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
Source spread
Where this theme appears
Mental Health Crisis Referral Delays has been flagged across 12 independent accountability sources:
253 PFD reports
53 committee recs
3 CQC actions
17 PPO recs
8 IOPC recs
21 IMB reports
223 IMB recs
1 Scottish FAI
6 Article 2 learning points
2 detention investigation recs
74 PHSO decisions
212 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.
PFD Reports (253) — showing 50 strongest matches
Lee Adams
Concerns: GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need to proactively inquire about patients' gambling habits.
Overdue
Delwyn Preece
Concerns: Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail and unacknowledged retrospective entries, hindering effective investigation.
Response (Rotherham Doncaster South Humber NHS Foundation Trust): • The Trust’s patient leave policy (including Section 17 leave for detained patients, and also applicable to informal patients) has been revised to clarify and strengthen documentation requirements around leave. …
Responded
Jardine Williams
Concerns: Communication between NWAS and CHOC was unclear, resulting in limited information transfer and significant delays in CHOC returning calls to NWAS after multiple unsuccessful patient contact attempts.
Overdue
Jardine Williams
Concerns: The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially hindering call handlers from understanding urgent risk.
Overdue
Keward Guy Domonic Harding
Concerns: 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.
Overdue
Ann Margaret Spearing
Concerns: Despite clear malnutrition and learning difficulties, the deceased was repeatedly assessed by mental health, hospital, and eating disorder services, yet consistently misdiagnosed or found not to have a treatable condition.
Response (Bristol Clinical Commissioning Group): Bristol has recently reviewed, redesigned and is currently re-procuring its specialist mental health and learning disability services and has piloted an enhanced advice and guidance support scheme to GPs.
Responded
Simon Sankey
Concerns: 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.
Responded
Kyle Ashley Smith
Concerns: 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.
Overdue
Michael Irlam
Concerns: 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.
Overdue
Matthew Dunham
Concerns: Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination among professionals.
Overdue
Amanda Vickers
Concerns: A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the CCG.
Response (Cumbria Clinical Commissioning Group): Cumbria Clinical Commissioning Group is reviewing the existing framework for wellbeing and mental health and developing a new mental health strategy in partnership with stakeholders. A review of mental health …
Responded
Lisa Inkin
Concerns: A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led to delayed escalation of suicidal intent and insufficient supervision for eating disorder patients.
Overdue
Lorna Cullen
Concerns: 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.
Overdue
Michael Tarratt
Concerns: There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions for an opiate-dependent patient.
Response (Leicestershire Partnership NHS Trust): An urgent memo was sent to the Drug & Alcohol team regarding GP communication standards (minimum every 3 months). Standard GP letter templates have been reviewed to ensure detailed updates …
Responded
Caroline Pilkington
Concerns: North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.
Response (Greater Manchester Police): Greater Manchester Police expresses concern about the increasing demand on police due to gaps in health services, emphasises that officers are trained in restraint but that medical emergencies require different …
Response (North West Ambulance Service NHS Trust): NWAS acknowledges the coroner's concerns but maintains that ambulance staff are not trained nor expected to restrain patients who are acting in a threatening or violent manner, as advanced control …
Response (Department of Health): The Department of Health acknowledges the coroner's concerns but supports the NWAS's collaborative approach with the police in handling patients requiring advanced control and restraint.
Response (Department of Health2): The Department of Health acknowledges the coroner's concerns about NWAS training, but supports the NWAS position that ambulance staff are sufficiently trained and that more advanced restraint training is not …
Responded
Jamie Barlow
Concerns: There was a lack of effective inter-agency working, clear protocols for police assistance, and a joint mental health assessment framework for high-risk patients.
Overdue
Andrew Horgan
Concerns: Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.
Response (Great Western Hospital NHS Foundation Trust): The Trust increased the number of Mental Health Liaison nurses from 2.6 to 6.8 and appointed a dedicated Consultant Psychiatrist. They also state that 82% of clinical staff had undertaken …
Responded
Michael Worrall
Concerns: The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior therapy is discontinued.
Overdue
Rosemary Oladejo
Concerns: A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and administration times for amitriptyline.
Response (Hillingdon Commissioning Group): Hillingdon CCG will review current processes for recording and communicating medication information by August 2014. They will discuss the possibility of developing one standard letter/form for use across all sectors …
Response (Central North West London NHS Trust): Central North West London NHS Trust will circulate a Clinical Risk Alert referencing this case in an anonymised form in the next few weeks to remind staff of the importance …
Responded
Mary Wanya
Concerns: Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by unqualified staff raise serious safety concerns.
Overdue
Samiyo Farah
Concerns: Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric referrals from A&E.
Response (Department of Health): The Department of Health acknowledges the concerns raised and highlights existing NICE guidance on self-harm and a government suicide prevention strategy. They note that Trusts develop their own transfer protocols …
Overdue
Stephen Ward
Concerns: 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.
Response (Camden Islington NHS Trust): Response is blank.
Responded
Jeffrey Gash
Concerns: Crisis Team failures included inadequate telephone assessment training, no clear policy for declining home visits, and insufficient exploration of new symptoms leading to poor risk assessment. The clinical risk policy was unclear for non-in-person assessments.
Response (Tees Esk and Wear Valleys NHS Trust): Following the inquest, the individual nurse received capability management and observed best practices. The Trust is reviewing policy and practice, planning further suicide prevention training, and monitoring implementation via the …
Responded
Caroline Carter Crowther
Concerns: Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically coerce grievously ill patients.
Overdue
Lucasz Lewandowski
Concerns: 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.
Response (Green Surgery Medical Dental Care): A protocol is being implemented for psychiatric practice, including risk assessment and communication with healthcare professionals, to be reviewed regularly. The referral system is being improved to flag occurrences like …
Response (Greater Manchester Police): The Operational Communications Branch (OCB) has reviewed its Escalation Policy, issued individual management advice to staff involved in the incident, and recirculated the policy with emphasis on accurate recording. The …
Overdue
Rowena Golton
Concerns: Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access for vulnerable patients.
Response (North Central South Manchester Clinical Commissioning Groups): The CCGs are working with colleagues to review service provision across all services and develop care pathways for service users. An external review of psychological therapies (IAPT) has been completed …
Responded
George Werb
Concerns: The lack of an effective child psychiatric bed bureau system caused significant delays and distant placements, leading to poor environment, limited family involvement, and inadequate communication.
Response (NHS England): NHS England details actions taken at the Priory Hospital, including additional risk documentation, observation policy updates, refresher training on care planning, therapy programme reviews, and increased documentation quality checks. Learning …
Overdue
Sandra Bodrozic
Concerns: 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.
Overdue
Stephen Morris
Concerns: Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, up-to-date patient history, compromising risk assessment and response.
Response (MDU Services Limited): The MDU is responding on behalf of a member, arguing that the coroner's report was not based on clear evidence and that the doctor's actions were reasonable in the circumstances.
Overdue
Anthony Williams
Concerns: Staff lacked clear guidance on psychiatric assessment pathways for 'exceptional cases', medical records were inaccessible out-of-hours, and there was insufficient engagement with family/carers on care plans.
Response: The health board now has a larger number of psychiatric nurses present on the Heddfan Adult Unit out of hours so socially anxious patients could be assessed at the Unit. …
Responded
Joanne Nobbs
Concerns: A correlation between the deceased's deteriorating physical and mental health was noted but not investigated, and a care plan was not revised despite the deceased no longer engaging with mental health services.
Responded
Paul Hyde
Concerns: 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.
Response (Sussex Partnership NHS): The trust recruited an additional administrator to the Triage team. GPs have been allocated named Consultant Psychiatrists and meetings have been arranged. Mr. Hyde's experience has been shared (anonymously) with …
Overdue
Eve Cullen
Concerns: 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.
Response (Worcestershire Health Care NHS Trust): Worcestershire Health Care NHS Trust conducted a serious review and acknowledges differences in urgent referral processes across the county. As a result, it is working with North CCGs to introduce …
Responded
Sian Armstrong
Concerns: 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.
Overdue
George Taylor
Concerns: A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk of future deaths.
Response (Department of Health): The Department of Health acknowledges the concerns, highlights the Crisis Care Concordat, and states that NHS England is aware of the report. They note that the local CCG is reviewing …
Response (NHS Kernow Clinical Commissioning Group): NHS Kernow is working with partners to develop alternatives to hospital admission and ensure early assessment and intervention, including a budget for community care to prevent admissions, reviewed in 2015. …
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
Barbara Mayer
Concerns: 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.
Response (Norfolk Suffolk NHS Trust): The Trust is implementing the 'Triangle of Care' model and nearing completion of the first stage of this multi-year plan. Localities are reviewing their escalation plans for services such as …
Responded
Mark Daniels
Concerns: The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.
Response (Camden and Islington NHS Trust): Camden and Islington NHS Foundation Trust have put in place a comprehensive action plan to address the concerns raised regarding failures by the Crisis team, with measures implemented across all …
Responded
Barry Thraves
Concerns: Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs led to unaddressed patient deterioration.
Response: Adult Social Care will send letters to individuals waiting for assessments from an Adult Mental Health Team, explaining Adult Social Care's role and how to contact the team if the …
Response: The LPT will review and update its DNA policy by March 2016; CMHTs are undergoing service redesign to remove internal barriers between the Outpatients Service and the wider CMHT, including …
Responded
Jacqueline Williams
Concerns: 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.
Response (Lancashire Care NHS Trust): • All staff were briefed on the referral process to ensure full understanding, and learning from the joint investigation was shared. • The Trust met with East Lancashire Teaching Hospitals …
Responded
David Pooley
Concerns: A named nurse was not allocated until the day before death, breaching trust policy and resulting in a failure to carry out essential risk assessments and care plans.
Response (Lancashire Care NHS Trust): • All staff have been briefed on the referral process, and learning from the joint investigation has been shared. • The Trust is exploring using the CRISP board in the …
Overdue
Matthew Groom
Concerns: 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.
Response: The Trusts strengthened the mental health referral protocol from Whittington ED triage and added a new black phone in Whittington Health ED specifically for the police to pre-alert them to …
Response (Matthew Groom): The Trusts strengthened the mental health referral protocol from Whittington ED triage and added a new black phone in Whittington Health ED specifically for the police to pre-alert them to …
Responded
Michael Valentine
Concerns: Inadequate communication and administrative procedures led to a GP not being informed about the rejection of an urgent mental health assessment, as rejected applications were not marked urgent nor accompanied by a phone call.
Response (Michael Valentine): The practice conducted audits of post and electronic communication review procedures and found them to be robust. They also met with Second Care Psychiatry colleagues to discuss the rejection process …
Response (Michael Valentine Response2): The organization will ensure staff that reject an urgent referral will contact the referrer directly to confirm the outcome. They will seek advice from the Local Medical Committee to ask …
Responded
Vanessa Dadswell
Concerns: 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.
Response (Vanessa DADSWELL): The triage system has been improved with direct bookable Priority Appointment slots for Triage Team Leaders and senior staff oversight. A protocol encompassing the improved system is being drafted throughout …
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
Anna Masson
Concerns: 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.
Response (Southern Health NHS Foundation Trust): The Trust is reviewing its CMHT Standard Operating Procedure (SOP) to standardize screening processes across all teams, ensuring appropriate staff expertise and multi-disciplinary team discussions. A randomised audit will be …
Responded
Richard Grant
Concerns: 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.
Response (Black Country NHS): Black Country NHS has developed and shared a MHLS checklist and reviewed the SPOR duty system. MHLS standard has been developed requiring all letters are drafted within the same or …
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
Oliver Ford
Concerns: The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for patients triaged on Fridays.
Response (Avon and Wiltshire NHS Trust): The telephone triage process now includes the access trigger tool, which assesses risk. There are now two clinicians on duty at PCLS until 8pm Monday to Friday, and the clinicians …
Responded
Christopher Jones
Concerns: Inadequate mental health care planning resulted in patients being without consultant review for extended periods post-discharge. Increased demand on services also created staff cover deficiencies.
Response: The Division produced a multi-agency document which became operational in August 2013 and has been reviewed regularly. MHM administrators send a report to managers of all CTPs due for review, …
Responded
Committee Recommendations (53) — showing 50 strongest matches
#28 — Prisons used as places of safety, despite Government aims to end the practice
Recommendation: We were shocked and appalled to hear that prisons are used as a place of safety. We acknowledge and welcome that the Government aims to end this practice in the Mental Health Bill. We request details of how this will …
Gov response: The Mental Health Bill includes a number of vital reforms to support people with severe mental illness in the criminal justice system. These include: • The introduction of a new statutory 28-day time limit for …
Accepted
#18 — Publish and implement urgent national access and waiting time standards for integrated care.
Recommendation: We heard that one way to track progress on integration would be through the establishment of national access and waiting time standards. The absence of national standards contributes to inconsistent access and undermines parity with physical health. NHS England should …
No Published Response
#17 — Create clear, actionable plan to deliver comprehensive mental health offer for 0-25 year olds.
Recommendation: 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 …
No Published Response
#11 — Extend 24/7 Neighbourhood Mental Health Centre pilot programme with funding and finalise metrics.
Recommendation: 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 …
No Published Response
#10 — Establish a 24/7 Neighbourhood Mental Health Centre in every community.
Recommendation: We believe there should be a 24/7 Neighbourhood Mental Health Centre in every community. (Recommendation, Paragraph 92)
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
#68 —
Recommendation: Now, with the effects of covid-19, NUS Scotland have found that students’ mental health has further declined.157 For example, students in self-isolation, in halls of residence, trying to come to terms with where they are, what they are trying to …
Not Addressed
#67 —
Recommendation: Mental health has been flagged to us as a particular area of concern. We have heard that students tend to suffer poor mental health at higher rates than the rest of the adult population.154 Matt Crilly, President of NUS Scotland, …
Not Addressed
#5 —
Recommendation: Students in Scotland, as with so many groups, faced unprecedented challenges over the course of the pandemic. Whilst we welcome the investments the Scottish Government has made in student wellbeing and mental health during this period, we have heard evidence …
Gov response: At Spending Review 2021, the UK Government confirmed funding for the Turing Scheme for the next three years, including maintaining total funding for mobilities and delivery of the scheme at £110 million for the 2022/23 …
Under Consideration
#10 —
Recommendation: 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 …
Gov response: 83. Please refer to the response to recommendation 3
Under Consideration
#19 —
Recommendation: The Department for Education also spoke about an NHS England consultation, which closed early in 2022, on introducing waiting time standards for community and A&E mental health care.48 The new standards would comprise a 24-hour standard for urgent community mental …
Gov response: 5: PAC conclusion: We are extremely concerned about the waiting time for children to receive support for mental health issues and about the proportion of adolescent girls seeking help. 5: PAC recommendation: Government should report …
Accepted
#5 —
Recommendation: We are extremely concerned about the waiting time for children to receive support for mental health issues and about the proportion of adolescent girls seeking help. A survey found nearly 1 in 5 of 6- to 16-year-olds in England had …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Recommendation implemented 5.2 In summer 2021, NHS England consulted on the potential to introduce five new waiting time standards as part of its Clinically-led Review of NHS …
Accepted
#42 — Improve access to CAMHS and adult mental health services for young people with severe conditions.
Recommendation: 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 …
Gov response: The government is committed to improving mental health support for FE students, promoting a whole-college approach through guidance and the Acol Mental Health Charter. Polly Harrow, appointed as the first FE Student Support Champion in …
Not Addressed
#40 — Slow rollout of Mental Health Support Teams leaves most post-16 students unsupported
Recommendation: 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 …
Gov response: The government is committed to improving mental health support for FE students, promoting a whole-college approach through guidance and the Acol Mental Health Charter. Polly Harrow, appointed as the first FE Student Support Champion in …
Not Addressed
#15 —
Recommendation: We were concerned to hear reports of children being remanded to custody pending psychiatric reports. Evidence received suggested that this is unnecessary and potentially damaging for a child. We ask the Ministry of Justice to set out how many children …
Gov response: 59. The recently published MHA White Paper accepts in principle the Independent Review’s recommendation. The Government agrees with the Review that prison should not be used as a place of safety on the grounds of …
Under Consideration
#73 —
Recommendation: Students in Scotland, as with so many groups, faced unprecedented challenges over the course of the pandemic. Whilst we welcome the investments the Scottish Government has made in student wellbeing and mental health during this period, we have heard evidence …
Not Addressed
#32 —
Recommendation: 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 …
Gov response: The Government is considering this recommendation. Within specialised commissioning, there are a number of programmes of work to reduce restrictive practice. The national Quality Improvement Taskforce for Children and Young People’s Mental Health, Learning disability …
Not Addressed
#28 —
Recommendation: 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 …
Gov response: We accept this recommendation. The NHS LTP commitment is all children and young people experiencing a mental health crisis will be able to access crisis care 24 hours a day, 7 days a week by, …
Not Addressed
#27 —
Recommendation: 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 …
Gov response: We accept this recommendation in part. All patients detained in hospital under the Mental Health Act are continually assessed and supported, and their need for detention is regularly reviewed. The Government does not see the …
Not Addressed
#26 —
Recommendation: 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 …
Gov response: We accept this recommendation in part. All patients detained in hospital under the Mental Health Act are continually assessed and supported, and their need for detention is regularly reviewed. The Government does not see the …
Not Addressed
#34 —
Recommendation: We again recommend that a duty be placed on ICBs for them to have regard to mental health and public health. (Paragraph 128) Clearing the backlog caused by the pandemic 39
Gov response: The Government agrees that it is important that ICBs have regard to mental health and public health. The Health and Care Act 2022 places a duty on ICBs to have regard to the need to …
Under Consideration
#1 —
Recommendation: Our key new recommendation is that, by April 2022, the Department of Health and Social Care works with NHS England to produce a broader national health and care recovery plan that goes beyond the elective backlog to emergency care, mental …
Gov response: Accept in principle. The Government recognises the importance of the NHS and the social care system working together to address the challenges they face. The Health and Care Act 2022 legislates to ensure effective partnership …
Under Consideration
#1 —
Recommendation: We repeat our previous calls for further mental health support for those affected by the building safety crisis.
Gov response: We recognise that the building safety crisis has had a negative effect on many residents; leaseholders, who are blameless, have been shouldering a desperately unfair burden and for some this has had an adverse impact …
Under Consideration
#17 —
Recommendation: In 2021, a NHS survey showed nearly 1 in 5 of 6- to 16-year-olds in England had a probable mental health disorder. The survey also found that almost 40% had experienced a deterioration in mental health since 2017 and 13.5% …
Gov response: 5: PAC conclusion: We are extremely concerned about the waiting time for children to receive support for mental health issues and about the proportion of adolescent girls seeking help. 5: PAC recommendation: Government should report …
Not Addressed
#4 —
Recommendation: We recommend that the Government provides additional funding and resources to bring forward the delivery of its perinatal mental health capacity-building programme. We also recommend that the Government fund primary healthcare services to invest in additional mental health catch-up services …
Gov response: In April 2021 the NHS announced 26 new hubs that will bring together maternity services, reproductive health and psychological therapy under one roof as part of the NHS Long Term Plan. Around 6,000 women will …
Accepted
#1 —
Recommendation: The Committee concludes that online harms affecting children are widespread, severe and systemic. The evidence we heard demonstrates clear links between children’s exposure to harmful online content (including material promoting self-harm, suicide, eating disorders, misogyny and sexual exploitation) and serious …
Response Pending
#8 —
Recommendation: We are aware that children coming into contact with the criminal justice system may not meet the criteria for generic child and adolescent mental health services, despite presenting with multiple needs. We recommend that the Ministry of Justice increase access …
Gov response: 23. We recognise that children who offend are some of the most vulnerable in our society and a significant proportion who enter the youth justice system do so with concerns relating to their mental health. …
Under Consideration
#72 —
Recommendation: On 25 February 2021, the Scottish Government announced an additional £4.4million to provide further mental health and wellbeing services to college students and staff as they deal with the impact of the pandemic, but this funding was not made available …
Not Addressed
#8 —
Recommendation: The Government must develop a more rounded view of what children need and what positive outcomes for children are as we recover from the pandemic. Specifically, with regard to mental health, we believe that the Department must fast-track its commitments …
Gov response: 24. The mental health and wellbeing of children and young people remains a priority for the Government, both in responding to the current pressures felt by the pandemic and in the longer term. 25. The …
Under Consideration
#35 —
Recommendation: The Work Capability Assessment (WCA) is not fit for purpose. The fact that a majority of appeals against fit for work decisions are successful is evidence that it is not achieving its aim of supporting disabled people who can and …
Gov response: Recommendation The Work Capability Assessment (WCA) is not fit for purpose. DWP should use the Green Paper as a starting point to carry out wholesale reform of the WCA. Response The Green Paper explores how …
Not Addressed
#31 —
Recommendation: The Department should commit to expanding Independent Mental Health Advocates support so that all children and young people admitted to hospital informally have the same legal right to an Independent Mental Health Advocate as those admitted under legislation without qualification. …
Gov response: The Government is considering this recommendation. Within specialised commissioning, there are a number of programmes of work to reduce restrictive practice. The national Quality Improvement Taskforce for Children and Young People’s Mental Health, Learning disability …
Not Addressed
#30 —
Recommendation: It is disappointing that the Government’s 2021 Mental Health White Paper leaves expanding the legal right to support from an advocate to all children and young people subject to future funding availability. There is a compelling case that Independent Mental …
Gov response: We accept this recommendation. As part of the reforms to the Mental Health Act, we plan to expand eligibility to Independent Mental Health Advocated services to informal patients, including children and young people, who are …
Not Addressed
#29 —
Recommendation: For those children and young people for whom inpatient admission cannot be avoided, a continued focus is needed to increase the quality of this care. As well as much improved data collection, this should include access to therapies, activities and …
Gov response: The Government is considering this recommendation. Where inpatient care is needed it should be the highest quality, close to home and for the shortest possible time. We are focussed on ensuring all patients, including people …
Not Addressed
#5 —
Recommendation: The Department of Health and Social Care—in partnership with the Department for Education and all other relevant Government departments—must take radical steps to shift the focus in mental health provision towards early intervention and prevention. This must ensure that all …
Gov response: 47. We accept this recommendation in part. 48. Although record numbers of children and young people are accessing support and the NHS exceeded the ambitions of the 5 Year Forward View for Mental Health nationally, …
Partially Accepted
#4 —
Recommendation: 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 …
Gov response: 41. The government is considering this recommendation. 42. We welcome the committee’s finding that commitments in the 2017 green paper and the NHS LTP have been taken seriously. 43. There has been good progress: the …
Under Consideration
#24 —
Recommendation: Access to specialist mental health support is essential in supporting children in care, and the Government must commit to funding specialist mental health support for every school. It must also invest targeted funding to fully level-up spend per-child on mental …
Gov response: We recognise that access to specialist mental health support is essential in supporting children in care. The government is transforming mental health services with an additional £2.3 billion per year by 2023/24. This will allow …
Partially Accepted
#7 —
Recommendation: Data sharing exercises need to be better used to understand the support vulnerable adolescents need. The poor outcomes experienced by vulnerable adolescents are often overlapping. For example, 72% of children sentenced in 2019–20 were assessed as having mental health concerns. …
Gov response: 1. PAC conclusion: Cancer waiting times are at their worst recorded level and NHS England (NHSE) will not meet its first cancer recovery target. 1. PAC recommendation: NHS England should be able to treat 85% …
Not Addressed
#3 —
Recommendation: We welcome the Government and NHS England’s planned programme of capacity- building for perinatal mental health services over the next 2–3 years. However, new parents are already experiencing the mental health impact of covid-19. Plans for long-term capacity-building must be …
Gov response: In April 2021 the NHS announced 26 new hubs that will bring together maternity services, reproductive health and psychological therapy under one roof as part of the NHS Long Term Plan. Around 6,000 women will …
Accepted
#2 —
Recommendation: Lockdown has undoubtedly worsened existing body image anxieties and inspired new insecurities for thousands of people across the country. In particular, we are alarmed by the rapidly rising rates in eating disorders and other mental health conditions. The impact of …
Gov response: 2. EHRC have responded directly to the Committee, a copy of their response is attached. How can we stop negative body image affecting our mental and physical Health?
Under Consideration
#38 —
Recommendation: For those children and young people for whom school is not the most accessible place to seek support, there must also be a community-based offer. This could be based on the network of drop-in hubs outlined in Chapter 4 of …
Gov response: Please refer to the response to Recommendation 3.
Not Addressed
#25 —
Recommendation: For those children and young people who prefer accessing help online, digital services can be an important way of reducing barriers to access so it is important that a digital offer should be available for all young people. To prevent …
Gov response: 173. We accept this recommendation in part. 174. As set out in the introduction, the department plans to launch a public discussion paper later this year to inform the development of a new longer term …
Partially Accepted
#7 —
Recommendation: Commitments in the 2017 Green Paper and the NHS Long Term Plan have been taken seriously by NHS England and led to a significant expansion of provision. We are, however, concerned that many commitments may not yet be ambitious enough …
Gov response: 55. The government is considering this recommendation. 56. Improving mental health care and support for young adults is a priority for us. We know people aged 18 to 25 can, when trying to access mental …
Under Consideration
#25 —
Recommendation: NHS England should also consider more appropriate and effective responses and services to patients facing lengthy waiting list times than the current communications. This must include access to trans/gender non-conforming inclusive or specific mental health services. The GEO, DHSC and …
Gov response: 52. DHSC are happy to provide the Committee with annual updates on the progress of the pilot clinics and the impact they are having on waiting times. The new pilots based in primary care seek …
Not Addressed
#24 —
Recommendation: We commend the work undertaken by NHS England to open more gender identity clinics and welcome the announcement of the opening of a further two pilot clinics. We are, however, concerned to learn that waiting times for these clinics continue …
Gov response: 49. NHSEI is committed to the commissioning of a new service model for adults in the future, building clinical capacity in primary care and sexual health services, to reduce waiting times. DHSC and NHSEI welcome …
Not Addressed
#23 —
Recommendation: The poor outcomes experienced by vulnerable adolescents are often overlapping. For example, we received written evidence highlighting research which shows people who have been in care are more likely to experience homelessness, long-term physical and 53 Q 39 54 C&AG’s …
Gov response: 7. PAC conclusion: Data sharing exercises need to be better used to understand the support vulnerable adolescents need. 7: PAC recommendation: The Department for Education should take the lead in coordinating and setting out within …
Not Accepted
#18 —
Recommendation: We asked the Department for Education what it considers it can do to support young girls with their mental health. It told us that it ensures the work it does with the Department of Health and Social Care is built …
Gov response: 5: PAC conclusion: We are extremely concerned about the waiting time for children to receive support for mental health issues and about the proportion of adolescent girls seeking help. 5: PAC recommendation: Government should report …
Accepted
#62 — Reduce National Referral Mechanism decision-making time and clear backlog by June 2024
Recommendation: We recommend that the Home Office significantly reduces the number of days taken to make National Referral Mechanism decisions and clears the backlog of National Referral Mechanism decisions. It should aim for the target timeframe outlined in the Modern Slavery …
Gov response: To reduce the average decision making time, we have significantly increased our workforce, including through a major recruitment exercise to further boost decision-maker numbers by around 200 staff. We have increased productivity and improved performance …
Accepted
#61 — Extensive National Referral Mechanism Conclusive Grounds decision time is unacceptable and detrimental
Recommendation: 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.
Gov response: 61. The Independent Review of the Modern Slavery Act 2015 (MSA) found in 2019 that the Section 45 defence struck the right balance between protecting victims and preventing abuse, however, the Government recognises that concerns …
Under Consideration
#37 —
Recommendation: We recommend that the Department implement a new system of early intervention to support children and young people who self-harm and are at risk of committing suicide. Educational settings, as a universal provision, can have an important role to provide …
Gov response: We accept this recommendation in part. The Government is accelerating the role out of MHSTs. We agree that education settings can have an important role in prevention and early intervention. MHSTs, where established, are a …
Not Addressed
#15 —
Recommendation: The number of missing referrals and the size of the waiting list make for a daunting situation when it comes to the needs of patients. Thinking about the recent changes to GPs’ workload to allow them to focus on booster …
Not Addressed
CQC Inspection Actions (3)
Psychiatry-UK LLP
The service must ensure patients who experience extended waits for treatment are appropriately managed for risk.
Must Do
Psychiatry-UK LLP
The service must ensure waiting lists are managed safely and effectively and that senior staff have a clear understanding of patient risks.
Must Do
Cherished Moments
The service must ensure a referral pathway for women potentially identified as experiencing mental health crises or acute anxiety is in place.
Must Do
PPO Death in Custody Recommendations (17)
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.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who are referred to the mental health team urgently are assessed within five days, in line with the local policy.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who appear acutely, psychiatrically unwell are considered for transfer to a psychiatric hospital, and these discussions are recorded in the medical record.
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.
The Head of Healthcare
The Head of Healthcare should develop a reporting tool to identify mental health referrals that are closed without action or explanation.
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 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.
The Head of Healthcare
The Head of Healthcare should ensure that: • mental health tasks are checked daily, clearly actioned and allocated to appropriate members of the team; • mental health services are prioritised and reallocated when staff leave the service; and • all …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that prison, healthcare and mental health teams share all relevant information to ensure that the prisoners identified as being at risk of suicide and self-harm are referred urgently for a mental health …
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.
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 Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that release planning processes are timely, collaborative and robust, including that appropriate referrals are made to community mental health providers for prisoners with complex needs and ongoing self-harming behaviour.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff refer prisoners to the mental health team the same day that they have concerns, using a clear and consistent template, containing sufficient information to triage the referral.
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
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 appropriate referrals occur in a timely manner and that there is a process to ensure referrals are actioned.
IOPC Learning Recommendations (8)
Recommendation - Sussex Police, June 2022
The IOPC recommends that Sussex Police review and amend their training for control room staff to ensure that it involves mental health episodes and that this reflects the full content of the College of Policing Authorised Professional Practice (APP). This …
Recommendations - Humberside Police, June 2022
The IOPC recommends that Humberside Police update their training on mental health issues by including this case as a scenario for officers to discuss and learn from whereby validation of information, de-escalation and discussion with those involved in an incident …
Recommendations - Humberside Police, June 2022
The IOPC recommends that Humberside Police review their training and guidance on mental health issues to ensure that officers are effectively trained in verbal de-escalation as the default response to any incident involving someone with mental health problems. Training and …
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 …
Recommendation - Cheshire Constabulary, December 2022
The IOPC recommends that Cheshire Constabulary should ensure that the procedures for call handlers to escalate incidents are set out clearly in force policy. This follows an IOPC review of a Serious Injury investigation, where a man took an overdose …
Recommendation – Greater Manchester Police, November 2023
The IOPC recommends that Greater Manchester Police implements essential changes to ensure the Greater Manchester Mental Health Tactical Advice Service (MHTAS) are being utilised by response officers and call handlers during mental health incidents. These changes should include: Amending the …
Recommendations - Northumbria Police, July 2024
The IOPC recommends that Northumbria Police provides guidance to front line officers and the Street Triage Team (STT) in respect of their responsibilities and actions to be taken when encountering a member of the public who has self-harmed in their …
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 …
IMB Annual Reports (21)
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, and unanswered cell bells, calling for urgent attention from government and prison management.
PRISON
Key concerns
Altcourse (2022)
HMP Altcourse remains a generally safe and humane prison, showing a reduction in self-harm and violence, and improved healthcare facilities. However, significant concerns persist regarding the containment of severely mentally unwell prisoners in unsuitable conditions and chronic staffing shortages impacting various services. The Board also highlights issues with the national food budget and a lack of external support following a 'cluster death site' designation.
PRISON
Key concerns
Channings Wood (2022)
HMP Channings Wood reported a largely settled year (Sept 2021-Aug 2022) despite a gradual return to a near-normal regime after Covid-19 restrictions. While self-harm incidents reduced by 17% and total assaults remained similar to the previous year, the use of force increased by 27%. Key concerns highlighted include the persistent challenges in mental healthcare, specifically accessing specialist placements, the ongoing issue of lost prisoner property during transfers, and the ineffectiveness of the key worker scheme in supporting sentence progression. The Board commended efforts in E&D, chaplaincy, and health and wellbeing initiatives while noting that many cells and showers need refurbishment.
PRISON
Key concerns
Brinsford (2022)
HMP/YOI Brinsford is deemed a safe prison with generally fair treatment of prisoners, showing reduced levels of self-harm and violence. Key concerns include an unfit education contract, a lack of purposeful activity, significant delays in transferring mentally ill prisoners to specialist care, and the poor condition of the estate and IT infrastructure. The key worker scheme also requires improvement to return to pre-pandemic effectiveness.
PRISON
Key concerns
Derwentside (2022)
This inaugural annual report for Derwentside IRC, based on weekly visits, finds the centre safe and well-run, with detainees treated humanely and with respect. However, its remote location and poor communications infrastructure contribute to unequal and sometimes inhumane treatment compared to male IRCs. Key concerns include delays in releasing vulnerable women due to accommodation issues, incomplete facilities, and a lack of mental health cover at weekends.
PRISON
Key concerns
Wakefield (2023)
HMP Wakefield, a high-security prison, is generally considered safe and humane, with observed improvements in healthcare provision. However, the Board noted a significant increase in prisoner-on-prisoner assaults and ongoing concerns regarding staffing experience levels, which impact prisoner safety and support quality. Delays in mental health transfers to secure hospitals remain a major issue, alongside an insufficient purposeful activity regime and challenges with prisoner property management.
PRISON
Key concerns
Yarl’s Wood IRC (2023)
Yarl's Wood IRC experienced a challenging year with a marked increase in violence and self-harm incidents, linked to higher occupancy and a greater proportion of TSFNOs. The Board raised significant concerns about the length of detention, the fragility of the centre's infrastructure, and the unsuitable environment of the CSU for detainees with mental health crises. Despite staffing improvements, issues persist with communication about immigration cases and the oversight of Rule 35 reports.
IRC
Key concerns
Chelmsford (2025)
HMP Chelmsford, a Category B local prison, reported three deaths in custody and a 4% reduction in self-harm incidents, though the total of 848 remains high. Operational capacity was 660, with 71% of the population being unsentenced, and overcrowding remains a significant concern, especially in the older Victorian wings. The prison saw a decrease in prisoner-on-staff violence but an increase in prisoner-on-prisoner violence and consistently high use of force incidents. Challenges persist with mental health provision due to a lack of specialist beds, property safeguarding, and staff conduct, while the Launchpad platform and improved dentistry services were positive developments.
PRISON
Key concerns
Belmarsh (2022)
HMP Belmarsh experienced a challenging reporting year with improvements in health and wellbeing provision and a commitment to safety, though HMIP noted safety had deteriorated. The prison addressed equality and diversity issues through dedicated leadership and improved data, but concerns remain regarding disparities in outcomes for protected characteristics. Staffing issues, particularly high ‘non-effectives’ despite target numbers, curtailed regimes and impacted key worker compliance, while lost property and prolonged mental health transfer waits persisted as significant and repeated concerns.
PRISON
Key concerns
Woodhill (2023)
HMP Woodhill, a Category B training prison, faced significant challenges during the reporting year, primarily due to persistent staff shortages that severely impacted regime consistency and access to purposeful activity. Key concerns included high levels of violence, the deteriorating state of the prison estate, and overburdened mental health services leading to long waits for transfers. The IMB called for urgent action on staff recruitment, infrastructure maintenance, and improving opportunities for prisoner progression and resettlement.
PRISON
Key concerns
Brinsford (2023)
HMP/YOI Brinsford, a resettlement prison, maintained low levels of self-harm and overall violence compared to similar establishments, with good provision of healthcare and fair treatment for prisoners. However, the report highlights significant ongoing challenges including an inadequate education contract, persistent delays in mental health transfers, and limited, unfulfilling purposeful activity. Infrastructure issues like heating problems and a long-standing leak in reception also remain key concerns.
PRISON
Key concerns
Featherstone (2023)
HMP Featherstone, a Category C training prison, faced significant challenges during the reporting year ending October 2023, primarily stemming from the dilapidated state of its infrastructure and chronic staffing shortages across key departments like healthcare and the OMU. These issues led to regime disruptions, delays in medication, and a persistent problem with property management. While there were positive developments such as improved education outcomes and a reduction in violence, the Board raised serious concerns regarding the inappropriate housing of mentally unwell prisoners in the CSU and inadequate gate security.
PRISON
Key concerns
Bristol (2022)
HMP Bristol has demonstrated positive improvements in safety, with reductions in self-harm and staff assaults, and effective Covid-19 management. However, the prison continues to face significant challenges, including an insufficient staffing budget and high non-effective rates that frequently impact regime delivery, purposeful activity, and key worker provision. Concerns persist regarding the Victorian infrastructure, particularly poor disability access and heating issues, alongside prolonged waits for specialist mental health transfers and an ongoing problem with lost prisoner property.
PRISON
Key concerns
Erlestoke (2023)
HMP Erlestoke, a Category C training prison, held 467 prisoners with an operational capacity of 468 during the reporting year ending March 2023. The prison experienced a reduction in self-harm incidents to 215 and violent incidents to 102 (65 prisoner-on-prisoner, 37 prisoner-on-staff), with no deaths in custody. Key improvements included enhanced gate security and the introduction of in-cell laptops for prisoners. However, significant challenges persist, notably chronic staff shortages across healthcare, education, and key working, persistent issues with illicit substances, and an inadequate constant watch cell. Delays in essential building works and national issues like parole restrictions for IPP prisoners continue to impede progression and resettlement efforts.
PRISON
Key concerns
Berwyn (2023)
HMP Berwyn faced staffing shortages and a more challenging prisoner cohort, impacting regimes and increasing violence in early 2023, despite overall reductions in self-harm and staff assaults. The Board noted positive staff-prisoner relationships, comprehensive resettlement services, and strong education/work provisions. However, significant concerns remain regarding healthcare (medication restrictions, mental health transfers, appointment attendance), estate maintenance, and the need for improved staff training and activity for vulnerable groups.
PRISON
Key concerns
Downview (2023)
HMP/YOI Downview experienced a challenging reporting year marked by significant operational changes and an increase in prisoners with complex mental health needs, leading to increased self-harm and use of force incidents. While staff demonstrated compassion, issues like delayed mental health transfers, inconsistent medication distribution, and an un-embedded key worker scheme persisted. The Board expressed concerns about population pressures, property loss during transfers, and a reactive approach to the new transgender policy.
PRISON
Key concerns
Belmarsh (2023)
HMP Belmarsh operates as a Category A men's prison, holding approximately 650 prisoners with an operational capacity of 814. The report highlights both positive developments, such as improved induction processes, a new employment hub, and dedicated staff supporting vulnerable prisoners, alongside significant concerns. Key issues include persistent property loss, prolonged waits for mental health transfers, a restricted regime limiting purposeful activity for many, and staffing challenges impacting key worker provision and educational opportunities. The IMB urges HMPPS and the Governor to address these long-standing issues and improve the daily life and progression pathways for prisoners.
PRISON
Key concerns
Bristol (2023)
HMP Bristol faced significant challenges in the reporting year, marked by an increase in deaths in custody (9), self-harm, and violence, alongside persistent overcrowding at over 50% capacity in single cells. Staffing shortages severely impacted regime delivery, leading to increased time in cell and reduced access to purposeful activity. The Board expressed concern that the HMIP Urgent Notification Action Plan did not adequately address systemic issues such as occupancy levels or substantive staff numbers, hindering effective prisoner care and safety improvements.
PRISON
Key concerns
Eastwood Park (2023)
HMP/YOI Eastwood Park, a closed local prison for women, faced significant challenges in staffing, self-harm, and the management of complex mental health needs during the reporting year. Despite positive recruitment efforts and a new regime increasing time out of cell, the Board highlighted concerns regarding delays in mental health transfers, a substantial rise in use of force, and the under-utilisation of new facilities. The report also commended improvements in social visits and property management, while calling for better support for remand and short-sentence prisoners and more reliable resettlement data.
PRISON
Key concerns
Cardiff IMB (2025)
Overall, HMP Cardiff has seen positive developments in safety, with significant reductions in self-harm and use of force incidents, and successful digital platform implementation. However, the prison continues to grapple with severe staffing shortages, particularly in healthcare, and the physical estate remains in poor condition, affecting prisoners with mobility issues and access to basic amenities. Concerns persist regarding delays in mental health transfers, lack of secure medication storage, and the underperformance of the key worker scheme.
PRISON
Key concerns
Chelmsford (2023)
HMP Chelmsford is a Category B local prison that faces significant challenges, particularly with overcrowding where 49% of prisoners share single cells, and an increasing use of force attributed to inexperienced staff. While positive developments include improved staff-prisoner interactions and an increase in key worker sessions, persistent issues like inadequate property safeguarding, frequent missed healthcare appointments due to officer shortages, and difficulties in transferring mentally ill prisoners require urgent attention. The IMB highlights these concerns and makes recommendations to the Minister, Prison Service, and Governor to address systemic failings.
PRISON
Key concerns
IMB Recommendations (223) — showing 50 strongest matches
Channings Wood (2020)
Why are there often significant delays, caused by NHS practices, in making arrangements for prisoners requiring secure mental health provision, despite concerted efforts by prison and healthcare staff?
HMPPS
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.
Ministry of Justice
Dartmoor (2021)
Take measures, working with other Departments, to reduce the long waiting times for psychiatric hospital placements, which reached 96 days in one case during the reporting year.
Ministry of Justice
Belmarsh (2021)
Will HMPPS improve the length of time those prisoners who are very unwell wait for mental health assessments and the transfer to more suitable accommodation (see section 6.2 Mental healthcare)?
HMPPS
Altcourse (2021)
The transfer of seriously mentally ill prisoners to appropriate healthcare facilities continues to be a problem, with one particular prisoner spending over 300 days in segregation this year. This case was escalated to a national level. In addition we are concerned about the long-term legacy of the pandemic on prisoners’ mental health. Altcourse is already seeing more seriously ill men …
Ministry of Justice
Bedford (2022)
We have also seen many prisoners at HMP Bedford with such severe mental health issues that effective treatment by the local mental health team has not been possible. These men do not belong in prison: they get no better and take up an enormous amount of officer time. Transfer to an appropriate mental health facility is hugely difficult and the …
Ministry of Justice
Thameside (2023)
We urge the Minister to look at the problem of transferring mentally ill prisoners to a secure hospital setting again, as the establishment of the Transfer Time Limit Working Group (TTLWG) has not improved the situation for mentally ill prisoners at HMP Thameside.
Other
Swinfen Hall (2023)
Can the Minister liaise with other departments to create a detailed and funded plan for sufficient spaces in secure mental health units to reduce the number of seriously mentally ill being held in prison, especially in segregation units?
Ministry of Justice
Liverpool (2023)
The Board has repeatedly raised concerns around the inhumane length of time prisoners experiencing mental health illness are kept segregated whilst waiting for transfer to an appropriate mental health establishment. A recent example is a prisoner who spent 377 days in the CSU waiting for a transfer, which the Board view as completely inhumane. What immediate action will the Minister …
Other
Huntercombe (2023)
How does the Minister plan to avoid this happening to other prisoners with mental health issues? [delay in transferring a prisoner with a significant mental health condition]
Ministry of Justice
Gartree (2023)
The Board is concerned that the length of time some prisoners have to wait to access specialist mental health services appears to be increasing. What can be done to improve the assessment and access to these services? Please can the Minister explain how the Government intends to address longstanding and yet unresolved problems with the assessment and transfer of prisoners …
Ministry of Justice
Foston Hall (2023)
The 28-day target for transfer from custody to a secure hospital was not met locally in five out of 29 cases. When will action be taken to address the gaps in hospital provision?
NHS / Healthcare Provider
Eastwood Park (2023)
Women with mental health issues and complex needs would be better treated in the health system rather than the criminal justice system. Women with complex needs continue to have delays in transferring to a secure hospital. Are there plans to address this concern?
Ministry of Justice
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 Board is …
Other
Dovegate (2023)
The number of secure mental health spaces available is not adequate for the number of seriously mentally ill prisoners. Funding for more spaces is desperately required.
Ministry of Justice
Berwyn (2023)
The Board is concerned about the waiting times for seriously mentally unwell prisoners to be transferred to secure psychiatric hospitals, due to a lack of beds.
HMPPS
Wormwood Scrubs (2024)
What further steps is the Minister considering with a view to ensuring an improvement in assessment and transfer times to hospital for those requiring specialist mental health facilities?
Other
Wealstun (2024)
As referenced in our previous report, what steps will the Minister take to ensure that prison is not used to house severely mentally ill people whilst they await a place in a suitable institution?
Ministry of Justice
Wakefield (2024)
Can the Minister explain how the Government intends to address longstanding and yet unresolved problems with the assessment and transfer of prisoners who present with serious mental health and personality disorders from HMP Wakefield to hospital (section 47, Mental Health Act 1983)?
Ministry of Justice
Thameside (2024)
The Board would like the new Minister to look at the continued lengthy delays in transferring mentally ill patients from a custodial setting to a secure hospital setting, an issue highlighted by this Board and the majority of other IMBs across the country for several years. In the Board’s view, these delays are not only inhumane for the patients involved …
Ministry of Justice
Stocken (2024)
It takes too long to transfer mentally ill prisoners to secure mental health facilities. This often means that they have to be held in the Care and Separation Unit (CSU) for their own safety for extended periods of time. What is the Minister doing in conjunction with the Department of Health to address the shortfall in secure mental health places?
Ministry of Justice
Ranby (2024)
Prisoners have been constantly located in the CSU due to their complex and challenging behaviour and mental health issues. Why is it taking so long to transfer these prisoners to an appropriate medical establishment?
Other
Northumberland (2024)
What measures can be implemented to ensure mental health support is available within a reasonable timeframe to prisoners who require it?
Ministry of Justice
New Hall (2024)
The Board wishes to highlight their concerns about the number of women with severe mental health conditions who are being sent to the prison solely as a place of safety.
HMPPS
New Hall (2024)
What will the Minister do to help accelerate the process of transferring prisoners with mental health issues to secure units?
Other
Liverpool (2024)
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. In the absence of any change will the Prison Service seek to bring additional resources to the site?
HMPPS
Featherstone (2024)
Mental illness is a serious issue within prisons. The compassionate answer appears to be to locate some of these prisoners in isolation in the CSU, where largely untrained staff attempt to deal with them in a humane way. This is not acceptable and there needs to be a way of speedily transferring these prisoners to more appropriate accommodation that can …
HMPPS
Exeter (2024)
When will the non-statutory independent role, referred to in the Minister’s response last year, improve the timely transfer of prisoners with serious mental health conditions?
Ministry of Justice
Altcourse (2024)
When will the statutory 28-day time limit for the transfer to hospital of prisoners requiring inpatient mental health treatment come into effect?
Ministry of Justice
Thameside (2025)
The Minister should take concrete steps, within a specified timeline, to address the issue of too many mental health transfers exceeding the 28-day limit.
Other
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 inpatient mental …
Other
Nottingham (2025)
As referenced in our previous report, we again raise with the Minister the issue of the wellbeing of prisoners who are severely mentally ill. The Board remains concerned at the length of time it takes for suitable places in secure mental health hospitals to become available. This means that severely unwell prisoners are having to be detained in the care …
Other
Hewell (2025)
What is being done to ensure that the 28-day limit for transfer of prisoners to a mental health hospital is enforceable?
Ministry of Justice
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 beds for …
Ministry of Justice
Doncaster (2025)
The Board remains extremely concerned about the prolonged delays transferring mentally ill patients to secure hospitals. What steps will the Minister take to urgently review and address this issue?
Other
Chelmsford (2025)
Many prisoners entering prison have mental health problems - some of them severe - and they urgently need care in a specialist unit. However, there are not enough secure places to meet the needs of the prison population, creating a ‘log-jam’ in local healthcare units, where facilities are taken up by prisoners who should be elsewhere. This obviously impacts on …
Ministry of Justice
Altcourse (2025)
When will the statutory 28-day time limit for the transfer to hospital of prisoners requiring in-patient mental health treatment come into effect?
Ministry of Justice
Brinsford (2025)
The Board is of the view there remains a problem in relocating prisoners with mental health problems to more suitable mental health facilities. All transfers to a secure mental health facility from HMP Brinsford continued to exceed the 28-day stipulated time frame. Will the Minister take steps to ensure that sufficient secure hospital places are available?
Ministry of Justice
Derwentside (2024)
To take steps to reduce waiting times for R35(3) assessments.
NHS / Healthcare Provider
Wymott (2020)
Too many prisoners with severe mental health problems get stuck in prisons, often in segregation units, because there are not enough place in secure psychiatric units (see paragraph 5.2.2). There is a desperate need for more of these places.
NHS / Healthcare Provider
Woodhill (2020)
To ask the minister to work with ministerial colleagues in the Department of Health to ensure that delays in transferring prisoners to secure mental health facilities are reduced.
Ministry of Justice
Whatton (2020)
The Board has had to report that a prisoner was held for a long time in secure conditions with deteriorating mental health while waiting for secure hospital accommodation (see paragraph 5.2.3). Despite regular assurances from the National Health Service (NHS) commissioners that this area of concern was being addressed nationally, there have been no improvements to the speedy resolution of …
Ministry of Justice
Wetherby (2020)
For the fifth consecutive year, the Board asks in its annual report what, if anything, is being done to increase the number of secure mental health hospital beds available to meet the needs of the complex YP who are in urgent need of such support, and for whom prison is clearly not the correct place? What is being done to …
Ministry of Justice
Wakefield (2020)
The Ministry of Justice should work with the Department of Health to ensure that – following repeated recommendations and concerns expressed by this Inspectorate and others, including the Public Accounts Committee – effective action is taken to complete transfers under the Mental Health Act within the target time of 14 days. (S37)
Ministry of Justice
Thameside (2020)
The wait for a secure outside hospital bed for severely mentally ill prisoners held in HMP Thameside continues to be a serious inhumanity which requires greater government priority.
Ministry of Justice
Stoke Heath (2020)
The Board has registered its concern about unacceptably long waiting times for assessment for transfer to prisons with inpatient beds. The Board supports the prison’s proposal to create a crisis unit within the prison’s decommissioned inpatient unit, to enable care to be provided appropriately on site while waiting for assessment and transfer under the Mental Health Act. The Board hopes …
Governor / Director
Nottingham (2020)
Yet again, we remain concerned about the difficulties encountered in transferring prisoners with severe mental health issues to an environment where they can be effectively treated. Once again, the Board would like to see greater availability of more suitable locations for these prisoners.
Other
New Hall (2020)
The Prison Service needs to address the issue of residents with severe mental health problems waiting long periods of time in prison before transferring to more appropriate accommodation elsewhere.
Ministry of Justice
Liverpool (2020)
The delays in transfer of seriously mentally ill prisoners to appropriate secure facilities is of great concern to the Board. Could the Minister assure the Board that this is given high priority for resolution?
Other
Lewes (2020)
The Board, once again, is concerned at the number of prisoners seen over the reporting year who are seriously mentally unwell and kept in conditions, be it accommodation standards or the regime, which are entirely unsuitable for their care or rehabilitation. The same applies to many of the prisoners with learning or other disabilities. Will the minister undertake a comprehensive …
Ministry of Justice
Article 2 Learning Points (6)
— LP J
When a prisoner is identified as requiring assessment by a psychiatrist, he should be escorted to that appointment where necessary. If, for whatever reason, such an appointment is missed, medical staff should ascertain the reasons for the missed appointment on the same day.
HMPPS and PPG
— LP C
In the period between an assessment by the Mental Health Outreach Team and a decision about whether to accept a prisoner on to the caseload, a pending case should be subject to a provisional zoning priority. A system of monitoring and auditing compliance with the zoning protocol should be in …
PPG
— LP A
The Mental Health Outreach Team should review any assessment undertaken by a team member within a maximum period of one week.
PPG
— LP 1
We recommend that assessments for transfer to psychiatric care are made much more quickly than in Ana’s case. We endorse the recommendation in Lord Bradley’s 2009 report on people with mental health problems or learning disabilities in the criminal justice system that the Department of Health should develop a new …
NHS England
Partially Accepted
— LP 1
The psychiatric in-reach service at HMP High Down should consider the delay in completing the actions arising from the assessment on GN in October 2015 and describe the current arrangements for avoiding such delays.
Central and North-West London NHS …
— LP Healthcare 2
A triaging process should be in place for individuals requiring referral to Primary Care Mental Health Services to ensure that those with significant needs are prioritized for early review, intervention and referral to secondary care mental health services when indicated.
Healthcare Provider
Detention Investigations (2)
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
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 39
as a minimum, every centre should engage the services of an in-reach psychiatric nurse and that the service be actively promoted on induction and afterwards.
Immigration Detention
PHSO Casework Decisions (74)
P-001120 — Bury CCG
Mrs E complains the CCG granted her thirty-six sessions of therapy but refused to provide them and denied her access to mental health services.
NHS in England
Sep 2021
P-001546 — Derbyshire Healthcare NHS Foundation Trust
Mrs E complains about the Trust’s decision not to accept a self-referral for her son for his eating disorder.
NHS in England
Sep 2022
P-001896 — Manchester University NHS Foundation Trust
Miss B and Mrs B complain the Trust's Child and Adolescent Mental Health Service (CAMHS) delayed making a diagnosis.
NHS in England
Upheld
Mar 2023
P-002305 — Cheshire and Wirral Partnership NHS Foundation Trust
Mr O complains the Trust did not give him step four mental health therapy in a timely manner between 2019 and June 2023. He complains it did not act on letters from his GP and consultants because he does not fall into the Trust's priority category. He also complains it …
NHS in England
Nov 2023
P-002745 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs I complains on behalf of her daughter after she was referred to the Trust’s Children and Young People’s Services for mental health purposes in November 2020. Mrs I says no action was taken until an initial assessment in July 2021. She also complains the support promised was not given, …
NHS in England
Upheld
May 2024
P-003020 — University Hospital Southampton NHS Foundation Trust
Mrs R complains the Trust rejected two adult mental health referrals from her daughter’s GP on 21 April and 6 July 2020.
NHS in England
Partly Upheld
Oct 2024
P-003219 — South West Yorkshire Partnership NHS Foundation Trust
Ms I complains the Trust wrongly rejected referrals for secondary care mental health services.
NHS in England
Dec 2024
P-003321 — Kent and Medway NHS and Social Care Partnership …
Mx E complains they did not receive an appropriate mental health assessment by the Trust's psychiatric nurse in August 2023.
NHS in England
Feb 2025
P-003713 — Somerset NHS Foundation Trust
Mr I complains about the Trust's decision to reject a referral for an adult ADHD assessment. He also complains about poor record keeping meaning the Trust was not able to explain why it did not accept his referral.
NHS in England
Upheld
Jul 2025
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.
NHS in England
Upheld
Sep 2025
P-004213 — Mersey Care NHS Foundation Trust
Mr C complains about delays in receiving talking therapy from Mersey Care NHS Foundation Trust and that the therapy wasn't provided on an ongoing basis.
NHS in England
Nov 2025
P-004305 — South West Yorkshire Partnership NHS Foundation Trust
Mrs J complains SWYPT did not offer her mental health support in December 2023. She complains SWYPT inappropriately rejected her referral.
NHS in England
Nov 2025
P-004408 — Tees, Esk and Wear Valleys NHS Foundation Trust
Miss L complains the Trust failed to accurately assess her son for ADHD between June 2021 and March 2024. She also complains about the way his ADHD medication was managed.
NHS in England
Dec 2025
P-004770 — Pennine Care NHS Foundation Trust
Mr J complains about the care he received from the Trust in 2023. He says the Trust wrongly declined his CMHT referral, did not properly communicate the decision and mishandled his complaint.
NHS in England
Feb 2026
P-004721 — A practice in the Stratford-on-Avon area
Mrs A complains that, over a number of years, GPs at the Practice failed to consider and refer her for diagnosis of ADHD.
NHS in England
Jan 2026
P-004699 — A practice in the Wealden area
Mrs K complains in November 2024 a Practice in East Sussex did not prescribe medication to help her mental health and sleep. She also says it delayed a referral to metal health services.
NHS in England
Jan 2026
P-004575 — Dorset Healthcare University NHS Foundation Trust
Mr I complains the Trust failed to return his voicemail, provided no ADHD care or treatment after his private diagnosis and did not inform him his dialectical behaviour therapy (DBT) referral had gone to the wrong place or he was being transferred to another service.
NHS in England
Jan 2026
P-001917 — South West Yorkshire Partnership NHS Foundation Trust
Mr A complains the Trust did not refer him to secondary psychological treatment until 2019 although he asked for it in 2014.
NHS in England
Not Upheld
Mar 2023
P-003905 — Cheshire and Wirral Partnership NHS Foundation Trust
Mr O complains the Trust has not given him the mental health therapy he needs since 2019. He says the Trust has not prioritised his therapy despite GP and consultant letters.
NHS in England
Jul 2023
P-002327 — West London NHS Trust
Miss L complains about how the Trust handled the concerns she had about her having autism spectrum disorder and about the waiting time for treatment.
NHS in England
Nov 2023
P-002469 — Tees, Esk and Wear Valleys NHS Foundation Trust
Mrs A complains about the mental health care and treatment given to her son in the last 20 years.
NHS in England
Feb 2024
P-002505 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation 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.
NHS in England
Mar 2024
P-002576 — A practice in the Rutland area
Miss A complains the Practice failed to refer her to Adult Autism Services for 13 months and it did not include the correct information on the referral. She also says the Practice did not review her medication.
NHS in England
Apr 2024
P-002532 — Sussex Partnership NHS Foundation Trust
Mr R complains the Trust failed to recognise his deteriorating mental health. He says the Trust did not prescribe him testosterone, delayed his referral for CBT treatment and his autism screening referral, it did not make his care providers or school know about his risk of suicidal ideation, it did …
NHS in England
Apr 2024
P-002767 — Hampshire and Isle of Wight Integrated Care Board
Mrs A complains the Hampshire and Isle of Wight Integrated Care Board did not ensure her son had the mental health care he needed, as it had agreed to following a tribunal. She also complains it delayed psychiatric funding for both her sons.
NHS in England
Jul 2024
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-003053 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mrs T complains about two NHS Trusts' treatment decisions and care when Mr T was in a mental health crisis and would not eat or drink.
NHS in England
Oct 2024
P-003046 — South East London Integrated Care Board
Miss R complains the ICB failed to diagnose her with attention deficit hyperactivity disorder (ADHD) in 2006.
NHS in England
Oct 2024
P-003236 — A practice in the City of Southampton area
Mr R complains the Surgery withdrew mental health support for him in February 2023 and failed to communicate this decision with him or provide alternative support.
NHS in England
Dec 2024
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.
NHS in England
Feb 2025
P-003463 — A practice in the Bristol area
Mr G complains Practice mental health specialists failed to contact or support him.
NHS in England
Mar 2025
P-003616 — A practice in the Canterbury area
Miss G complains the Practice referred her to a community mental health team without her consent and prescribed inappropriate medication for her condition.
NHS in England
Jun 2025
P-004228 — South West Yorkshire Partnership NHS Foundation Trust
Mr H complains the Trust took too long to arrange for his wife to go to hospital after she fell in a mental health inpatient unit.
NHS in England
Oct 2025
P-004265 — Cornwall Partnership NHS Foundation Trust
Dr J complains about the care provided to her son during a mental health assessment. She says the assessment was inappropriate and labelled him as having a mild learning disability.
NHS in England
Nov 2025
P-004369 — Norfolk and Suffolk NHS Foundation Trust
Mrs I complains the Trust refused to reassess her son for ADHD despite his school’s request, did not refer him for a second opinion, did not properly document clinical discussions and declined to refer him to another trust for specialist autism and oppositional defiant disorder support.
NHS in England
Partly Upheld
Nov 2025
P-004383 — An independent provider in the Colchester area
Mrs O complains about the care and treatment her son received from the community paediatrics service for ADHD.
NHS in England
Dec 2025
P-004386 — Devon Partnership NHS Trust
Miss E complains about her recovery coordinator’s involvement in her care while she was in hospital and in the months afterwards. She also complains that the Trust took too long to respond to her complaints.
NHS in England
Dec 2025
P-004388 — Gloucestershire Health and Care NHS Foundation Trust
Mr C complains the Trust's Child and Adolescent Mental Health Service (CAMHS) delayed prescribing him medication which was recommended in July 2024. He also complains about its decision to decline his referral to its eating disorder services in August 2024.
NHS in England
Dec 2025
P-004418 — Hampshire and Isle of Wight Healthcare NHS Foundation …
Miss A complains about the standard of care her daughter; Miss B, received from the Trust's mental health team from February to May 2023.
NHS in England
Upheld
Dec 2025
P-004442 — Black Country Healthcare NHS Foundation Trust
Mr X complains about the care and treatment provided by the hospital Trust in 2024. Mr X complains he was not given a bed in a psychiatric hospital as planned and staff were rude and refused to speak to him.
NHS in England
Dec 2025
P-004476 — West London NHS Trust
Miss X complains about the care and treatment she received from the Trust in October 2022.
NHS in England
Upheld
Dec 2025
P-001240 — Norfolk and Suffolk NHS Foundation Trust
Mrs A complained about the mental health service provision by the Trust to her son, saying it had not done what is should have to address his refusal to engage with services.
NHS in England
Dec 2021
P-002468 — Midlands Partnership NHS Foundation Trust
Mr W complains about the care he had after he phoned the Trust’s mental health crisis line in January 2023.
NHS in England
Feb 2024
P-002477 — Kent and Medway Integrated Care Board
Mr O complains the Integrated Care Board has failed to provide adapted CBT as recommended by his psychiatrist.
NHS in England
Feb 2024
P-002490 — A practice in the Barnet area
Miss I complains the Practice did not refer her quickly for an ADHD or autism assessment and did not allow her to select a service provider with the NHS Right to Choose pathway for the assessments.
NHS in England
Mar 2024
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.
NHS in England
Mar 2024
P-002544 — Isle of Wight NHS Trust
Mrs R complains the Trust's memory service delayed seeing her husband after he was urgently referred by his GP.
NHS in England
Apr 2024
P-002679 — Surrey and Borders Partnership NHS Foundation Trust
Mr N complains the Trust failed to diagnose his wife’s long standing mental health disorder when it admitted her in February 2023.
NHS in England
Jun 2024
P-002774 — North West Ambulance Service NHS Trust
Mrs S complains the Trust’s 111 service did not correctly handle a call it received from her son in January 2021 and this contributed to his death.
NHS in England
Jul 2024
P-002779 — Cumbria, Northumberland, Tyne And Wear Area Team
Mrs K complains about the long waiting time to be seen in a gender identity clinic.
NHS in England
Jul 2024
LGO / SPSO Decisions (212)
NIPSO-18438 — South Eastern Health and Social Care Trust
A woman who complained about the time it took for a hospital consultant psychiatrist to treat her mother has had her complaint upheld by the Public Services Ombudsman.
NIPSO (NI Public Service…
Health & Social Care
Mar 2020
PSOW-202503182 — Powys Teaching Health Board
Ms A complained that Powys Teaching Health Board assessed and then discharged her son from the neurodevelopment pathway. She also said that the Health Board did not respond to all of the concerns raised in her initial complaint. Whilst the Ombudsman noted that Ms A’s son had initially been discharged …
PSOW (Public Services Om…
Health
Sep 2025
21-018-569b — NHS Norfolk and Waveney ICB (21 018 569b)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or …
LGO (Local Government & …
Health
Upheld
Oct 2022
23-017-445a — South West London & St. Georges Mental Health …
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.
LGO (Local Government & …
Health
May 2024
202106214 — Glasgow City Health and Social Care Partnership
C, an adult with autism, was receiving treatment from the Partnership as a new patient after moving into the area and was unhappy with their psychiatrist. C felt that the Partnership did not have appropriate staff who specialised in treating adults with autism. C complained that the psychiatrist questioned the …
SPSO (Scottish Public Se…
Health and Social Care
Upheld
Sep 2023
PSOW-202103119 — Swansea Bay University Health Board
Mr B complained on behalf of Mr A about the Health Board’s failure to keep the information about Mr A’s address up to date resulting in him missing key appointments. A complaint had been made about a data breach concerning Mr A’s personal information which the Health Board was investigating …
PSOW (Public Services Om…
Health
Oct 2021
PSOW-202202446 — Betsi Cadwaladr University Health Board
Mrs X complained about aspects of her care under Adult Mental Health Services. Whilst Mrs X had received a formal complaint response from the Health Board, she indicated to the Ombudsman’s office that it did not fully address her complaint regarding the service she received from her Community Psychiatric Nurse. …
PSOW (Public Services Om…
Health
Aug 2022
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 …
PSOW (Public Services Om…
Health
Upheld
May 2024
19-018-519a — Sussex Partnership NHS Foundation Trust (19 018 519a)
Summary: The complainant, Ms B, said she learnt in 2020 the Council, the Trust and two Clinical Commissioning Groups did not properly consider her daughter’s, Miss G’s, entitlement to free aftercare following her detainment under the Mental Health Act 1983. She also complained about the care and support provided to …
LGO (Local Government & …
Health
Upheld
Mar 2022
21-007-637a — NHS East Sussex Clinical Commissioning Group (21 007 …
Summary: Mrs B complained about the care provided to her late husband, Mr B, by a care provider commissioned by the Council and the CCG to meet his aftercare needs. We found the care provider failed to properly record Mrs B’s late husband’s needs around eating and food consistency. As …
LGO (Local Government & …
Health
Upheld
Mar 2022
20-004-266a — Central and North West London NHS Foundation Trust …
Summary: We found fault with the care and treatment provided to Mr B over the period June 2018 to May 2019. These faults caused avoidable distress and frustration to Ms B. We recommended an apology, service improvements and financial recompense to address this injustice
LGO (Local Government & …
Health
Upheld
Mar 2022
21-003-925a — Cambridgeshire and Peterborough NHS Foundation Trust (21 003 …
Summary: We found fault with the Trust; it did not allocate Mr Q a new care coordinator, did not conduct a S117 review or formally discharge him, and it was not clear with Mr P during the complaints process. We also found the Council did not understand the care package …
LGO (Local Government & …
Health
Upheld
May 2022
21-002-477a — Nottinghamshire Healthcare NHS Foundation Trust (21 002 477a)
Summary: Mr B complained about the care provided to his father at four health and social care locations from October 2018 to April 2019. We found there was fault by a Trust for not doing enough to involve key stakeholders when it assessed Mr B’s father, and for failing to …
LGO (Local Government & …
Health
Upheld
Jun 2022
21-006-452a — Humber Teaching NHS Foundation Trust (21 006 452a)
Summary: The Council was at fault for a delay in deciding whether to reassess Y’s special educational needs, a delay in carrying out that reassessment and a failure to either provide full-time alternative education whilst Y was out of school or record the reasons part-time provision was a suitable education …
LGO (Local Government & …
Health
Upheld
Jul 2022
20-012-449a — East London NHS Foundation Trust (20 012 449a)
Summary: We do not consider Bedford Borough Council and East London NHS Foundation appropriately supported Mr Q’s sensory, mental health, social care, and communication needs. This most likely impacted his wellbeing. The Council also did not offer his mother, Mrs P, a carer’s assessment after June 2020, which caused her …
LGO (Local Government & …
Health
Upheld
Sep 2022
22-009-742b — NHS Northamptonshire ICB (22 009 742b)
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Health
Upheld
Apr 2024
22-009-742a — NHS Northamptonshire ICB (22 009 742a)
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Health
Upheld
Apr 2024
22-009-742d — Northamptonshire Health Care NHS Foundation Trust (22 009 …
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Health
Upheld
Apr 2024
22-009-742c — Northamptonshire Health Care NHS Foundation Trust (22 009 …
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Health
Upheld
Apr 2024
23-017-881b — NHS Gloucestershire ICB (23 017 881b)
Summary: Mrs A complains about the section 117 aftercare being provided to her sister, Ms B. We should not investigate this complaint because the Trust has already admitted fault and taken steps to remedy the injustice to Ms B. Further investigation would not achieve anything more.
LGO (Local Government & …
Health
May 2024
23-017-881a — Gloucester Health & Care NHS Foundation Trust (23 …
Summary: Mrs A complains about the section 117 aftercare being provided to her sister, Ms B. We should not investigate this complaint because the Trust has already admitted fault and taken steps to remedy the injustice to Ms B. Further investigation would not achieve anything more.
LGO (Local Government & …
Health
May 2024
23-005-445a — Norfolk & Suffolk NHS Foundation Trust (23 005 …
Summary: We investigated a complaint about the care and support provided to Mr O’s late brother Mr K by a Council and NHS Trust. We found fault by both organisations. The Council took too long to allocate Mr K a social worker and too long to respond to Mr O’s …
LGO (Local Government & …
Health
Upheld
Jul 2024
23-007-089b — NHS Humber and North Yorkshire Integrated Care Board …
Summary: We will not investigate Mr P’s complaint. We are unlikely to find fault with the way North East Lincolnshire Council and NHS Humber and North Yorkshire Integrated Care Board decided how much to pay towards his direct payment.
LGO (Local Government & …
Health
Jul 2024
23-007-089a — NHS Humber and North Yorkshire Integrated Care Board …
Summary: We will not investigate Mr P’s complaint. We are unlikely to find fault with the way North East Lincolnshire Council and NHS Humber and North Yorkshire Integrated Care Board decided how much to pay towards his direct payment.
LGO (Local Government & …
Health
Jul 2024
23-005-368b — NHS Cheshire and Merseyside ICB (23 005 368b)
Summary: Mrs K complained the Council and the Integrated Care Board (ICB) stopped paying for Miss D’s housing costs when the property changed to supported housing. She said this resulted in
LGO (Local Government & …
Health
Upheld
Sep 2024
23-005-368a — NHS Cheshire and Merseyside ICB (23 005 368a)
Summary: Mrs K complained the Council and the Integrated Care Board (ICB) stopped paying for Miss D’s housing costs when the property changed to supported housing. She said this resulted in
LGO (Local Government & …
Health
Upheld
Sep 2024
24-004-207b — East London NHS Foundation Trust (24 004 207b)
Summary: Ms A complains about the care provided to her sister at Bridgeside Lodge Care Home (the Care Home). We will not investigate this complaint because the Care Home is willing to reinvestigate. There is nothing more we can achieve by looking at the complaint before the Care Home completes …
LGO (Local Government & …
Health
Sep 2024
24-004-207a — NHS North Central London ICB (24 004 207a)
Summary: Ms A complains about the care provided to her sister at Bridgeside Lodge Care Home (the Care Home). We will not investigate this complaint because the Care Home is willing to reinvestigate. There is nothing more we can achieve by looking at the complaint before the Care Home completes …
LGO (Local Government & …
Health
Sep 2024
24-001-411a — NHS Humber and North Yorkshire Integrated Care Board …
Summary: We do not uphold G’s complaint about City of York Council and NHS Humber and North Yorkshire Integrated Care Board’s decision to reduce their section 117 aftercare in December 2023. However, the Council and ICB should have reviewed G’s aftercare need before they left hospital in March 2024. That …
LGO (Local Government & …
Health
Upheld
Jun 2025
23-012-397d — North London NHS Foundation Trust (23 012 397d)
Summary: We found London Borough of Enfield, North London NHS Foundation Trust and North Central London Integrated Care Board failed to properly assess and review Miss X’s aftercare needs following her discharge from hospital in 2018. This caused Miss X significant uncertainty and distress. These organisations will apologise to Miss …
LGO (Local Government & …
Health
Upheld
Jul 2025
23-012-397c — North London NHS Foundation Trust (23 012 397c)
Summary: We found London Borough of Enfield, North London NHS Foundation Trust and North Central London Integrated Care Board failed to properly assess and review Miss X’s aftercare needs following her discharge from hospital in 2018. This caused Miss X significant uncertainty and distress. These organisations will apologise to Miss …
LGO (Local Government & …
Health
Upheld
Jul 2025
23-012-397b — NHS North Central London ICB (23 012 397b)
Summary: We found London Borough of Enfield, North London NHS Foundation Trust and North Central London Integrated Care Board failed to properly assess and review Miss X’s aftercare needs following her discharge from hospital in 2018. This caused Miss X significant uncertainty and distress. These organisations will apologise to Miss …
LGO (Local Government & …
Health
Upheld
Jul 2025
23-012-397a — NHS North Central London ICB (23 012 397a)
Summary: We found London Borough of Enfield, North London NHS Foundation Trust and North Central London Integrated Care Board failed to properly assess and review Miss X’s aftercare needs following her discharge from hospital in 2018. This caused Miss X significant uncertainty and distress. These organisations will apologise to Miss …
LGO (Local Government & …
Health
Upheld
Jul 2025
24-021-213a — NHS Buckinghamshire, Oxfordshire and Berkshire West ICB - …
Summary: Dr C complained about a Mental Health Act assessment. We consider Dr C’s complaint is late. In any event, we are unlikely to find fault with the issues complained about.
LGO (Local Government & …
Health
Jul 2025
24-020-393a — NHS Frimley ICB (24 020 393a)
Summary: Miss X complained about the way professionals assessed her under the Mental Health Act 1983 and their recommendation that she should be detained. We will not investigate Miss X’s complaint. This is because it is unlikely an investigation would be able to find evidence of fault.
LGO (Local Government & …
Health
Jul 2025
24-016-385a — NHS Kent & Medway ICB (24 016 385a)
Summary: Ms F complained that Kent County Council and NHS Kent and Medway Integrated Care Board’s flawed Section 117 aftercare policy meant she would have to unfairly contribute toward accommodation costs. We consider the Council and ICB’s Multi-Agency Policy is flawed, which has caused Ms F confusion, uncertainty and distress. …
LGO (Local Government & …
Health
Upheld
Aug 2025
24-022-100a — NHS Suffolk & North East Essex ICB (24 …
Summary: Mrs X complained the Council did not provide her brother, Mr Y, with satisfactory support for 28 days. We will not investigate this complaint. Although it is clear the events caused Mr Y some distress, the Council has accepted some fault and taken action to resolve the issues brought …
LGO (Local Government & …
Health
Aug 2025
25-005-190a — NHS Somerset Integrated Care Board (25 005 190a)
Summary: Ms X complained about Somerset Council and Somerset Integrated Care Board’s care and support to her son, Mr Y, under Section 117 of the Mental Health Act in 2022 and 2023. We have decided we should not accept Ms X acting as Mr Y’s representative.
LGO (Local Government & …
Health
Nov 2025
23-012-177a — Avon & Wiltshire Mental Health Partnership NHS Trust …
Summary: Avon & Wiltshire Mental Health Partnership NHS Trust did not appropriately record Miss X’s reasonable adjustments during a meeting. That did not cause her an injustice but the Trust should still take action to stop similar fault happening to others. Also, an Approved Mental Health Professional for North Somerset …
LGO (Local Government & …
Health
Upheld
Oct 2024
24-003-060b — NHS Buckinghamshire, Oxfordshire and Berkshire West ICB - …
Summary: Mrs X complained about top-up fees for accommodation without being offered of a suitable and affordable alternative. We did not find fault with the accommodation the Council offered. We found fault with some communication and recommended the Council and the NHS Trust apologise for any distress this caused to …
LGO (Local Government & …
Health
Not Upheld
Dec 2024
24-003-060a — Oxford Health NHS (24 003 060a)
Summary: Mrs X complained about top-up fees for accommodation without being offered of a suitable and affordable alternative. We did not find fault with the accommodation the Council offered. We found fault with some communication and recommended the Council and the NHS Trust apologise for any distress this caused to …
LGO (Local Government & …
Health
Upheld
Dec 2024
24-021-800a — NHS Leicester, Leicestershire and Rutland Integrated Care Board …
LGO (Local Government & …
Health
Not Upheld
25-005-077b — NHS North West London ICB (25 005 077b)
LGO (Local Government & …
Health
Not Upheld
25-005-077a — West London NHS Trust Headquarters (25 005 077a)
LGO (Local Government & …
Health
Upheld
24-020-798b — Availl Huntingdon (24 020 798b)
LGO (Local Government & …
Health
Not Upheld
24-020-798a — NHS Cambridgeshire & Peterborough ICB (24 020 798a)
LGO (Local Government & …
Health
Not Upheld
25-011-075a — NHS Humber and North Yorkshire Integrated Care Board …
LGO (Local Government & …
Health
PSOW-202201578 — Cardiff and Vale University Health Board
Mr X complained that he was detained in Hospital, when he should not have been, for 5 weeks. Mr X also complained that, as a result of being detained incorrectly, he has encountered health issues. The Ombudsman was concerned that Mr X had yet to receive a formal response to …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202203027 — Swansea Bay University Health Board
Ms A complained that Swansea Bay University Health Board failed to respond to her concerns raised in 2021, about the progression of her care and treatment, communication with her and her involvement in the planning and decision-making process. The Ombudsman considered that aspects of Ms A’s complaint remained outstanding. She …
PSOW (Public Services Om…
Health
Sep 2022
PSOW-202106332 — Cwm Taf Morgannwg University Health Board
Mr D complained that Cwm Taf Morgannwg University Health Board (“the First Health Board”) failed to provide care and support to his late daughter, Miss E, when her mental health deteriorated during 2020. Mr D said the First Health Board failed to transfer her section 117 aftercare (free help and …
PSOW (Public Services Om…
Health
Upheld
Jan 2023