Mental Health Crisis Referral Delays
Procedural gaps preventing direct referral of acutely unwell patients to emergency Crisis Resolution and Home Treatment Teams.
873 items
12 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
98match
#28 - Eighth Report - Children and young people’s mental health
In order to achieve this shift towards community-based care, every area should have a community service for children in crisis which is available 24 hours a day, seven days a week. A clear map is needed of where current gaps in this provision are and a plan should be in place to ensure these services are available in...
Matched on
terms: crisi, health, mental
Committee recommendation
95match
#11 - Extend 24/7 Neighbourhood Mental Health Centre pilot programme with funding and finalise metrics.
The design of these centres must be informed by the learnings from the pilot programme so they can be tailored to the needs of their communities. In order for the learnings to be robust, the 24/7 Neighbourhood Mental Health Centre pilot programme must be extended by at least 12 months beyond April 2026, with additional service development funding...
Matched on
terms: delay, health, mental
Committee recommendation
95match
#1 - Severity gap reveals unacceptable failing in timely access to mental health care
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. The severity gap, where people fall between high and low intensity services, reflects an unacceptable failing of the...
Matched on
terms: crisi, delay, health, mental
Committee recommendation
94match
#40 - Slow rollout of Mental Health Support Teams leaves most post-16 students unsupported
Poor mental health is a growing crisis for young people, with rising rates of anxiety, depression and eating disorders—particularly for those aged 17 to 19. The Government has pledged specialist mental health support in all schools and colleges, but the rollout of Mental Health Support Teams (MHSTs) has been slow—only 41% of post-16 students are currently covered. There...
Matched on
terms: crisi, health, mental
PPO recommendation
94match
The Head of Healthcare and Mental Health Clinical Manager
The Head of Healthcare and Mental Health Clinical Manager should ensure that referrals to the mental health team, reporting that a prisoner feels suicidal, prompts an additional mental health assessment within 48 hours.
Matched on
terms: health, mental, referral
PFD report
93match
Vanessa Dadswell
Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention for patients requiring urgent but not emergency care.
Matched on
terms: health, mental, referral
IMB recommendation
93match
Swansea (2025)
Prisoners with significant mental health needs are being held for lengthy periods, often in segregated conditions, whilst waiting for specialist hospital care. Given that demand for inpatient care appears to exceed healthcare capacity, what specific actions will the Minister take to reduce delays, prevent the use of segregation for acutely unwell prisoners and ensure timely access to appropriate...
Matched on
terms: delay, health, mental
Committee recommendation
90match
#10 - Eighth Report - Children and young people’s mental health
We welcome and support the proposals in the recent access and waiting times consultation that concluded on 1st September, including crisis response times and a four-week waiting time limit for children and young people, and call on NHS England to publish a detailed roadmap as to how it will be delivered including the additional funding requirements.
Matched on
terms: crisi, health, mental
PHSO casework decision
90match
P-003355 - Birmingham and Solihull Mental Health NHS Foundation Trust
Mr R complains Birmingham and Solihull Mental Health NHS Foundation Trust incorrectly rejected his referrals to its community mental health team between August 2023 and February 2024.
Matched on
terms: health, mental, referral
PFD report
89match
Matthew Dunham
Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination among professionals.
Matched on
terms: delay, health, mental, referral
PFD report
89match
Barry Thraves
Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs led to unaddressed patient deterioration.
Matched on
terms: delay, health, mental
PFD report
89match
Jacqueline Williams
The mental health referral system was prone to human error, failing to provide ED staff with confirmation of accepted referrals or assessment times. The Mental Health Liaison Team also lacked a process to identify patients awaiting assessment.
Matched on
terms: health, mental, referral
PFD report
89match
Richard Grant
Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment outcomes. This risked the patient not receiving timely mental health support.
Matched on
terms: delay, health, mental
PFD report
85match
Keward Guy Domonic Harding
An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.
Matched on
terms: delay, health, mental
PFD report
85match
Kyle Ashley Smith
An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical communication failure remaining unknown and uninvestigated.
Matched on
terms: delay, health, mental, referral
PFD report
85match
Michael Irlam
A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in care, risking patient abandonment.
Matched on
terms: crisi, health, mental
PFD report
85match
Andrew Horgan
Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.
Matched on
terms: health, mental, referral
PFD report
85match
Samiyo Farah
Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric referrals from A&E.
Matched on
terms: health, mental, referral
PFD report
85match
Stephen Ward
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did not respond.
Matched on
terms: crisi, delay, health, mental
PFD report
85match
Paul Hyde
Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a deteriorating condition, despite anxieties being raised by community mental health workers.
Matched on
terms: health, mental, referral
PFD report
85match
Matthew Groom
Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, did not involve hospital security, and inadequately communicated the patient's detention need to police.
Matched on
terms: delay, health, mental
PFD report
85match
Anna Masson
A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice across the Trust's mental health teams.
Matched on
terms: health, mental, referral
PFD report
85match
Rohan Fitzsimons
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.
Matched on
terms: delay, health, mental
Committee recommendation
85match
#4 - Eighth Report - Children and young people’s mental health
During the pandemic, children and young people’s mental health has significantly worsened and the scale of the backlog mean that the NHS will not be able to treat its way out of this crisis. The need for early intervention and prevention in children and young people’s mental health has been consistently overlooked by successive governments and although there...
Matched on
terms: crisi, health, mental
PHSO casework decision
85match
P-002499 - Avon and Wiltshire Mental Health Partnership NHS Trust
Ms E complains that when the Trust's Crisis Team visited her they did not listen to her concerns. She complains that staff did not give her options for engagement with mental health services or offer access to community support groups or further health support.
Matched on
terms: crisi, health, mental
IMB recommendation
85match
Downview (2025)
Acutely mentally unwell prisoners continue to arrive at the prison. They often face long delays in transfer to secure psychiatric units, following assessment and referral (6.1). How confident is the Minister that the statutory 28-day time limit for transfer from prison to hospital, envisaged by the Mental Health Bill, will be achievable, given the low number of suitable...
Matched on
terms: delay, health, mental, referral
IOPC learning recommendation
84match
Recommendations - Northumbria Police, July 2024
The IOPC recommends that Northumbria Police should work with Cumbria, Northumbria Tyne and Wear NHS (CNTW) to review and revise the referral points discussed in the Street Triage Team (STT) Operational Policy document around when a member of the public may require CRISIS intervention or home based treatment, to ensure that the referral points and guidance to staff...
Matched on
terms: crisi, health, mental, referral
Committee recommendation
83match
#17 - Create clear, actionable plan to deliver comprehensive mental health offer for 0-25 year olds.
Despite nearly a decade of commitments, the transition from Children and Young People’s Mental Health Services (CYPMHS) to Adult Mental Health Services (AMHS)—including Community Mental Health Services (CMHS)— remains a cliff edge and continues to fall short of what young people need. The Government, NHS England, and Integrated Care Boards must treat this issue as a national priority....
Matched on
terms: health, mental
Committee recommendation
83match
#10 - Establish a 24/7 Neighbourhood Mental Health Centre in every community.
We believe there should be a 24/7 Neighbourhood Mental Health Centre in every community. (Recommendation, Paragraph 92)
Matched on
terms: health, mental
Committee recommendation
82match
#42 - Improve access to CAMHS and adult mental health services for young people with severe conditions.
The Government must improve access to Children and Adolescent Mental Health Services (CAMHS) and adult mental health services for those children and young people with more severe mental health conditions and whose education is often interrupted for months or years at a time by the long waits for services and treatment. (Recommendation, Paragraph 161)
Matched on
terms: health, mental
Committee recommendation
82match
#26 - Eighth Report - Children and young people’s mental health
Inpatient units have a role to play in treating some of the most severe and complex mental health conditions, especially those that are resistant to community treatment. However, in most cases the most compassionate and effective care for children and young people is provided in the community–and increasing its provision must be the overall aim of the Department...
Matched on
terms: health, mental
PFD report
81match
Simon Sankey
The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of the urgency category, and the electronic system for prioritising referrals was not available to all senior nurse practitioners.
Matched on
terms: health, mental, referral
PFD report
81match
Sandra Bodrozic
Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private bed options.
Matched on
terms: delay, health, mental
PFD report
81match
Eve Cullen
Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for "urgent" and no agreed timeframes. The process led to lost opportunities for timely intervention in mental health care.
Matched on
terms: health, mental, referral
PFD report
81match
Sian Armstrong
A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.
Matched on
terms: delay, health, mental
PFD report
81match
Barbara Mayer
Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed due to increased demand. Treatment options were also not adequately discussed with the patient.
Matched on
terms: crisi, delay
PPO recommendation
81match
The Head of Healthcare
The Head of Healthcare should ensure there is an effective system for urgent mental health referrals to be tracked and carried out within a reasonable timescale.
Matched on
terms: health, mental, referral
IMB recommendation
81match
Thameside (2021)
Delays in transferring severely mentally ill prisoners to secure establishments that provide more specialist treatment have been a longstanding concern of the Board. While the government’s positive response to Sir Simon Wessely’s mental health review is noted, transfer wait times for these vulnerable individuals have remained this year overall in excess of NHS England guidelines.
Matched on
terms: delay, health, mental
IMB recommendation
81match
Downview (2023)
As commented on last year, the considerable rise in the number of prisoners being transferred to the prison, often from HMP Bronzefield, who exhibit more challenging mental health symptoms and consequent behavioural issues is causing safety concerns. Prison is not an appropriate environment for these women and staff do not have the appropriate training to manage them. The...
Matched on
terms: delay, health, mental
PPO recommendation
81match
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff at Pentonville understand that referrals to secure mental health units should only be made through the prison’s mental health Inreach team.
Matched on
terms: health, mental, referral
PPO recommendation
81match
The healthcare provider and the NHSE quality team
The healthcare provider and the NHSE quality team should consider whether the behaviour of the nurse who cancelled multiple mental health referrals requires discussion with the appropriate regulator.
Matched on
terms: health, mental, referral
LGO / SPSO decision
81match
PSOW-202105577 - Betsi Cadwaladr University Health Board
Mrs A complained about the care that she received from Betsi Cadwaladr University Health Board’s mental health services. Specifically, Mrs A complained that the Health Board failed to recognise and correctly diagnose her symptoms, and that there was an unreasonable delay in starting appropriate treatment. Mrs A also raised concerns about the contents of two conversations that she...
Matched on
terms: delay, health, mental
Committee recommendation
81match
#61 - Extensive National Referral Mechanism Conclusive Grounds decision time is unacceptable and detrimental
The extensive time taken for Conclusive Grounds decision-making within the National Referral Mechanism is unacceptable. Lengthy decision-making is detrimental to victims’ mental health and wellbeing and puts significant pressure on the services that support them during this time.
Matched on
terms: health, mental, referral
PHSO casework decision
78match
P-003994 - Kent and Medway Mental Health NHS Trust
Ms N complains about the support given to her and her son when he was experiencing mental health crises in the community. This includes a failure to assess his level of risk, review his medication, and support her as his carer.
Matched on
terms: health, mental
LGO / SPSO decision
78match
23-017-445a - South West London & St. Georges Mental Health NHS Trust (23 017 445a)
Summary: We will not investigate Mr X’s complaint about the decision to detain him under Section 2 of the Mental Health Act 1983. This is because Mr X appealed this decision to the First Tier Tribunal (Mental Health). This means we are prevented from investigating this complaint.
Matched on
terms: health, mental
Committee recommendation
78match
#32 - Eighth Report - Children and young people’s mental health
We welcome the Government’s commitment to reducing the use of seclusion, segregation and restraint for children and young people in inpatient units and the Mental Health Units (Use of Force) Act in particular. However, we have heard that 60 Children and young people’s mental health restrictive interventions, and particularly restraint, are still used excessively and avoidably against children...
Matched on
terms: health, mental
Committee recommendation
78match
#27 - Eighth Report - Children and young people’s mental health
We therefore recommend that the Department accelerates the shift towards increased community-based provision and a reduced inpatient bed base as a national priority to ensure that children and young people with the most complex needs receive good quality care in a setting that is right for them. A national strategy should be set out to establish jointly commissioned...
Matched on
terms: health, mental
PFD report
77match
Lorna Cullen
The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated patients needing mental health assessments were regularly waiting in excess of 2 hours due to staffing shortages.
Matched on
terms: health, mental
PFD report
77match
Lucasz Lewandowski
The report identifies concerns regarding the timeliness of the police response, communication gaps between agencies, use of the Mental Health Act due to resource constraints, and a lack of correspondence from a psychiatric practice with the patient's GP.
Matched on
terms: health, mental
IMB annual report
77match
Doncaster (2025)
HMP Doncaster was rated the top local prison nationally, demonstrating strong performance in areas like refurbishment and support services. Despite an improved regime and full staffing, significant challenges persist, including increased prisoner violence due to overcrowding, and persistent, prolonged delays in mental health transfers. The IMB highlights critical issues such as national probation staffing deficits, property management concerns,...
Matched on
terms: delay, health, mental