of the offence may, or may not, take …
Recommendation - Merseyside Police, April 2022
The IOPC recommends that Merseyside Police takes steps to ensure that custody staff, in particular custody officers, understand when detained persons require an Appropriate Adult. This should include consideration of: This recommendation follows an IOPC review into a complaint where …
Recommendation - Suffolk Constabulary, January 2022
Suffolk Constabulary should implement a process to ensure that in all cases where there are mental health concerns for a member of the public who comes into contact with the police, reasonable action is taken to facilitate those individuals receiving …
Investigation into the response to a concern for welfare call prior to …
The IOPC recommends that Greater Manchester Police should issue a reminder to officers regarding the breadth of assistance available from the Mental Health Tactical Advice Service (MHTAS). This follows an IOPC investigation where two officers, who were involved in this …
IMB Annual Reports (212) — showing 50 strongest matches
Eastwood Park (2025)
HMP Eastwood Park, a women's closed local prison, maintained a population of 351 against an operational capacity of 395. The report highlights ongoing challenges with an extremely high rate of self-harm (4,479 incidents) and 235 assaults on staff, although no deaths in custody occurred for the second consecutive year. Significant concerns include the detention of mentally unwell women awaiting hospital transfers, persistent staffing shortages exacerbated by vetting delays, and a restrictive regime for the general population due to the management of segregated prisoners.
PRISON
Key concerns
Wakefield (2025)
HMP Wakefield is a high-security prison for men, reporting an operational capacity of 744 and a population of 793. The Board noted significant improvements in staff recruitment and key worker sessions, as well as the delivery of healthcare and a varied education curriculum. However, it raises serious concerns regarding prisoner safety, including drone incursions and increased violence. Longstanding issues with delays in mental health transfers to hospitals, inadequate physical infrastructure, and insufficient purposeful activity opportunities for prisoners remain critical areas for development.
PRISON
Key concerns
New Hall (2025)
HMP/YOI New Hall operates as a closed prison for women, holding 313 prisoners against an operational capacity of 376. The report highlights several positive developments, including effective reception processes, successful key worker implementation, and improved chaplaincy services. However, significant concerns remain regarding inadequate mental health provision and lengthy transfer delays for acutely unwell prisoners, a 50% increase in healthcare complaints, and ongoing issues with regime limitations and prison maintenance.
PRISON
Key concerns
Bronzefield (2020)
HMP/YOI Bronzefield, a local female prison, effectively managed the initial COVID-19 lockdown, maintaining a nearly virus-free environment, but the sustained restricted regime led to a significant rise in self-harm and mental health concerns. Key issues included a high proportion of prisoners released without stable accommodation, persistent challenges with timely mental health transfers, and a shortage of cell keys affecting prisoner property security. Despite these, the Board noted positive developments in food quality, key worker implementation, and effective education provision during the pandemic.
PRISON
Key concerns
Feltham (2020)
HMYOI Feltham's report (Nov 2019-Aug 2020) highlights a challenging period dominated by COVID-19 lockdown. While staff were commended for their dedication and a reduction in violence and self-harm was noted, concerns persist regarding the long-term impact of extreme confinement on prisoners' mental health. Significant issues include deteriorating accommodation, delays in mental health transfers, and insufficient purposeful activity for young adults.
PRISON
Key concerns
Cookham Wood (2020)
The IMB report for HMYOI Cookham Wood covers 1 August 2019 – 31 August 2020, focusing heavily on the impact of the COVID-19 lockdown. While staff are commended for their caring approach and efforts to maintain safety and welfare, particularly during initial lockdown, the severe and protracted regime resulted in boys being locked in their rooms for over 23 hours a day, raising significant concerns about inhumane treatment, especially for those in segregation or with mental health issues. Key challenges include the unfit Phoenix segregation unit, national shortages of mental health beds, delays in transferring young adults, and an increasing remand population, all exacerbated by the lack of IT capacity during the pandemic.
PRISON
Key concerns
Hewell (2020)
The COVID-19 pandemic significantly impacted HMP Hewell, leading to a full lockdown, 23.5-hour cell confinement, and cessation of most activities. While staff are commended for averting a direct catastrophic impact from the virus and improving cleanliness, concerns remain regarding prisoner welfare, mental health, and rehabilitation. The prison saw leadership changes and continued a journey of improvement after years of poor performance, with some areas showing progress despite ongoing challenges in safety, healthcare provision, and regime delivery.
PRISON
Key concerns
Channings Wood (2020)
This IMB annual report for HMP Channings Wood (September 2019 – August 2020) highlights the significant impact of COVID-19 restrictions. The Board commends staff for maintaining a safe and well-run prison, noting reductions in assaults and ACCT cases, and improvements in education and complaint handling. However, key concerns persist regarding the detrimental effect of COVID-19 on prisoners' mental health and self-harm, unacceptably long delays in mental health transfers, the poor condition of the prison estate, and inefficient management of prisoners' property during transfers.
PRISON
Key concerns
Brook House (2020)
In 2020, Brook House IRC faced significant challenges due to the COVID-19 pandemic, a contract change to Serco, and a compressed charter flight programme for Dublin Convention removals. The Board found the centre unsafe for vulnerable detainees in the latter months, marked by a dramatic increase in self-harm and suicidal ideation, and inhumane treatment of detainees due to Home Office policies. Delays in Rule 35 assessments, inadequate inductions, and issues with property and communication from the Home Office were key concerns, despite a welcome increase in staff numbers and some improvements in facilities.
PRISON
Key concerns
Heathrow Immigration Removal Centre (2020)
The IMB report for Heathrow IRC (Jan-Dec 2020) highlights that the Centre generally maintained safety and humane treatment, successfully minimizing COVID-19 spread and sustaining services during lockdowns. Key concerns remain regarding the detention of individuals with severe mental health issues, inadequate detention gatekeeping, and the presence of illegal substances. Delays in police response, issues with remote DET engagement, and long periods of detention for some individuals are also noted as significant challenges.
IRC
Key concerns
Downview (2021)
HMP/YOI Downview operated under severe Covid-19 restrictions, leading to a significantly reduced regime with prisoners largely confined to cells for 22.5 hours a day. Despite these challenges, the Board found Downview to be a safe prison, with staff highly commended for their efforts in maintaining safety and humane treatment. Concerns persist regarding mental health provision, the impact of prolonged lockdown on prisoners' well-being, and the limited availability of purposeful activity and external support services.
PRISON
Key concerns
Bronzefield (2021)
HMP/YOI Bronzefield operated under severe Covid-19 restrictions, impacting prisoner well-being and regime delivery, exacerbated by staff absences. Despite these challenges, the prison managed the pandemic effectively, improved mental health transfers, and achieved Hepatitis C elimination. However, concerns remain regarding escalating self-harm incidents, a high number of prisoners released without accommodation, the prison's use as a 'place of safety' for mentally unwell women, and persistent drug ingress.
PRISON
Key concerns
Aylesbury (2021)
This report covers a year dominated by the Covid-19 pandemic at Aylesbury YOI, which saw a reduced prisoner population of around 209. Despite a severely curtailed regime and poor education provision, the prison maintained stability, low infection rates among prisoners, and provided daily showers and exercise. Key concerns include the lack of mental health beds, the weakening of the key worker scheme, and the risk that post-pandemic priorities will shift from prisoner outcomes to risk management as population numbers increase.
PRISON
Key concerns
Wetherby (2021)
This report highlights HMYOI Wetherby's effective management of the Covid-19 pandemic and positive staff-prisoner relationships, alongside significant improvements in facilities and family contact. However, it raises serious concerns, particularly the chronic shortage of secure mental health beds, delays in transferring young adults, and persistent issues with maintenance. The Board also notes challenges in staffing stability, ACCT application, and high levels of violence, urging action from the Minister, Youth Custody Service, and Governor.
PRISON
Key concerns
Guys Marsh (2021)
HMP Guys Marsh, a Category C training prison, navigated a challenging year (Dec 2020 – Nov 2021) under a restrictive "red regime" due to COVID-19. While recording no deaths in custody and a 20% drop in self-harm, concerns persisted regarding a significant increase in staff assaults, high mental health transfer waiting times, and problems with key working and purposeful activity due to staffing pressures and regime restrictions. The Board highlighted the need for improved staff retention, better IT systems, enhanced resettlement provisions, and a more consistent application of incentive schemes.
PRISON
Key concerns
Berwyn (2021)
HMP Berwyn, a category C resettlement prison, experienced its first period near full operational capacity during a reporting year largely impacted by the Covid-19 pandemic. Despite restrictions, the IMB found the establishment safe with generally good staff-prisoner relationships and efforts made to provide education and essential work. However, significant concerns persisted regarding infrastructure defects (heating, paint), lengthy healthcare waiting times, and delays in transferring prisoners with mental ill-health or those eligible for Category D.
PRISON
Key concerns
Gatwick IRC (2021)
The 2021 report covers the first year of the combined Gatwick IRC (Brook House and Tinsley House) under merged IMB oversight and Serco management, with the year dominated by Covid-19 restrictions, unprecedented Channel crossing arrivals through Tinsley House, and ongoing Home Office case management failures leading to prolonged and often unnecessary detention. While Serco staff generally treated detained men with respect and compassion, systemic failings in mental health support, access to legal advice, property management, and Home Office communication remained serious and in many cases repeated concerns.
IRC
Key concerns
Heathrow Immigration Removal Centre (2021)
The IMB report for Heathrow IRC (Jan-Dec 2021) identifies generally safe conditions but raises serious concerns regarding the management of Short-term Holding Facility (STHF) detainees, particularly South Coast Arrivals (SCAs), which compromised safety and humane treatment. Significant issues include the inappropriate detention of individuals with severe mental health needs, a critical lack of engagement from the Detention Engagement Team (DET), and unacceptably prolonged detention periods for many. The Board calls for urgent policy reviews, capital investment in infrastructure, and improved communication and service provision to address these systemic problems.
IRC
Key concerns
Leicester (2022)
HMP Leicester maintained its status as a well-run establishment during the reporting year, demonstrating strong leadership and staff commitment despite ongoing Covid-19 restrictions. Safety remained a high priority, with reductions in violence and self-harm, improved security, and good management of Covid cases. However, the Board raised significant concerns regarding the long waits for mental health transfers, the management of IPP prisoners, and the impact of a high remand population on resettlement, alongside persistent issues with staff recruitment and retention.
PRISON
Key concerns
Nottingham (2022)
HMP Nottingham operated under pandemic restrictions for most of the reporting year, gradually easing, with effective governance despite management flux. While self-harm incidents decreased, violence between prisoners increased significantly. Key concerns include the ongoing situation for IPP prisoners, the lack of separation for remand and convicted prisoners, and inadequate mental health facilities, alongside regime restrictions and low education attendance.
PRISON
Key concerns
Moorland (2022)
HMP/YOI Moorland, a Category C resettlement prison, reported a population of 915 against a reduced operational capacity of 964 for the year ending February 2022. The report noted positive trends with reduced self-harm and violence incidents but highlighted significant concerns regarding the treatment and progression of IPP prisoners and persistent delays in mental health transfers. Staffing shortages affected key worker provision and programme delivery, while long waiting times for dental care were also an issue.
PRISON
Key concerns
Low Newton (2022)
HMP/YOI Low Newton provides a generally safe and humane environment with good staff-prisoner relationships and a supportive regime, despite Covid-19 challenges. The Board commended staff commitment to safety and highlighted positive outcomes in education and various support initiatives. However, significant concerns remain regarding the national shortage of secure mental health places for women, the effectiveness of resettlement accommodation, and the consistent implementation of key worker schemes and use of body-worn cameras.
PRISON
Key concerns
Send (2022)
HMP Send is a closed prison for adult women with an operational capacity of 191, holding 182 prisoners at the end of the reporting year, including 63 ISPs. The Board considers Send a safe prison but highlights a significant increase in self-harm incidents (837) and one death in custody. Key concerns include the need for specialist mental health provision for prolific self-harmers, slow progress on digital in-cell technology, and persistent staffing shortages.
PRISON
Key concerns
Peterborough (Men) (2022)
HMP Peterborough operated under significant Covid-19 restrictions, impacting regime and staffing, yet saw a welcome continued decrease in violence and self-harm incidents. Concerns persist regarding the adequacy of healthcare services, resettlement provision post-CRC transition, and the length of time some remand prisoners are held. The prison demonstrated strengths in staff commitment, SEN provision, and resettlement accommodation outcomes, while acknowledging ongoing challenges in staff retention and property management.
PRISON
Key concerns
Peterborough (Women) (2022)
HMP Peterborough (Women) navigated a challenging year with Covid-19 restrictions, managing outbreaks and staff shortages while still making improvements in safety and achieving its accommodation on release target. Despite this, prisoner dissatisfaction with healthcare services remained high, alongside concerns about the effectiveness of the key worker system and the impact of probation service changes on resettlement. The Board noted the prison's strong commitment to prisoner welfare and its proactive efforts in communication and SEN support.
PRISON
Key concerns
Stocken (2022)
HMP Stocken generally provides a safe and humane environment, with strong efforts in safer custody and no deaths in custody this year. However, the Board highlights significant challenges including chronic understaffing across various departments, persistent delays in staff vetting, and a critical shortage of secure mental health provision, leading to unsuitable placements within the prison. Issues with prisoner transfers, including incomplete assessments and uncontrolled property, and a lack of category D prison places continue to hinder progression and resettlement efforts. The performance of the education provider is also a key concern.
PRISON
Key concerns
Wakefield (2022)
HMP Wakefield, a high-security prison for men, is generally considered safe but experienced increases in assaults and use of force. Key concerns include persistent issues with mental health transfers, a lack of robust healthcare complaints processes, and the absence of in-cell telephony. The Board also highlighted unsatisfactory property management and insufficient purposeful activity for prisoners.
PRISON
Key concerns
Usk and Prescoed (2022)
HMP Usk and Prescoed are considered effective, well-run prisons with low levels of violence and self-harm, successfully navigating Covid-19 restrictions while maintaining humane treatment. Challenges include reduced education funding, inadequate mental health and probation staffing, and persistent issues for men serving IPP sentences. The Board commends the cooperation between staff and prisoners, and the impressive rate of successful resettlement via Release on Temporary Licence.
PRISON
Key concerns
Leicester (2023)
HMP Leicester is well-led, maintaining a relatively safe environment with reduced self-harm and assaults on staff, and improved reception facilities. Despite generally good physical and mental healthcare, significant concerns persist regarding long delays for mentally ill prisoners awaiting transfer, which can result in inhumane segregation. Staffing shortages have severely impacted key working and the regime on weekends, while aging infrastructure requires substantial capital investment, particularly for the gym. Resettlement efforts are hindered by a high proportion of men released without accommodation and underdeveloped substance misuse services.
PRISON
Key concerns
Northumberland (2022)
HMP Northumberland generally provides a safe and humane environment, with improvements in regime and education post-Covid, and promising employment initiatives like The Recruitment Junction. However, significant challenges persist concerning mental health support and transfers, unreliable healthcare provision, and poor resettlement outcomes, especially regarding post-release employment and housing. These issues, particularly mental health and homelessness, remain areas of repeated concern for the Board.
PRISON
Key concerns
Littlehey (2023)
HMP Littlehey is a Category C training prison for men convicted of sexual offenses, holding 1,171 prisoners. The Board commended the prison for its generally safe environment, compassionate end-of-life care, and excellent PE regime. Key concerns include persistent overcrowding due to shared cells, long waiting times for specialist healthcare, and significant issues with managing prisoner property transfers between prisons. The report also highlights the over-representation of Black and Muslim prisoners in adjudications and use of force incidents, and ongoing problems with heating infrastructure and the use of temporary freezers.
PRISON
Key concerns
Lincoln (2023)
HMP Lincoln, a Category B prison, experienced a decrease in self-harm incidents and drug finds during the reporting period, alongside generally positive staff-prisoner relationships. However, significant concerns persist regarding the length and quality of maintenance work by Amey, and the inadequate access to specialist mental health facilities. Other key challenges include the impact of increasing operational capacity, difficulties for transient prisoners accessing education, issues with property transfers, and unsuitable infrastructure for vulnerable prisoners.
PRISON
Key concerns
Usk and Prescoed (2023)
HMP Usk and Prescoed maintained good relationships between staff and prisoners and effectively restored regime activities following Covid-19 restrictions. While safety levels were low for assaults and self-harm, concerns persist regarding understaffing in mental health and probation services, and issues with prisoner property transfers. The prisons continue to demonstrate success in purposeful activity and resettlement, including high rates of first-night housing on release.
PRISON
Key concerns
Swansea (2022)
HMP Swansea is generally considered a safe and humane prison by the Board, with notable improvements in education, purposeful activity, and resettlement support. However, significant concerns persist regarding the inadequate mental health provision and the challenge of securing accommodation for prisoners on release. Other key issues include delays in cell refurbishment, poor disability access, and inconsistent reporting of segregation decisions to the Board.
PRISON
Key concerns
Foston Hall (2023)
HMP/YOI Foston Hall has shown positive developments in regime provision and some safety initiatives, yet it continues to grapple with persistently high self-harm rates and increased use of force. Staffing shortages have impacted key work and overall experience levels, while healthcare faces challenges with recruitment, missed appointments, and inadequate facilities. The Board highlights significant concerns regarding accommodation decency, delays in parole and mental health transfers, and a lack of analytical focus on protected characteristics, affecting fair treatment and access to services.
PRISON
Key concerns
Gartree (2023)
HMP Gartree maintains a calm and ordered environment with positive staff-prisoner relationships, though faces significant challenges with its ageing infrastructure and an increase in use of force incidents. While basic healthcare access is good, mental health services and purposeful activity require improvement. The Board highlights key concerns regarding building repairs, drug infiltration, fire safety, and adequate provision for vulnerable prisoners, while acknowledging efforts in staff recruitment and regime development.
PRISON
Key concerns
Leicester (2024)
HMP Leicester, a busy local prison, continues to be well led despite the challenges of old buildings needing investment and high prisoner churn. While staff-prisoner interactions are positive and resettlement planning is a strength, the Board remains concerned by rising self-harm incidents, delays in mental health transfers, prisoners leaving without accommodation, and deteriorating cell conditions. Key working remains insufficient, and the substance misuse unit is not delivering its full therapeutic regime.
PRISON
Key concerns
Low Newton (2024)
The IMB finds HMP/YOI Low Newton a reasonably safe and clean environment with generally good staff-prisoner relationships. However, the Board is concerned about the increasing number of women with severe mental health issues being sent to prison, impacting self-harm and assault rates. Delays in accessing healthcare and mental health support, along with the negative effects of custodial transport and staffing shortages leading to lockdowns, remain key challenges.
PRISON
Key concerns
Downview (2024)
HMP/YOI Downview experienced significant population pressures and a more complex demographic during the reporting year, leading to an unsettled environment and increased safety incidents. While healthcare saw some positive working relationships and good mental health support, there were critical delays in transferring acutely unwell women to psychiatric units and persistent issues with medication distribution. The Board raised concerns about the accuracy of education attendance data, the inconsistent key worker system, and a decline in library services.
PRISON
Key concerns
Nottingham (2024)
HMP Nottingham, a Category B adult male and YOI establishment, has an operational capacity of 950. The reporting year saw increases in self-harm incidents (898), prisoner assaults (296), staff assaults (114), and use of force (760), with two deaths in custody. The Board raises concerns about restricted time out of cell, particularly for vulnerable prisoners, persistent healthcare staff shortages impacting provision, and insufficient capacity for mental health transfers. Positive developments include improved food quality, a new neurodiversity lead, and reduced IMB applications.
PRISON
Key concerns
Hewell (2024)
HMP Hewell, a local Category B prison, faced significant challenges in the reporting year, including persistent crowding and a high remand population. Despite these pressures, the IMB noted dedicated efforts by staff to maintain a safe and humane regime, introducing positive initiatives like 'here to help' mentors and a prison council. Key concerns remain around increased self-harm and violence, the lack of IT for prisoners, and inadequate mental health and family contact provisions, many of which are recurrent issues.
PRISON
Key concerns
New Hall (2024)
HMP/YOI New Hall, a closed category prison for women, held 365 residents against an operational capacity of 381. The Board noted positive developments in reception, staff-prisoner relationships, and the introduction of a drug recovery wing. However, significant concerns persist regarding the inadequate funding and suitability of the prison environment for women with complex mental health needs, leading to unacceptable delays in transfers to secure units. There was also a notable increase in healthcare-related applications to the IMB and issues impacting access to Release on Temporary Licence (ROTL).
PRISON
Key concerns
Doncaster (2024)
The Independent Monitoring Board at HMP Doncaster reports a generally fair and humane treatment of prisoners, with good staff-prisoner relationships and improved education attendance. However, the prison faces significant challenges, primarily due to severe overcrowding and population pressures, leading to inhumane double occupancy of cells and restricted regimes. Key concerns include extended waits for mental health transfers, a problematic reception and induction process, and insufficient community support for released prisoners.
PRISON
Key concerns
Eastwood Park (2024)
HMP/YOI Eastwood Park, a closed local prison for women, faced significant challenges in the reporting year, particularly concerning high levels of self-harm and use of force incidents. While staffing shortages and the concentration of complex prisoners strained the regime, efforts were made to improve healthcare, purposeful activity, and resettlement support. The Board highlighted concerns regarding mental health transfers, estate development, and the overall impact of managing complex individuals on staff and the general prison population.
PRISON
Key concerns
Northumberland (2024)
HMP Northumberland, a Category C prison, experienced a challenging year due to RAAC issues impacting various areas, including education and reception, and contributing to spikes in self-harm and violence. Despite these challenges, the Board noted significant improvements in accommodation, healthcare provision, and progress in securing housing for prisoners on release. Key concerns remain around the inadequacy of mental health support and the effectiveness of education and vocational training in preparing prisoners for employment.
PRISON
Key concerns
Cardiff (2024)
HMP Cardiff, a Category B local training prison, maintained a 'Good' HMIP rating despite significant population pressures, with the IMB noting positive staff-prisoner relationships and cell refurbishment efforts. However, the Board expressed serious concerns over rising self-harm, violence, and use of force incidents, alongside persistent overcrowding leading to inhumane eating conditions. Key challenges included inadequate mental health staffing at weekends, a doubling of medication complaints, and poor key worker scheme delivery.
PRISON
Key concerns
Leicester (2025)
HMP Leicester, a busy local male prison, continues to be well-led despite the challenges of an aging Victorian estate and high prisoner turnover. The reporting year saw a positive 33% reduction in self-harm incidents and no deaths in custody, alongside effective intelligence work to intercept illicit items. However, concerns persist regarding an increase in violent incidents, significant delays in mental health transfers, a lack of accommodation for 33% of prisoners on release, and the persistent availability of drugs.
PRISON
Key concerns
Low Newton (2025)
HMP/YOI Low Newton is a women's closed prison that has seen improvements in culture and regime under new leadership. While safety is prioritised, challenges remain with a high number of self-harm incidents and significant mental health needs among the population, often leading to the prison acting as a place of safety. Efforts are being made in purposeful activity, resettlement, and healthcare, with strong staff dedication noted.
PRISON
Key concerns
Lewes (2025)
HMP Lewes saw improvements in its regime, leading to increased time out of cell and a fall in prisoner-on-prisoner violence. Healthcare provision also improved, with reduced waiting times for routine appointments. However, significant challenges persist with the prison's heating system, gaps in mental health services, and a worrying increase in self-harm and assaults on staff. The Board highlighted ongoing concerns regarding disproportionality in the use of force and adjudications against certain prisoner groups.
PRISON
Key concerns
Lancaster Farms (2025)
HMP Lancaster Farms, a Category C resettlement prison, continues to provide a largely safe environment for its 560 prisoners, with positive initiatives like the complex care unit and CrossFit program. However, significant concerns persist, particularly around healthcare provision, including long waiting times and issues with medication and data transparency. The Board also highlights problems with property management during transfers, a rise in prisoners on the restrictive basic regime, and continued challenges in placing prisoners with complex mental health needs in specialist facilities.
PRISON
Key concerns
IMB Recommendations (81) — showing 50 strongest matches
Guys Marsh (2021)
The Minister should continue to liaise with other Ministers to ensure a coordinated approach to the humane incarceration of prisoners with poor mental health, addressing the national concerns about their increasing numbers.
Ministry of Justice
Swansea (2022)
The Board remains concerned as to the mental health service offered to prisoners within HMP Swansea.
Other
Peterborough (women) (2023)
Can the Minister take action to prevent prisons being deemed a place of safety for women with serious mental health issues?
Ministry of Justice
Peterborough (women) (2023)
Can the Minister work with the Department of Health and Social Care to ensure women with serious mental health issues in the criminal justice system are directed to an appropriate pathway?
Ministry of Justice
Parc (2023)
Despite efforts by management and staff at Parc to support those prisoners serving an Imprisonment for Public Protection (IPP) sentence, not knowing when they will be released is a cause of anxiety impacting on the mental health of those affected. We urge the Government to put in place a process where IPP prisoners’ sentences are reviewed, and a single sentence …
Ministry of Justice
Liverpool (2023)
The Prison Service is aware of the inhumane length of time some prisoners have been in the CSU at HMP Liverpool whilst waiting for transfer to an appropriate mental health establishment. What will the Prison Service do to ensure that prisoners at HMP Liverpool are not waiting for inhumane periods of time for such transfers?
HMPPS
Heathrow immigration removal centre (2023)
The numbers of people experiencing mental health issues are increasing at Heathrow IRC. It is important that external mental health beds in the community are made available to detained people who present with a severe mental condition, that cannot be managed within Heathrow IRC.
NHS / Healthcare Provider
Heathrow immigration removal centre (2023)
People with severe mental health problems should not be detained in the CSU for extended periods of time. Detained individuals with severe mental health issues should be treated in a mental health setting external to the Heathrow Detention Centre. The Home Office should reduce the use of CSU for those who do not wish to share a room with another …
Home Office
Heathrow immigration removal centre (2023)
The Board is very concerned about the deterioration in the mental health of many detained people and too many detained people are resorting to self-harm. It is imperative that appropriate support, care, and mental health services are promptly provided to individuals grappling with mental health vulnerabilities.
Home Office
Heathrow immigration removal centre (2023)
More work is required to consider different ways of dealing with those who have mental health problems. There should be an increase in external mental health beds for people in detention who display increased or increasing levels of mental health problems. A clear mental health pathway should be made available to those with mental health difficulties, the detention centre is …
Ministry of Justice
Heathrow immigration removal centre (2023)
The Board consider Rules 40 and 42 are being misused. There were several instances in 2023 where Rule 40 and 42 have been used for prolonged situations. It is imperative that Rules 40 and 42 are used for the shortest possible time and as a means of last resort. It should not be used to hold mentally ill detained people …
Ministry of Justice
Heathrow immigration removal centre (2023)
The Home Office has a duty of care for those with mental health problems and to ensure that they are safe in the community they are released into. Robust support is required for detained people with mental health people who are released on bail.
Ministry of Justice
Lewes (2024)
How does the Minister plan to work with colleagues across Government to increase the provision of specialist secure mental health services for offenders with serious mental health problems?
Ministry of Justice
Heathrow Immigration Removal Centre (2020)
The procedures followed in the detention gate-keeping process should be reviewed to ensure that the processes in place to protect those with severe mental health issues from being detained in the Immigration Estate are robust and effective.
Home Office
Heathrow Immigration Removal Centre (2020)
The policy which results in people with severe mental health issues being held in IRCs should be reviewed.
Other
Foston Hall (2021)
The IMB is concerned about: the ‘short-term’ closure of the mental health office to facilitate the demolition of A and B wings, which by November had extended into three months, causing acute problems for the delivery of mental health services
Governor / Director
Foston Hall (2021)
The IMB is concerned about: staffing pressures in healthcare and mental health, impacting on services provided.
Governor / Director
Berwyn (2021)
The Board notes that the prison experienced significant delays in being able to transfer men to more appropriate establishments and settings, especially those relating to mental ill-health. The Board considers that this lack of secure mental health facilities needs to be addressed as a matter of urgency.
Ministry of Justice
Wormwood Scrubs (2022)
We urge the Minister to heed the CPT’s request for rapid transfer of people with serious mental illness to appropriate mental health settings, and to put in place sufficient funds to enable this to happen.
Ministry of Justice
Sudbury (2022)
As the population of the prison continues to increase inevitably some of the additional prisoners received will have addiction issues. How does the prison plan to support these additional prisoners with their substance misuse needs? What plans are in place to prevent the ingress of these substances?
Governor / Director
Send (2022)
Provision should be made in appropriate secure specialist mental health facilities for the small number of very challenging women with highly complex mental health needs. These are often a result of traumatic lives and manifest as prolific self-harm. Prison is a totally inadequate ‘revolving door’ for these prisoners (4.2).
Ministry of Justice
Heathrow Immigration Removal Centre (2022)
In our 2021 annual report, we urged the Minister to review the policy which results in people with severe mental health issues being held in IRCs. The Board repeats its recommendation: The role of the Home Office Gate Keeper and accountability for their decisions, in particular, needs to be urgently reviewed.
Ministry of Justice
Bedford (2022)
We believe that there would be significant benefits in the co-location of healthcare and mental health services and are disappointed that this has not yet happened.
Governor / Director
Lincoln (2023)
Will the Minister speak to colleagues in the Department for Health and Social Care to improve prisoners’ timely access to specialist mental health facilities, where required?
Ministry of Justice
Lewes (2023)
Will the Minister speak to colleagues to seek to ensure that there are sufficient beds in secure mental health hospitals to speed up the transfer of prisoners and support their rehabilitation?
Ministry of Justice
Hewell (2023)
Will the Minister advise on the progress of the Mental Health Bill which offered remedies for concerns raised in our annual report last year? Our concerns about the lack of appropriate services for prisoners with complex mental health needs remain and are growing.
Other
Heathrow immigration removal centre (2023)
The IMB would support broader use of the Colnbrook Care Suite for short term respite, particularly for detained people with deteriorating mental health conditions. We also urge the Contractor to replicate the Colnbrook Care Suite facility in Harmondsworth.
Governor / Director
Exeter (2023)
Work with other Ministers and agencies to increase mental health support for the prison and to ensure resources are in place to facilitate the timely transfer of prisoners with serious mental health conditions?
Ministry of Justice
Woodhill (2024)
Will the Minister work with colleagues in the Department of Health and Social Care to consider how to address the mental health needs of prisoners, many of whom require specialist care alongside their punishment and rehabilitation?
Ministry of Justice
Thorn Cross (2024)
To make mental health provision available in the evenings and at weekends.
Governor / Director
Thorn Cross (2024)
To develop mental health provision.
Governor / Director
Send (2024)
The Board continues to believe that the continued detention of IPP prisoners is unfair and inhumane.
Other
Rye Hill (2024)
The Board remains concerned that there is no centrally directed, long-term solution to the injustice of the IPP (imprisoned for public protection) sentence and its impact on the mental health and wellbeing of affected prisoners. The IMB has raised this for a number of years, but since the rejection of the Justice Select Committee’s recommendations, there does not seem to …
Ministry of Justice
Low Newton (2024)
What plans do you have to improve prisoner access to healthcare & mental health support?
Governor / Director
Low Newton (2024)
Why are so many prisoners who present with severe mental ill health and personality disorders continuing to be sent to prison?
Other
Leicester (2024)
Can the Governor work with healthcare commissioners and the provider to ensure that the healthcare unit provides a more holistic, therapeutic regime for prisoners who are seeking to reduce their substance misuse?
Governor / Director
Send (2025)
The Board reiterates that the needs of complex individuals with multiple mental health issues are not served well in prison. Such prisoners also take up a disproportionate amount of staff time (4.2) (6.2).
Other
Bronzefield (2020)
The prison has successfully maintained an almost COVID-19-free environment, in contrast to the situation in the community. What steps are the government taking to end the current severe lockdown restrictions in prison, taking into account the impact on the mental health of the prisoners (see section 8)?
Ministry of Justice
Drake Hall (2021)
Additionally, during the year the prison had to deal with a prisoner experiencing difficulties associated with an eating disorder. However, no facility existed that could provide specialist services for this individual. As a result, the prison was forced to manage the situation without specialist support. This constitutes a service deficit (see section 6.3).
HMPPS
Bristol (2021)
Can you facilitate access to appropriate room allocations, so that the mental health, substance misuse and other teams can deliver their full range of programmes effectively?
Governor / Director
Styal (2022)
Nationally, there is still a pressing need for more specialist facilities that can be easily accessed, particularly psychiatric units.
HMPPS
Foston Hall (2022)
Limited access to Listeners, resulting in a significant increase in phone calls to the Samaritans (see paragraph 4.2.4)
Governor / Director
Lancaster Farms (2023)
Given concerns expressed above, to invite Department of Health colleagues to work with the minister to review the capacity of provision of mental health services and provide more secure mental health provision across the prison estate for those prisoners with severe and enduring mental illness.
Ministry of Justice
Isle of Wight (2023)
What will the Minister do about the impact of transferring prisoners from secure hospitals to an already full and stretched prison?
Ministry of Justice
Heathrow immigration removal centre (2023)
The Home Office should improve the time scales for those that wish to return to their home country voluntarily. Any Delays to voluntary returns can acerbates anxiety and mental health issues for detained people.
Home Office
Guys Marsh (2023)
Will the Minister work with his colleagues in the Department of Health and Social Care to find further ways mental health provision can be extended into the Prison Service in order to avoid lengthy incarceration in isolation of troubled prisoners and those with challenging behaviour?
Ministry of Justice
Erlestoke (2023)
What long term strategy is in place to address the chronic shortage of suitable mental health provision?
Other
Nottingham (2024)
How does the Minister plan to work with colleagues across the Government to increase the provision of specialist secure mental health services for prisoners with serious mental health problems?
Ministry of Justice
Cardiff (2024)
The Board recommends the Health Board review the level of weekend cover in the mental health team in view of the significant demand for mental health support within the prison.
NHS / Healthcare Provider
Derwentside (2024)
To increase the range of activities for women, with a view to better supporting those with anxiety or mental health issues.
Governor / Director
Article 2 Learning Points (7)
— LP 2
We recommend that across the Prison Service Estate nationally there is enhanced provision for the assessment and treatment of alcohol misuse and dependence disorders.
HMPPS
Accepted
— LP E
In a case where a prisoner has both substance misuse and mental health problems – so-called dual diagnosis – a joint assessment by a mental health and a substance misuse specialist should be carried out.
PPG
— LP 4
A prisoner presenting with an altered mental state, particularly with possible psychotic symptoms, should be assessed at the earliest opportunity by a suitably-qualified mental health practitioner. The practitioner should take a full history, review previous entries and assess the person’s current mental state to establish the diagnosis. The prisoner should …
HMP Altcourse and HMPPS
Accepted
— LP 3
I recommend that all prisoners should have a mental health assessment within 72 hours of entering custody, for case-finding. Prison Service Instruction (PSI) 74/2011 Early Days in Custody – Reception In, First Night in Custody, and Induction to Custody indicates that all prisoners should have a health review within a …
HMP Altcourse and HMPPS
Partially Accepted
— LP 5
A prisoner admitted as an in-patient to Healthcare should have a full assessment, with review of the case notes and a current mental state examination. Their needs and risks of self-harm and harm to others should be established and suitable care plans developed. This assessment should inform the ACCT process, …
HMP Altcourse and HMPPS
Accepted
— LP 3
A specialist service should be available to address the underlying social problems associated with risk of self-harm, where needed, for prisoners identified under ACCT (formerly F2052SH).
HMPPS
Accepted
— LP 13
We recommend that the managers responsible for the Southampton court custody suite work with the Hampshire Liaison and Diversion Service to ensure that the service is well understood by custody staff and used effectively.
HMPPS
Accepted
Detention Investigations (8)
Review into the Welfare in Detention of Vulnerable Persons — Rec 55
The Home Office and NHS England should conduct a clinical assessment of the level and nature of mental health concerns in the immigration detention estate.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 58
I recommend that the Home Office, NHS England, and the Department for Health develop a joint action plan to improve the provision of mental health services for those in immigration detention.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 57
I recommend that talking therapies become an intrinsic part of healthcare provision in immigration detention.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 12
I recommend that those with a diagnosis of Post Traumatic Stress Disorder should be presumed unsuitable for detention.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R31
Serco managers should undertake a thorough review of the initial training course and the refresher training programme to ensure that they enable staff to fulfil their roles and responsibilities. The review and any consequent redesign of staff training should ensure that staff are adequately trained in mental health matters affecting …
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R29
Serco should open discussions with G4S, NHS England and local mental health care providers to consider how best to meet the needs of detainees with severe mental health issues, and ensure that they are assessed and receive care and treatment in a timely and appropriate fashion.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 56
I recommend that the creation of care suites across the IRC estate should be taken forward as a priority.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 54
The Home Office should draw up a research strategy for immigration detention. In particular, it should consider commissioning clinical studies on the impact of detention upon women, and research aimed at improving models of care.
Immigration Detention
PHSO Casework Decisions (19)
P-004573 — A practice in the Norwich area
Mrs H complains about a GP Practice in Norwich that failed to support her husband Mr H mental health needs.
NHS in England
Jan 2026
P-004604 — A practice in the Colchester area
Mr X complains the Practice and Independent Clinical Commissioning Board will not agree to enter a shared care agreement to fund his ADHD medications.
NHS in England
Jan 2026
P-001806 — A practice in the West Midlands area
Ms O complains the Practice should have referred her mother, Ms I, to specialists to help with her nutrition, alcohol intake and mental health conditions. She says her mother should have been sectioned for her own wellbeing.
NHS in England
Feb 2023
P-002870 — Nottinghamshire Healthcare NHS Foundation Trust
Mr E complains the Trust neglected his mental health care between December 2022 and April 2024.
NHS in England
Aug 2024
P-003163 — South Central Ambulance Service NHS Foundation Trust
Mrs X complains the Trust should have done more to prevent her son’s death from alcohol misuse. The day before two ambulances attended her home after him becoming unwell and he refused treatment.
NHS in England
Nov 2024
P-003600 — Rotherham, Doncaster and South Humber NHS Foundation Trust
Mr A complains the Trust has wrongly discharged him from its services following an appointment on 16 October 2023 and it will not provide him with any care or treatment for his psychological health.
NHS in England
Jun 2025
P-003733 — Avon and Wiltshire Mental Health Partnership NHS Trust
Mr E complains about his brother's care and treatment from April - October 2019. He told us the Trust did not raise a safeguarding alert when concerns were raised by both his brother and his family about drug dealers taking over his flat.
NHS in England
Partly Upheld
Jul 2025
P-001647 — Avon and Wiltshire Mental Health Partnership NHS Trust
Ms U complains about the delays, appropriateness, suitability and professionalism of the treatment she received from Avon and Wiltshire Mental Health Partnership NHS Trust in 2018 and 2019.
NHS in England
Not Upheld
Oct 2022
P-002030 — Somerset NHS Foundation Trust
Mrs E complains the Trust should have admitted her father under Section 3 of the Mental Health Act. She also complains the Trust put her under pressure to find a private care home and to pay for the care.
NHS in England
Jun 2023
P-002105 — Bedfordshire Hospitals NHS Foundation Trust
Miss H complains the Trust refused gastric sleeve surgery because of her mental health issues and it did not speak to her mental health team or GP first. She also complains a dietician wrote rude and unprofessional comments about her.
NHS in England
Jul 2023
P-004076 — Humber and North Yorkshire Integrated Care Board
Mr R complains about the lack of NHS-commissioned services for avoidant restrictive food intake disorder (ARFID) for his son. He believes ARFID is a clinically recognised eating disorder and is concerned that no local services are available to support his son’s needs.
NHS in England
Sep 2025
P-004126 — Lincolnshire Partnership NHS Foundation Trust
Mrs I complains about the care and treatment provided to her son Mr I from 2011 to 2023. Mrs I complains her son did not get the appropriate treatment for his heart condition or mental health support.
NHS in England
Oct 2025
P-001986 — Livewell Southwest
Mr N complains a doctor was not interested during an appointment and did not know anything about his circumstances. He also complains Livewell Southwest refused to give him a new psychiatrist and discharged him from mental health services in September 2022.
NHS in England
May 2023
P-002057 — United Lincolnshire Hospitals NHS Trust
Ms A complains the Trust dismissed and incorrectly diagnosed her medical symptoms in August 2020, June 2021 and June 2022 because of her previous mental health issues.
NHS in England
Jun 2023
P-002857 — Herefordshire and Worcestershire Health and Care NHS Trust
Mr A complains about the Adult Mental Health Team at the Trust. He specifically complains he was misdiagnosed with a mixed personality disorder in February 2019 when he had bipolar affective disorder. He also says he was not provided with psychological help for anxiety and other mental health issues including …
NHS in England
Partly Upheld
Aug 2024
P-002854 — South West Yorkshire Partnership NHS Foundation Trust
Miss P complains the Trust wrongly diagnosed her with a personality disorder. She says the Trust did not recognise her privately-made diagnosis and stopped prescribing medication for it.
NHS in England
Aug 2024
P-003034 — Essex Partnership University NHS Foundation Trust
Miss R complains that the Trust should not have removed her from the care coordination service in November 2021. She also complains that despite planning to see her in June 2022, after a psychiatry outpatient appointment in February, the Trust did not invite her for a review until December.
NHS in England
Oct 2024
P-004047 — An independent provider in the West Berkshire area
Ms X complains about her care and treatment whilst in custody between April to May 2024. She says that PPG failed to manage her eating disorder causing her to relapse and require hospitalisation.
NHS in England
Sep 2025
P-004426 — South West Yorkshire Partnership NHS Foundation Trust
Mrs Whyman complains about care and treatment from the Trust in relation to her outpatient mental health care. We understand this was a very difficult experience for Mrs Whyman. We have not found any indications of failings on behalf of the Trust.
NHS in England
Nov 2025
LGO / SPSO Decisions (26)
PSOW-202503627 — Newport City Council
Mr A complained that Newport City Council did not appropriately address his complaint in relation to a communication failure, where staff of the vulnerable adult services were directing the public to use a callback system which cannot connect the caller back to them. The Ombudsman found that the Council mischaracterised …
PSOW (Public Services Om…
Health
Sep 2025
PSOW-202100024 — Wrexham County Borough Council
Mrs X complained that the Council failed to provide appropriate and adequate support to her sister, Ms Y, in the months leading to her death, including whether information was shared appropriately between the Council and a third-party organisation providing services on behalf of the Council (“the Provider”), and whether the …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202401795 — Newport City Council
Mr S complained that Newport City Council had failed to respond to a complaint he raised in March 2024. The Ombudsman found that the Council had received a complaint but it had failed it as it was received with incorrect contact details. She also found that the Council had been …
PSOW (Public Services Om…
Health
Jul 2024
PSOW-202103295 — Cardiff Council
Ms B complained that Cardiff Council (“the Council”) did not appropriately handle her complaint and failed to follow the statutory adult safeguarding procedure and appropriately deal with the safeguarding concerns she raised for her friend, Mr C. The Ombudsman’s investigation found that in the handling of Ms B’s complaint, the …
PSOW (Public Services Om…
Health
Upheld
Sep 2022
PSOW-202206010 — Powys Teaching Health Board
Mr and Mrs J complained to the Ombudsman that Powys Teaching Health Board (“the Health Board”) had failed to undertake an independent investigation into their son’s care. Mr and Mrs J also said that the Health Board failed to maintain communication in respect of updates and outcomes of reviews. The …
PSOW (Public Services Om…
Health
Mar 2023
21-011-082a — NHS Sussex Integrated Care Board (21 011 082a)
Summary: Ms D complains the Council and NHS Sussex refuse to pay for the full cost of her mother, Ms M’s, mental health aftercare. We have upheld the complaint and recommended remedies for Ms M and service improvements for the organisations. The Council and NHS Sussex accept our recommendations, so …
LGO (Local Government & …
Health
Upheld
Sep 2022
21-011-082 — East Sussex County Council
Summary: Ms D complains the Council and NHS Sussex refuse to pay for the full cost of her mother, Ms M’s, mental health aftercare. We have upheld the complaint and recommended remedies for Ms M and service improvements for the organisations. The Council and NHS Sussex accept our recommendations, so …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
PSOW-202200853 — Ceredigion County Council
Ms A complained about the Council’s failure to properly implement the terms of an early resolution undertaken in September 2020. Ms A was aggrieved that a Carer’s Assessment was not properly completed and that there remained significant uncertainty about respite care. Ms A was also aggrieved that the Council appeared …
PSOW (Public Services Om…
Health
Dec 2022
21-016-550 — East Suffolk Council
Summary: Ms X complains about the way the Council dealt with her housing application and wish to move from her current accommodation on medical grounds impacting on her mental health. We found no evidence of fault in the way the Council considered these matters. So, we have completed our investigation.
LGO (Local Government & …
Housing
Not Upheld
Aug 2022
22-006-453 — Southampton City Council
Summary: Mr X complained the Council wrongly declined his application for a toll bridge fee exemption. He said the Council did not consider his application as someone with a mental health disability in the same way as it would consider an application from a person with a physical disability. Mr …
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
23-014-263 — London Borough of Brent
Summary: Mr X complained about how the Council dealt with his housing application. He said the Council produced a duplicate account, which meant he could not bid on properties. Mr X said the Council did not complete an allocation review within timescales. Mr X said this impacted his mental health. …
LGO (Local Government & …
Housing
Upheld
May 2024
24-019-632 — Leeds City Council
Summary: We will not investigate Miss X’s complaint about the Council’s decision to end her day centre placement at a mental health hub. This is because there is insufficient evidence of fault. In addition, the claimed fault has not caused any injustice.
LGO (Local Government & …
Adult Care Services
Apr 2025
25-006-298 — Adur District Council
Summary: We will not investigate this complaint about the Council serving a community protection order for causing fear and injury in the community. Miss X says the Council failed to consider her mental health vulnerability and that she was not given assistance in how to appeal the notice.
LGO (Local Government & …
Environment And Regulation
Oct 2025
25-000-377 — Rotherham Metropolitan Borough Council
Summary: Mr X complained about how the Council completed the Disabled Facilities Grant (DFG) process and works to his home. Mr X said this impacted his finances and mental health. There was fault in the way the Council delayed making a payment, has not recorded communications and its complaint handling …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
PSOW-202409734 — Cardiff and Vale University Health Board
Miss C complained about the care and treatment her father, Mr A, received from Cardiff and Vale University Health Board. Specifically, the investigation considered whether it was appropriate not to carry out a CT head scan on Mr A following his fall at University Hospital of Wales on 15 December …
PSOW (Public Services Om…
Health
Not Upheld
Jan 2026
PSOW-202500889 — Aneurin Bevan University Health Board
Miss C complained about the care and treatment her father, Mr A, received from Aneurin Bevan University Health Board. Specifically, the investigation considered whether Mr A’s discharge from Yysbyty Ystrad Fawr on 3 January 2024 was appropriate and whether referral to mental health or psychiatric services should have taken place …
PSOW (Public Services Om…
Health
Upheld
Jan 2026
PSOW-202507906 — Cardiff and Vale University Health Board
Mrs B complained that Cardiff and Vale University Health Board had not properly assessed her son, Mr A’s mental health needs. She said that he had been discharged from services without support and she was worried about his welfare. The Ombudsman decided that there had been errors in progressing referrals …
PSOW (Public Services Om…
Health
Jan 2026
21-009-264 — Thanet District Council
Summary: Mr C said the Council failed to take sufficient action to prevent a business close to his home from disturbing his family early in the mornings. The Council was at fault for a failure to take action against the business for a period of two months. This fault caused …
LGO (Local Government & …
Environment And Regulation
Upheld
Jul 2022
23-014-756 — Royal Borough of Windsor and Maidenhead Council
Summary: Ms X complained the Council failed to provide her son with a full-time suitable education meaning he missed out on education and affected his mental and physical health. The Council failed to evidence why it was in Ms X’s son’s best interest to only receive 12 hours per week …
LGO (Local Government & …
Education
Upheld
May 2024
23-012-569 — Leicestershire County Council
Summary: Mrs X complained on behalf of her husband about the way the Council handled his application for an extended dropped kerb. Mrs X said this caused unnecessary distress and frustration, and impacted her husband’s physical and mental health. We do not find the Council at fault.
LGO (Local Government & …
Transport And Highways
Not Upheld
Jun 2024
24-011-434 — Cornwall Council
Summary: Mrs X complained that since 2021, the Council has not updated her child Y’s Education, Health and Care Plan or provided Y with an education. We find the Council at fault, resulting in a loss of education for Y. This has impacted Y’s mental health and caused Mrs X …
LGO (Local Government & …
Education
Upheld
Apr 2025
24-017-161 — Sefton Metropolitan Borough Council
Summary: Mr X complained the Council has not investigated his reports of Anti-Social Behaviour. He said this has impacted his mental health. The Council was not at fault.
LGO (Local Government & …
Environment And Regulation
Not Upheld
Jul 2025
24-000-378 — Bournemouth, Christchurch and Poole Council
Summary: Mr X complained the Council failed to provide his child with a suitable fulltime education. Mr X said there has been an impact of the missed education, and it has also impacted his child’s mental health. Mr X said it caused unnecessary distress. We do not find the Council …
LGO (Local Government & …
Education
Not Upheld
Dec 2024
23-020-659 — London Borough of Haringey
Summary: Mr X complained about the Council’s handling of his housing application and said his home is overcrowded. He said this impacted his family’s physical and mental health. The Council was not at fault.
LGO (Local Government & …
Housing
Not Upheld
Oct 2024
22-006-671 — Derbyshire County Council
Summary: There is no fault in the decision to stop funding Ms X’s phone line. Council staff were not involved with assessing Ms X’s mental health in December 2021.
LGO (Local Government & …
Adult Care Services
Not Upheld
Dec 2022
22-007-661 — Lancashire County Council
Summary: Mr X complained the Council did not assess his application for a blue badge properly. He complained the Council did not understand his situation and did not have all the information it needed to make a decision. Mr X says this has affected his mental health. The Council was …
LGO (Local Government & …
Adult Care Services
Not Upheld
Dec 2022