Unclear psychiatric referrals
Ambiguous or poorly defined referral processes for psychiatric units, leading to delays or inappropriate patient placement.
35 items
7 sources
Source spread
Where this theme appears
Unclear psychiatric referrals has been flagged across 7 independent accountability sources:
22 PFD reports
1 committee rec
2 PPO recs
2 IMB recs
1 Article 2 learning point
6 PHSO decisions
1 LGO/SPSO decision
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 (22)
Sarah Shepherd
Concerns: The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines due to unclear training and misleading aide-memoires, risking inappropriate patient care.
Overdue
Kirabo Kiwanuka
Concerns: Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.
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
Stuart Long
Concerns: Confusion regarding appropriate responses to anti-social behavior in intoxicated, mentally unwell individuals led to a failure to take Mr. Long to a place of safety, exposing him to significant danger.
Overdue
Andrew Frost
Concerns: A crucial misunderstanding existed between the GP and the crisis team regarding the team's capacity for emergency assessment, highlighting a need for specific training on crisis team service limitations.
Response (Killick Street Health Centre): The health centre met with the Crisis Team to discuss service provision and will hold meetings every 6 months to discuss the Crisis Team service and individual clients.
Responded
Richard Jones
Concerns: Inadequate recording of patient information, perceived risk levels, and assessment urgency was observed. There was also contradictory evidence and confusion regarding responsibilities and communication between mental health services.
Response (Ministry of Defence): The Ministry of Defence is adding guidance to JSP 950 Leaflet 2-7-2 regarding medical information handling, entitlement of service personnel to NHS services, liaison between DCMHs and local NHS services, …
Response (Avon and Wiltshire NHS Trust): The Trust will conduct a root cause analysis investigation jointly with Salisbury District Hospital and the Armed Forces to explore the issues raised in the report and review relevant policies …
Response (Department of Health2): The Department of Health is in discussion with the Ministry of Defence and NHS England to address concerns about mental health care for armed forces members, and is working to …
Response (Salisbury NHS Trust): Following the case review, the SFT Emergency Department implemented a new mental health risk assessment tool, improved information sharing with mental health services, and implemented a system to record and …
Response (UK Health Security Agency): Public Health England states its role is to help the public health system achieve 'public health parity' for mental health. They are aware the Department of Health is in discussion …
Responded
Christopher Higgins
Concerns: Inconsistent mental health observation practices, inadequate patient escort protocols during police transfers, unassessed safety risks in the environment, and poor inter-agency agreements for A&E assessment of detained patients led to unsafe conditions.
Response (James Paget University Hospitals NHS Trust): The Trusts have worked together to develop a process for ensuring that patients under the care of mental health services who require acute care have a clear pathway which includes …
Response (Norfolk and Suffolk NHS Trust): The Trust updated its Observation and Engagement of Service Users policy and communicated changes to staff. Additional height bars were added to a railing on the disabled access ramp and …
Response (Queen Elizabeth Hospital NHS Trust): The hospital has worked with Norfolk and Suffolk NHS Foundation Trust to develop a referral pathway to ensure inpatients from the local mental health facility can access care and treatment …
Responded
Clarice Hilton
Concerns: Psychiatric units lack a policy or guidance for staff on how to manage patients who refuse physical health observations, leading to critical delays in medical assessment.
Response (5 Borough Partnership NHS Trust): The Trust has reviewed and revised its Modified Early Warning Scores (MEWS) operational guidance to include instruction for staff on assessing those who refuse to engage with MEWS monitoring, including …
Responded
Dean Saunders
Concerns: Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.
Response (NHS England): NHS England states that Care UK circulated a document with contact details of medical staff who can sign Mental Health Assessment documents, and a new provider will deliver healthcare at …
Response (Essex Partnership NHS Trust): Essex Partnership NHS Trust has submitted its admissions protocol for regional review by the Secure Services Catchment Group for East of England and will inform the coroner of the outcome; …
Response (Care UK): Care UK developed a new Mental Health Pathway, formally signed off on 28 March 2017, and is rolling it out across all Care UK sites via mental health workshops to …
Overdue
Daisy French
Concerns: The report identifies concerns regarding communication and information sharing between CAMHS and Adult Services, the transition of care, and out-of-hours provision for 16 to 18 year olds, and the appropriateness of placing under 18s in adult crisis houses or supported living without staff.
Response (Sheffield Health and Social Care): Sheffield Health and Social Care NHS Foundation Trust and Sheffield Children's NHS Foundation Trust are working jointly, updating team protocols to ensure young people returning home to independent or supported …
Response (Department of Health): The Department of Health acknowledges the concerns and explains the national position on transitioning between children's and adult mental health services, referencing NICE guidelines and NHS England's financial incentives. They …
Responded
Colette Dunn
Concerns: A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge protocols between agencies and inadequate facilities for mental health crisis intervention were identified.
Overdue
Khalid Yousef
Concerns: Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This is compounded by misunderstanding of L&D's role and a reduction in qualified Forensic Medical Examiners.
Response (NHS England): NHS England clarifies that Liaison and Diversion services do not directly commission psychiatrists but are for referral. They are developing a new service specification to clarify expectations for access to …
Response (NHS England): NHS England clarifies that while the Liaison & Diversion service model does not directly commission psychiatrists, access can be arranged via urgent referral. They state that a Career and Competency …
Response (West Midlands Police): West Midlands Police will create a formal escalation process for custody staff disputing Liaison and Diversion decisions, review mental health training for custody officers, and provide clear advice to frontline …
Response (West Midlands Police): West Midlands Police will create a formal escalation process for custody staff regarding Liaison & Diversion decisions, review mental health training for custody officers/staff, and provide clear advice on the …
Response (response form Birmingham and Solihul Mental Health Trust): Birmingham and Solihull Mental Health Trust plans to discuss liaison clarity with West Midlands Police, develop internal communications about the L&D team's role, and review/update the L&D induction programme and …
Response (Birmingham and Solihull Mental Health): Birmingham and Solihull Mental Health Trust plans to discuss liaison clarity with West Midlands Police, develop internal communications about the L&D team's role, and review/update the L&D induction programme and …
Response (NHS England): NHS England clarifies that the Police Custody Healthcare Service (PCHS) policy and commissioning responsibilities lie with the Home Office and Police and Crime Commissioners (PCCs) respectively, not NHS England. They …
Response (Home Office): The Home Office clarifies that commissioning for L&D services is for NHS England and police custody healthcare services for PCCs, and it is not their place to intervene. However, Home …
Responded
Roy Draper
Concerns: There is no clear protocol for initiating and managing unblinding requests for clinical trial patients treated in other hospitals. The absence of a formal referral system also hinders transparent communication about adverse events and unblinding.
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA states that no action is required, explaining existing systems for unblinding clinical trials and the responsibilities of those executing the processes, particularly regarding informing participants and documenting contact …
Responded
Andrew Shambrook
Concerns: The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.
Response (Betsi Cadwaladr University Health Board): The Health Board will review and ratify its Home Treatment Team Operational Policy by 31 January 2024, incorporating the coroner's comments. An interim addendum has been created to address immediate …
Responded
Girmaye Guyo
Concerns: There's a risk of patients being discharged under the Nearest Relative Power despite still meeting detention criteria, due to a lack of clear procedures and legal tests for clinicians to apply.
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns regarding the use of Nearest Relative powers under the Mental Health Act. The response notes the Responsible Clinician's powers to bar …
Overdue
Rachel Garrett
Concerns: A technical issue regarding the employment status of Mental Health Liaison staff prevents them from detaining patients under the Mental Health Act in acute hospitals, creating a serious risk of vulnerable patients absconding.
Response (NHS England): NHS England notes that pathway reviews are being undertaken, SPFT is in the planning stages of putting together a business case for direct employment of Mental Health Staff by the …
Response (NHS Sussex Integrated Care Board): NHS Sussex will make contact with other ICBs to explore how they are addressing the employment of Mental Health Liaison Teams within the Acute Care Hospitals and also to look …
Responded
Donna Donnellan
Concerns: A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role and appropriate referral pathways to specialist eating disorder services.
Response (Northern Care Alliance NHS Foundation Trust): The Trust has finalised and ratified the policy 'Management of Medical Emergencies in Adult Patients with Eating Disorders' and shared it with Pennine Care NHS FT. The policy clarifies roles, …
Response (Pennine Care NHS Foundation Trust): The Trust has worked with Northern Care Alliance NHS Foundation Trust to review policies and procedures following the Inquest, to add clarity regarding referral. The learning from this inquest and …
Responded
Aaron Deeley
Concerns: Patients held under Section 5(2) MHA in acute wards lack a Responsible Clinician or Mental Health Liaison assessment. Acute staff lack specialist mental health training, and policy for 1:1 observation is confusing, leaving a critical protocol gap.
Response (NHS England): NHS England acknowledges the concerns and highlights existing national guidance on liaison mental health services. They note actions taken by the Trusts involved, including a joint working group, and describe …
Response (Essex Partnership University NHS Foundation Trust): The trust has reviewed the Mental Health Liaison SOP to provide clearer direction for staff in supporting patients awaiting assessment under the Mental Health Act, focusing on risk management. A …
Response (Mid and South Essex NHS): The trust has reviewed its policy on the admission and treatment of patients with mental health disorders in acute settings, reinforcing mental health support available in ED. They have also …
Responded
Caroline Staite
Concerns: Procedures for referring clients between the Neighbourhood Mental Health Team and Mind, and for patients returning to NHS care from Mind, lack robustness and transparency.
Response (Herefordshire Worcestershire NHS): Herefordshire Worcestershire NHS states that the Community Service Manager has worked with Herefordshire MIND to co-produce a Standard Operating Procedure (SOP) for the Community Mental Health Link Worker Service in …
Responded
Hayley Beavington
Concerns: A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed to guide the junior doctor on challenging this decision, leading to premature discharge and the patient's death.
Response (North London NHS Foundation Trust): The Trust has implemented changes including a new Risk Escalation Standard Operating Procedure, a Crisis Hub Health Professional Line, and updates to the Admission Avoidance Standard Operating Procedure, with improved …
Responded
Man Ng
Concerns: Complex and non-streamlined processes for subarachnoid haemorrhage treatment, compounded by neurointerventionalists lacking admitting rights, create unclear overall clinical responsibility and risk patient safety.
Response (Royal College of Physicians): The Royal College of Physicians notes the concerns but clarifies existing pathways for subarachnoid haemorrhage management and explicitly supports that these pathways remain unchanged, citing NICE guidance and challenges like …
Response (Royal College of Surgeons): The Royal College of Surgeons will work with the Society of British Neurological Surgeons and British Neurovascular Group to develop a position statement with recommendations for managing clinical care of …
Response (The Royal College of Radiologists): The Royal College of Radiologists acknowledges concerns about delays and fragmented care, committing to continued advocacy with partner organisations for sustainable workforce planning, clear clinical governance, and equitable access to …
Responded
Warren Green
Concerns: High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service lacks clear escalation criteria to consultants, leading to insufficient oversight for vulnerable patients.
Response (Mid and South Essex NHS Foundation Trust): Mid and South Essex NHS Foundation Trust has updated relevant policies and flowcharts to assist staff with managing patients at high risk of self-harm. The Trust's Mental Health Lead and …
Response (Essex Partnership University NHS Foundation Trust): Essex Partnership University NHS Foundation Trust states that its Mental Health Liaison Team includes nurses, health care assistants, psychologists and occupational therapists and that patients can be reviewed by a …
Responded
PPO Death in Custody Recommendations (2)
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 prisoners who appear acutely, psychiatrically unwell are considered for transfer to a psychiatric hospital, and these discussions are recorded in the medical record.
IMB Recommendations (2)
Wakefield (2022)
We ask the minister to 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
Belmarsh (2023)
Would the Minister consider the impact of prison on those with serious mental illness and review systems for assessment and more appropriate placements?
Ministry of Justice
PHSO Casework Decisions (6)
P-001294 — North West Boroughs Healthcare NHS Foundation Trust
Miss Y complained about aspects of the care and treatment provided by North West Boroughs Healthcare NHS Foundation Trust (the Trust). Miss Y said the staff member completing her assessment was unsympathetic, and the Trust referred her incorrectly to outreach services instead of a psychiatrist.
NHS in England
Feb 2022
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-003967 — Surrey and Borders Partnership NHS Foundation Trust
Mrs E complains the Trust misdiagnosed her son's psychotic crisis and about the lack of assessment by a consultant.
NHS in England
Sep 2025
P-004260 — Oxford Health NHS Foundation Trust
Dr J complains that a mental health nurse from the Trust gave incorrect advice to the police, who had attended her home following a 999 call.
NHS in England
Nov 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-004668 — Kingston and Richmond NHS Foundation Trust
Mr A complains about the care and treatment he received from the Trust following three consultations from the end of 2023 to 2024. He explains he feels dismissed, ignored, and pressured into accepting a psychiatric diagnosis and treatment without adequate investigation into his symptoms.
NHS in England
Jan 2026