Mental Health Crisis Referral Delays
238 items
1 source
Procedural gaps preventing direct referral of acutely unwell patients to emergency Crisis Resolution and Home Treatment Teams.
Cross-Source Insight
Mental Health Crisis Referral Delays has been flagged across 1 independent accountability source:
238 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (238) — showing 100 most recent
Mansoor Zaman
Concerns: Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the police via emergency channels.
Pending
Kallum Reed
Concerns: Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and ongoing close care.
Pending
Martin Bryant
Concerns: Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental health beds, and inadequate facilities for appropriate waiting.
Response: NHS England defers to EPUT for concerns regarding waiting areas, but outlines national plans to roll out 24/7 neighbourhood mental health centres, open specialist Mental Health Emergency Departments, and reduce …
Response: EPUT has changed management processes for risk assessment of patients waiting in reception, installed privacy screens, and implemented a Therapeutic Acute Inpatient Operating Model to reduce length of stay. They …
Responded
Stephen Taylor
Concerns: Multiple services failed to coordinate risk escalation for escalating mental distress, relying on patient denial despite high-risk indicators. Urgent mental health referrals and family concerns were not actioned promptly or effectively.
Response: Vita Health Group reviewed and updated its Duty Standard Operating Procedure in November 2025 to mandate same-day actioning of routine referrals and emphasize careful consideration of family information in clinical …
Response: Kent and Medway Mental Health NHS Trust has updated its Urgent Mental Health Helpline Standard Operating Procedure, including clearer high-risk categories, faster triage (from 72 to 24 hours), and new …
Responded
Andrew Hughes
Concerns: The 'Right Care Right Person' system lacks clarity on how concerned families can access emergency mental health services, and there is insufficient provision for such emergencies in Greater Manchester.
Response: Greater Manchester Integrated Care clarified that mental health services provide a crisis response, not an emergency response, which is the responsibility of 999 services. They acknowledge an ongoing risk regarding …
Response: The Deputy Mayor clarifies that their role is one of scrutiny and oversight for RCRP implementation, not operational accountability for GMP or partner agencies. They suggest future Regulation 28 notices …
Responded
Mark Vidler
Concerns: Mental health services suffered from process-driven care, unclear clinical decision-making in triaging referrals, and pre-determined discharge decisions lacking receiving team involvement. The CAMS program also lacked dedicated resources and IT integration.
Response: Kent and Medway NHS Mental Health Trust has delivered refresher training focusing on patient-centred care and introduced regular service user/carer feedback. They are revising their Rapid Response Standard Operating Procedure …
Responded
Paul Appleby
Concerns: The absence of a regular Saturday Court Service by the Liaison and Diversion Team, relying solely on an 'On Call' system, raises concerns about potential future deaths.
Response: The Trust clarified the specific incident by explaining communication failures and stated that to mitigate future risks, they have reissued the Standard Operating Procedure to Saturday court operators on how …
Responded
Brian Ingram
Concerns: Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments by triage staff resulted in missed symptoms.
Overdue
Kaine Fletcher
Concerns: A critical lack of shared understanding and adherence between emergency services regarding local policies and working standards for Section 136 detentions creates significant risks for vulnerable individuals.
Overdue
John Kirkman
Concerns: Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information and incorrect prioritisation for referrals.
Responded
Callan Atkins
Concerns: Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when local teams lack capacity, risking timely patient care.
Overdue
Callum Hargreaves
Concerns: The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge his refusal to inform his mother about discharge, contrary to GMC guidance.
Responded
Julie Beasley
Concerns: Inadequate mental health assessments, medication errors, and poor communication with the GP and patient led to missed opportunities to gather critical information. A lack of professional curiosity and poor record-keeping also contributed.
Responded
Sophie Cotton
Concerns: Police applying "Right Care, Right Person" policy refused attendance despite immediate risk and multiple calls, disregarding mental health teams' inability to enter locked premises, and leading to dangerous delays in supervisor reviews.
Responded
James Masheter
Concerns: The NHS Pathways system's limited mental health triage options inadequately assess serious mental health crises, leading to low priority categorisation and significant delays in ambulance response for at-risk patients.
Responded
Zahra Mohamed
Concerns: Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling issues, increasing the risk of harm to vulnerable patients.
Responded
Ronald Bainborough
Concerns: Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police delays, expose individuals to significant harm before assessment.
Responded
Sapphire Bernard
Concerns: Critical shortage of psychiatric beds leads to dangerously long waits in unsuitable A&E environments, exacerbating mental health for neurodiverse patients.
Responded
Alexander Channing
Concerns: Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing policies created significant risks for a vulnerable student.
Responded
Shaun Hall
Concerns: The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified and no record of the rationale, posing a serious safety failure.
Responded
Harry Southern
Concerns: Suicide prevention information is inadequately provided and often inaccessible for young people, with contact numbers unmonitored or unsuitable for those with disabilities, exacerbated by potential funding cuts.
Responded
REDACTED
Concerns: Student accommodation staff caused significant delays in initiating and physically conducting a welfare check, and showed reluctance to fully enter the room, prolonging emergency response for a distressed student.
Responded
Matthew Sheldrick
Concerns: Severe national shortages of mental health beds, especially for autistic and transgender patients, led to dangerously long A&E waits, where the environment was unsuitable and exacerbated mental health conditions.
Responded
Matthew Sheldrick
Concerns: Critical shortages of mental health inpatient beds, particularly for neurodiverse and transgender patients, led to dangerous A&E wait times and an unsuitable environment, alongside service gaps for high-risk individuals.
Responded
Timothy De Boos
Concerns: A severe and persistent shortage of mental health inpatient beds, combined with a crisis team overriding the experienced mental health professional, family, and patient's wishes for admission, led to a denied hospitalisation.
Responded
Amy Butcher
Concerns: The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in crisis to contact multiple services. This is compounded by out-of-hours issues and restrictions on certain medications.
Responded
Jamie Harding
Concerns: A lack of compulsory training on the Dual Diagnosis pathway, poor communication, and an inefficient system for the Frontline Resolution Team to manage caseloads and follow up referrals led to significant care failures.
Responded
Kashim Ali
Concerns: Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.
Responded
George Kyriacos Petrou
Concerns: Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a risk that vulnerable individuals with suicidal intentions may not receive necessary observation.
Overdue
Stephen Dulling
Concerns: The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple lapses, including inadequate nutritional assessments and delayed responses to critical incidents.
Responded
Oliver Davies
Concerns: Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care coordinator then improperly prioritized Oliver's case, failing to ensure timely support before going on leave.
Responded
Nigel Hammond
Concerns: An Authorised Mental Health Professional was unable to directly refer a high-risk patient needing immediate mental health support to the Crisis Resolution and Home Treatment Team, leading to critical delays over a weekend.
Responded
Parminder Sanghera
Concerns: Hospital and police custody failed to recognise a mental health crisis and conduct a Mental Health Act assessment, leading to inadequate risk assessments that missed suicide/self-harm concerns before release.
Responded
Phephisa Mabuza
Concerns: The Trust's Crisis Response Service deviated from national guidance by extending mental health triage response times and maintained an incorrectly coded operational policy.
Responded
Liam McCarlie
Concerns: Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage and ambulance dispatch for patients with mental health needs.
Responded
Juan Martin
Concerns: Inadequate mental health bed capacity in London leads to prolonged waits for patients in unsuitable environments, directly posing a risk of future deaths.
Responded
Harry Hall
Concerns: Mental health services failed to adequately manage a patient with suicidal ideation, including a delayed crisis team response, significant wait times for appointments, and poor record-keeping.
Responded
Jason Pulman
Concerns: Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and CAMHS being unaware of new national support offers, risking patient safety.
Responded
Paul Dow
Concerns: Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not escalated despite the patient becoming unresponsive.
Responded
Ellen Woolnough
Concerns: Concerns persist regarding inadequate mental health discharge decisions, insufficient crisis team risk assessments, and downgrading of urgent referrals, with many identified safety measures remaining prospective or unimplemented by the Trust.
Responded
Christopher Sidle
Concerns: Concerns remain regarding the crisis team's understanding of comprehensive assessments, mental capacity, and other services. There were also communication failures, insufficient telephone support, and an ongoing national mental health bed shortage.
Responded
Jonathan Harris
Concerns: Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental health care.
Responded
Roberto Bottello
Concerns: Failures in mental health service follow-up and assessment, alongside significant delays in Mental Health Act assessment at hospital, despite clear signs of acute psychosis.
Responded
Nicolas Gerasimidis
Concerns: Persistent severe staffing shortages, bed unavailability, and long waiting lists for psychological treatment in mental health services resulted in inadequate patient screening and care coordination.
Responded
Matthew Wickes
Concerns: The university failed to ensure academic staff had adequate, compulsory, and monitored training on student mental health, particularly for neurodiverse students, leading to a gap in pastoral support and risk of overlooking struggling individuals.
Overdue
Nadia Wyatt
Concerns: Failures in care planning included incomplete patient records, lack of bespoke care plans with "cutting and pasting," inadequate risk assessments, and an over-reliance on the patient's carer.
Responded
Tom Sweeting
Concerns: Poor communication between the hospital and General Practice led to a critical delay in prescribing antidepressant medication for a patient reporting suicidal thoughts.
Responded
Meghan Chrismas
Concerns: Inadequate supervision of police control room operators and the absence of effective information-sharing structures between NHS and private healthcare providers posed significant risks.
Responded
Larry Spriggs
Concerns: Systemic failures include a lack of demonstrated cultural change in patient care, inadequate risk assessment and management, poor information sharing, and insufficient management of intermittent observations.
Responded
Barbara Woodman
Concerns: Missed opportunities for collateral history gathering, inaccessible information systems, inadequate risk assessment handling, and poorly recorded care plans collectively hindered effective mental health support.
Responded
Denise Porter
Concerns: The Trust's failure to thoroughly interrogate a police referral and reliance on an incomplete incident summary led to a critical misassessment of suicide risk and an inadequate care plan.
Overdue
Nicholas Dymond
Concerns: Independent mental health assessors lack mandated access to full patient records, while staff misunderstand voluntary admission and the "least restrictive option," potentially hindering appropriate care.
Responded
James Campion
Concerns: Significant delays in 999 call triage and ambulance dispatch, stemming from high demand, critically impacted the timely provision of medical and psychiatric assistance for an overdose.
Overdue
Reece Nelson
Concerns: Mental health services lacked a system to inform families of staff absence or provide alternative contacts, preventing a family from seeking assistance during a crisis.
Responded
Paul Perrott
Concerns: Inadequate observation charting, unclear staff responsibility for checks, and a lack of historical risk analysis meant staff were unaware of the patient's critical suicide risk history.
Overdue
Katharine Fox
Concerns: A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer systems, resulted in substantial wait times and impaired continuity of care.
Responded
Teresa Chmielek
Concerns: Critical failures in mental health referral management include missed suicide risk, inadequate MDT discussions, no patient contact, unmanaged absences, and a lack of standard operating procedures and audit for decision-making.
Responded
Leya Adris
Concerns: A patient with escalating mental health concerns, including suicidal ideation, did not receive critical psychiatrist input because the GP's urgent referral was incorrectly diverted by the single point of access system.
Responded
Michael Hindes
Concerns: There were significant delays in community mental health follow-up and crisis team referral, and a failure to adequately involve or inform the patient's family about his mental health.
Responded
Ronald Harris
Concerns: Incomplete triage documentation, failure to contact the patient, and a lack of awareness by the triage doctor regarding appointment waiting times and call details, resulted in no revised mental health triage protocol after the incident.
Responded
Shaun Houghton
Concerns: A junior doctor allowed a high-risk patient with impulsivity and suicidal intent to self-discharge against medical advice, without consulting senior clinicians, raising concerns about the decision-making process.
Responded
Amanda Kramer
Concerns: A patient was prescribed Zoplicone for 18 years without review, despite the drug's short-term license and her high-risk overdose behaviour, raising concerns about medication management.
Responded
Allison Aules
Concerns: Under-resourced and underfunded CAMHS services, coupled with a lack of consultant leadership, led to significant delays in mental health assessments for children, despite rapidly increasing demand.
Responded
Peter Fleming
Concerns: No specific safety issues or systemic failures were identified in the provided concerns text, which only stated that action should be taken to prevent future deaths.
Responded
Oleg Khala
Concerns: A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, likely due to a shortage of care-coordinator provision and lack of consultant advice.
Responded
Michael Sullivan
Concerns: Delays between GP referrals and Crisis Review Team assessments for vulnerable mental health patients highlight unclear processes regarding GP understanding, CRT prioritization, or triage effectiveness, causing patients to become seriously unwell before assessment.
Responded
Nicholas Stout
Concerns: Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and safeguarding referrals for children are frequently missed.
Responded
Marlene McCabe
Concerns: Systemic issues include a lack of clinician understanding for urgent mental health referrals, poor information sharing between providers, and a risk of misdiagnosis or delayed assessment due to assumptions about substance misuse.
Overdue
Nigel Harper
Concerns: A critical communication breakdown between two NHS Trusts led to a patient with suicidal thoughts not receiving an intended urgent mental health assessment. This misunderstanding of urgent referral protocols poses a risk of future deaths.
Responded
Daniel Lyle
Concerns: A police officer responding to a mental health crisis reported insufficient specific training on symptoms, presentation, and de-escalation techniques for individuals experiencing psychotic episodes. The officer's training was described as a "patchwork" over many years.
Overdue
Caroline Forte
Concerns: There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading to a loss of critical patient history in acute and mental health settings.
Responded
Ben Shipley
Concerns: A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in A&E for hours, unable to be legally detained and without appropriate specialist care.
Overdue
Thomas Jayamaha
Concerns: Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation process, raise concerns about effective service improvement.
Responded
REDACTED
Concerns: Unacceptably long waiting times for young people's assessments due to finite resources placed children at risk, suggesting that earlier diagnosis and professional support could prevent deaths.
Overdue
Benjamin Hart
Concerns: A severe nursing staff shortfall in the community mental health team prevented patient care coordinator reallocation, highlighting a lack of resilience and capacity in mental health services.
Overdue
Jai Singh
Concerns: Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded by the mental health team's lack of a psychiatrist and ongoing risk assessment documentation.
Responded
Nicola Norman
Concerns: The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, follow up on distressed callers, or routinely escalate critical concerns to clinicians or the GP.
Overdue
Jayden Booroff
Concerns: Inadequate risk assessments at Essex Partnership NHS Foundation Trust led to reduced observations. There was also critical miscommunication and misunderstanding between the Trust and emergency services regarding escaped detained patients.
Responded
Andrew Largin
Concerns: Significant delays in patient allocation and critical failures by the crisis team to reassess a depressed patient were compounded by an inadequate serious incident review and unclear team responsibilities.
Responded
Leroy Hamilton
Concerns: Critical shortages of inpatient mental health beds and PDU spaces leave acutely ill patients without specialist care. Police also failed to correctly classify and risk-assess mentally unwell individuals as high-risk missing persons.
Responded
Lucy Jones
Concerns: Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including limited contact attempts, were identified.
Responded
Carl Ellson
Concerns: Unclear and unsafe systems hinder GPs from urgently contacting mental health teams, placing the burden of initiating contact on patients in crisis and leaving GPs unaware of proper referral protocols.
Responded
Philip Battle
Concerns: The ambulance service triage system prioritized physical health over acute mental health risks like suicide, failing to assess for self-harm or coordinate mental health crisis intervention resources with police and health providers.
Responded
Vincenzo Lippolis
Concerns: Mental health services failed to consider Mental Health Act admission criteria, focusing instead on social stressors after suicide attempts. A recommended face-to-face assessment was replaced by a telephone call, leading to case closure.
Overdue
John White
Concerns: The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, bespoke training for officers responding to mental health crisis incidents is not widely available.
Overdue
Charley Patterson
Concerns: A significant post-pandemic surge in children and young people experiencing mental health difficulties has led to severe, prolonged waiting times (up to 63 weeks) for treatment. Current services and resources are insufficient to meet this drastically increased demand.
Overdue
Adam Gallagher
Concerns: The ambulance service failed to conduct a detailed assessment for a mental health incident, resulting in inadequate clinical input and limited learning from a serious event. Trust-wide policy review and comprehensive retraining are urgently required.
Overdue
Demet Akcicek
Concerns: A mental health duty worker failed to escalate a patient's severe distress, omitted their case from multi-disciplinary team discussion, and made inadequate notes, with no clear trust-level actions to prevent future recurrences.
Responded
Lily Girton
Concerns: Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.
Overdue
Pauline Keen
Concerns: A lack of formal communication policy between KMPT and Kent County Council AMHP service caused delays in processing Mental Health Act applications.
Overdue
Cynthia Finlay
Concerns: There is no protocol for safeguarding at-risk individuals who are alone in the community while awaiting Mental Health Act assessments.
Overdue
Joshua Rennard
Concerns: Significant and systemic delays in actioning recommendations for Mental Health Act assessments place individuals with mental illness at risk of harm and death.
Overdue
Matthew McManus
Concerns: An adult with complex mental health and social care needs lacked coordinated care and a single point of contact, resulting in inadequate assessment, information sharing, and risk management.
Responded
Sheila Steggles
Concerns: Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.
Responded
John Skinner
Concerns: A significant medication overdose resulted from a junior doctor mishearing a verbal dosage instruction, highlighting a foreseeable communication risk when numbers are expressed orally in clinical settings.
Overdue
Michelle Jennings
Concerns: Critically long national waiting lists for mental health therapy, inconsistent application of referral/discharge policies, and a lack of proper consideration for mental health vulnerabilities during prosecutions, with no clear mechanism for sharing lessons.
Overdue
Benjamin Stroud
Concerns: A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing a significant risk.
Overdue
Joy Burgess
Concerns: Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.
Responded
Mark Jones
Concerns: Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent cases being missed.
Responded
Oskar Nash
Concerns: Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low risk, despite potential for significant harm.
Responded