Fragmented menopause and mental health care
Lack of joined-up care between menopause and mental health services, insufficient understanding, and inadequate national guidance.
Source spread
Where this theme appears
This theme appears across 10 independent accountability sources, so the source mix matters as much as the headline total.
61 PFD reports
37 committee recs
2 HSSIB recs
3 PPO recs
2 IMB reports
7 DHR recs
4 PHSO decisions
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.
Prevention of Future Deaths reports(61)— showing 50 strongest matches
Matthew Dunham
Concerns: The coroner noted delays in acting on an emergency mental health referral and a lack of clear understanding of appropriate team roles. Concerns also included insufficient action on specific suicidal ideation and poor information sharing between mental health professionals.
Overdue
Janet Blackman
Concerns: The coroner noted psychiatric units struggle to provide physical health care and that deep vein thrombosis (DVT) prophylaxis policies were not consistently applied to patients in these units. The report suggests developing a system for integrated physical and mental health care delivery.
Overdue
Samiyo Farah
Concerns: Concerns included the absence of national observation protocols for young people in mental health units and a lack of formal information transfer protocols between healthcare sectors. The coroner also noted inconsistent psychiatric referral decisions in A&E.
Response (Department of Health): • The Department stated that the National Institute for Health and Care Excellence (NICE) produced detailed guidance on self-harm in 2013, which covers issues related to moving between services. • … (AI summary)
Overdue
Aaron Vranas
Concerns: The coroner noted difficulties in managing patients with both psychiatric illness and ADHD when their treatment is split between two geographically distant hospitals.
Response (Bedfordshire Clinical Commissioning Group): • The CCG stated it would consider supporting people with ADHD through local services as part of mental health service procurement, due for completion by April 2015. • The CCG … (AI summary)
Responded
Stephen Morris
Concerns: The coroner noted a limited exchange of mental health information between professionals in Cheshire and Blackpool, meaning Blackpool staff lacked a detailed understanding of the patient's recent presentation and risks upon his return.
Response (MDU Services Limited): • The GP will request written confirmation from mental health professionals for any future changes to patient prescriptions. (AI summary)
Overdue
Nancy Hughes
Concerns: The coroner identified a lack of medication reviews in accordance with accepted practice and no system to ensure them. There was also insufficient cohesion between mental health and medical treatment, which meant staff lacked access to mental health information for vulnerable patients.
Response: • The Health Board confirmed that patients are allocated a named care coordinator or nurse responsible for coordinating care, including medication review and communication during transfers. • A Prescribing Guideline … (AI summary)
Responded
Elizabeth Godwin
Concerns: The coroner identified concerns regarding the process for gathering information for mental health assessments, assessing their urgency, and sharing this information with other agencies. Further concerns relate to establishing responsibility for patient care and ensuring clear communication during transfers between agencies.
Response (Royal United Hospitals Bath NHS Trust): • The Royal United Hospitals Bath NHS Trust has implemented an allocated space on the self-harm proforma for next of kin information. • The Trust, in collaboration with Avon and … (AI summary)
Response (Avon and Wiltshire NHS Trust): • The Trust developed a Standard Operating Procedure for Primary Care Liaison Services and a triage tool to establish urgency of response. • The Trust's policies outline requirements for urgent … (AI summary)
Responded
Charlotte Bevan and Zaani Malbrouck
Concerns: The coroner noted a lack of evidence that multi-disciplinary team meetings are consistently held or that comprehensive, widely-circulated care plans are consistently developed for pregnant individuals with known mental health conditions.
Response: • Dr Kathryn Bundle has been tasked to review perinatal pathway arrangements against NICE guidelines, with draft algorithms developed and being consulted on. • The Trust plans to prepare and … (AI summary)
Responded
Philip Denning
Concerns: The coroner identified fragmented service provision for patients with co-occurring substance misuse and mental health issues, with insufficient information sharing and joint working between providers. There is also a lack of understanding in primary care about accessing appropriate help.
Overdue
Gillian Taylor
Concerns: The coroner identified the absence of an acute mental health facility in Powys, leading to patients being moved long distances and a resulting lack of continuity of treatment. This situation may negatively impact patient engagement with mental health services.
Response (Welsh Government): • The Welsh Government facilitated a meeting of Health Board mental health managers. • The meeting discussed the use of Welsh NHS beds when local beds are unavailable. • It … (AI summary)
Response (Powys Teaching Health Board): • The Health Board established Crisis Resolution Home Treatment Teams and allocated additional funding for care co-ordination in Montgomeryshire. • The management of adult mental health services in Montgomeryshire and … (AI summary)
Responded
Grant Burns
Concerns: The coroner noted a lack of co-operative working and communication between the Early Intervention in Psychosis Service and the Substance Misuse Service, which also led to an incomplete Root Cause Analysis report.
Response (Solent NHS Trust): • A spreadsheet of clients involved with both Adult Mental Health and Substance Misuse Services was compiled and added to weekly and twice-weekly meeting agendas. • New processes were established … (AI summary)
Responded
Jonathan Zucker
Concerns: The coroner identified the absence of a requirement or system for a lead clinician to oversee and coordinate Mr. Zucker's care, which was provided by both private and NHS mental health services.
Response (PSYCH): • The Royal College of Psychiatrists stated that its Professional Practice and Ethics Committee would consider issues related to consultant accountability, ownership during transitions, and care involving multiple teams. • … (AI summary)
Response (Department of Health): • Department of Health officials liaised with the Royal College of Psychiatrists regarding the concerns raised. • The Royal College of Psychiatrists intends to ask its Professional Practice and Ethics … (AI summary)
Responded
Lee Swain
Concerns: The coroner identified a lack of co-ordinated mental health service transfers between NHS Trusts, as removing a user from the Care Programme Approach led to GP-mediated referrals, delaying intervention and hindering information exchange.
Overdue
Margaret Conway
Concerns: The coroner notes that Acute Medical Wards and Mental Health Services are geographically and operationally separate, making transfers of patients with co-occurring serious mental and physical health problems challenging. Improved integrated working, clear pathways, and shared resources are needed to enhance care.
Overdue
Thomas Wall
Concerns: The coroner identifies a lack of local in-patient detox facilities, requiring patients to travel and experience long waiting lists. There is also a need for a more collaborative approach to dual diagnosis patients, noting that separating treatment components exacerbates distress.
Response (Susssex Partnership NHS Trust): • The Trust stated it works closely with partner organisations to achieve a collaborative approach for dual diagnosis patients. • The Trust ensured Public Health England guidance was provided to … (AI summary)
Response (Brighton Hove City Council): • The council detailed the arrangements for inpatient detoxification services, explaining that patients are referred to a unit in London following the closure of local facilities in 2016. • The … (AI summary)
Response (Brighton and Hove Clinical Commissioning Group): • A Dual Diagnosis integrated model has been implemented, including the co-location of 3.5 whole-time equivalent Dual Diagnosis workers with mental health services. • Agreed referral and care pathway protocols … (AI summary)
Overdue
David Buttriss
Concerns: The coroner identified communication gaps between GP and mental health services, disparate healthcare record systems hindering information sharing, and a lack of clarity regarding appropriate crisis pathways and team roles for patients in mental health crisis.
Response (Devon Doctors): • Devon Doctors stated they no longer provide urgent care in Cornwall and are unable to implement changes in that area. • For services in Devon, the organisation's Medical Director … (AI summary)
Response (NHS England): • NHS England is leading initiatives, including the Global Digital Exemplar programme and Local Health and Care Record Exemplars, to improve electronic information sharing and integrate care across health and … (AI summary)
Response (Cornwall NHS Trust): • The Trust implemented a new assessment service for Adult Mental Health Services, which includes a designated administrator for referrals and routine communication with GPs. • The Trust updated its … (AI summary)
Responded
Maureen Campbell-Scott
Concerns: The coroner identified significant delays in mental health referrals due to misdirection and loss, and frequent delays in delivering clinic letters from the mental health trust to the GP. This caused challenges for GPs in rapidly and accurately implementing specialist-directed medication changes, indicating a need for improved inter-agency communication and protocols.
Response (NELFT): • NELFT held two meetings with the practice and will reconvene another to discuss and agree a way forward on prescribing responsibilities. • NELFT provided personal contact details of consultants … (AI summary)
Overdue
Nigel Malloy
Concerns: The coroner noted a lack of follow-up for the patient after multiple emergency department admissions for alcohol dependence. There was insufficient information sharing between the Alcohol Liaison and Inclusion services, resulting in no coordinated treatment plan for his alcohol dependence.
Response (Hampshire Hospitals NHS Trust): • The Trust maintained a 24-hour referral service and dedicated pathway with the Inclusion service. • The Trust engaged in regular telephone liaison with the Inclusion service regarding inpatients and … (AI summary)
Overdue
Robin McEwan
Concerns: The coroner identified a lack of direct communication between private therapy and the GP regarding the patient's welfare, and insufficient exploration of potential family support when professional help was not immediately available.
Response (Harrogate CCG): • The CCG will review the referral process for private counselling services to ensure GPs are informed of patient progress. • The CCG will review and further develop its website … (AI summary)
Responded
Ursula Keogh
Concerns: The coroner highlighted a need to review GP referral practices to schools for CAMHS consideration and improve communication between health and education professionals to eliminate contradictory advice. Additionally, the report called for consideration of fast-tracking preventative measures at North Bridge, Halifax.
Response (Department of Health and Social Care): • The Department for Education updated its guidance, 'Mental health and behaviour in schools,' to include advice on identifying mental health problems and making efficient CAMHS referrals. • The Department … (AI summary)
Response (Calderdale CCG): • A review of the existing CAMHS referral pathway for GPs and schools was completed, and new actions for external training and education were identified. • The multi-agency Open Mind … (AI summary)
Responded
Danyon Chesters
Concerns: Delays in accessing NHS mental health services led the individual to private therapy, resulting in a lack of joined-up care and information sharing. Concerns were also raised that private therapists have no obligation to obtain information about medication prescribing.
Response (Department of Health and Social Care): • The Department committed to expanding Improving Access to Psychological Therapies (IAPT) services to increase access for an additional 600,000 people annually. • The Department confirmed an additional £2.3 billion … (AI summary)
Responded
Jennifer Lewis
Concerns: The coroner raised concerns regarding the lack of consultation between mental health and physical health doctors, and the failure to provide suitable and adequate care for the patient's needs at the Centre.
Response (Oxleas NHS Trust): • The Trust has implemented a Long Term Condition (LTC) register, managed by the practice nurse and GP, to record physical health interventions and appointments. • A monthly complex care … (AI summary)
Responded
David Price
Concerns: The coroner noted a lack of an integrated mental health counselling and detoxification service in Stockport, which would enable joint treatment for co-occurring alcohol dependency and anxiety.
Response (Stockport NHS CCG): • Self Help Services will continue to promote their eTherapy/online computerised treatment programme for substance misuse. • The CCG and Local Authority Public Health Department will request regular updates on … (AI summary)
Responded
George Twiddy
Concerns: The coroner identified a lack of clarity between two agencies regarding responsibility for providing immediate patient assistance, causing confusion for the patient's family and practitioners. Direct liaison between frontline staff is recommended to clarify roles in crisis situations.
Response (Southern Health NHS Foundation Trust): • The Trust and Hampshire County Council committed to producing a s140 policy to ensure greater understanding for frontline staff involved in Mental Health Act assessments. • The agencies agreed … (AI summary)
Overdue
Beverley Shaw
Concerns: The coroner identified a lack of communication between Turning Point and the GP regarding Ms Shaw's significant butane gas use. Additionally, only recent medical records were transferred between substance misuse service providers, limiting access to a full patient history.
Response (Oldham NHS CCG): • The appropriate electronic code for butane misuse was identified and will be communicated to all GP practices. • Locum GP competency issues identified during the review were addressed, and … (AI summary)
Response (Hopwood House Medical Practice): • The practice will use a specific electronic code for butane misuse to add it to patients' problem lists. • The practice has decided to employ a clinical pharmacist to … (AI summary)
Response (Turning Point): • Turning Point undertook a wide-ranging review of GP communication across its community substance misuse services. • The organisation reviewed its systems for following up GP information requests and client … (AI summary)
Responded
Reece Lapina-Amarelle
Concerns: The coroner identified a lack of resources, treatment systems, and information sharing for individuals with serious mental illness and co-occurring alcohol or drug misuse. The Mental Health Act was also noted as outdated in addressing these complex needs and prioritising patient safety.
Response (Department of Health and Social Care): • The Department asked officials to make the report and circumstances known to the Care Quality Commission. • The Department noted that Public Health England developed guidance and the National … (AI summary)
Response (NHS England): • NHS England stated that the NHS Long Term Plan details new and integrated models of primary and community health services to transform mental health care for adults with serious … (AI summary)
Responded
Thomas Wedrychowski
Concerns: The coroner noted that expert evidence suggested more frequent diabetes monitoring than annually for individuals with a higher baseline risk, and that physical healthcare findings were not consistently shared between primary and secondary care providers.
Overdue
Toby Nieland
Concerns: The coroner identified insufficient coordination and management of a patient with a complex dual diagnosis, lacking a structured care programme, assertive outreach, and a dedicated drug and alcohol recovery team, leading to missed opportunities for assessment.
Response (Lincolnshire County Council): • We Are With You is enhancing the questions asked when people attend Needle Syringe Programmes with immediate effect. • A review of the joint working protocol between mental health … (AI summary)
Response (We Are With You charity): • The charity participated in 'Planned Dual Diagnosis Work' meetings and agreed to review Dual Diagnosis pathways across the treatment system. • Staff now use a prompt system and an … (AI summary)
Response (Lincolnshire Partnership NHS Foundation Trust): • The Trust has implemented a range of services to support carers and ensure their views are considered, including dedicated staff, training, and communication channels. • The Trust will strengthen … (AI summary)
Responded
Sarah Smith
Concerns: The coroner noted that mental health clinicians did not consider hormonal factors as a potential contributor to a peri-menopausal patient's depressive illness. It was also noted that NICE guidelines do not currently recommend routine hormone monitoring or considering this factor in such cases.
Overdue
Samantha Gould
Concerns: The coroner raises concerns about the lack of national guidance for pharmacies to be involved in medication safety plans for mental health patients aged 16-17, noting this poses a risk of future fatalities.
Response (NHS England): • A local protocol has been introduced for CAMHS to advise pharmacies and GPs of relevant care plans for 16-17 year old patients. • This local protocol is now part … (AI summary)
Response (RPS): • The Royal Pharmaceutical Society (RPS) stated it continues to campaign for improved access and sharing of patient health records for community pharmacies. • The RPS has published a policy … (AI summary)
Response (GPC): • The General Pharmaceutical Council stated it would proactively look for opportunities to share the learnings from this case with key stakeholders. • The General Pharmaceutical Council stated it would … (AI summary)
Response (CCA): • The Community Pharmacy Patient Safety Group will discuss the incident to identify learnings and share best practice. • A summary of this discussion will be shared nationally via internal … (AI summary)
Responded
Fadhia Seguleh
Concerns: There was insufficient information sharing and coordination between the NHS Mental Health Trust, GP, and private therapist, leading to an incomplete understanding of risks and treatment. Remote mental health assessments and unaccompanied A&E attendance due to COVID-19 also limited comprehensive care.
Overdue
Jude Lloyd
Concerns: The coroner identified inadequate diabetes care planning and monitoring before discharge, alongside insufficient communication between inpatient, community mental health teams, and GPs. There was also a lack of formal mental capacity assessments and robust audit systems.
Response (Greater Manchester Mental Health NHS Foundation Trust): • The Trust has implemented an eLearning training package for staff on physical health, including diabetes management, and employs physical health nurses within CMHTs to conduct annual assessments. The physical … (AI summary)
Responded
Darren Lawrence
Concerns: Inadequate communication and transfer processes between mental health teams and general practitioners led to insufficient follow-up and unprescribed medication. Concerns also included a lack of escalation protocols for patient disengagement and gaps in medication monitoring.
Response (Droylsden Road Family Practice): • The practice developed a pathway for the management of patients with suicidal tendencies. • A lead and deputy lead for suicide prevention were nominated to review suicidal patients monthly. … (AI summary)
Response (Greater Manchester Mental Health NHS Foundation Trust): • The Trust implemented daily multi-disciplinary zoning meetings in CMHTs, with HBTT staff attending twice weekly to improve communication and care transfers. • A policy for Managing Did Not Attend … (AI summary)
Responded
David Walker
Concerns: The coroner noted frequent changes in Mr. Walker's care co-ordinators, many of whom were locum staff, hindering therapeutic relationships. Additionally, collateral information from other Trusts was not sought upon hospital admission, a requirement missing from the admission checklist.
Response (North East London NHS Foundation Trust): • Agency staff have been sourced on a semi-permanent basis to support community recovery teams, and approval has been given to recruit over the establishment budget. • Communication has been … (AI summary)
Responded
Gaia Pope-Sutherland
Concerns: The coroner identified a lack of communication between community psychiatric and neurology teams across England and Wales, alongside under-resourced epilepsy services, particularly insufficient nursing staff. The report also noted a need for improved police training on epilepsy and complex mental health conditions when dealing with missing persons.
Response (NHS Dorset Integrated Care): • NHS Dorset Integrated Care stated that a review of nursing resources in epilepsy care within the Dorset Epilepsy Service would be undertaken. • The review will encompass communication processes … (AI summary)
Response (BCP Council): • BCP Council's Approved Mental Health Professionals (AMHP) Service operates a Quality Assurance Framework to monitor information sharing standards. • The AMHP Service requires full reports to be distributed to … (AI summary)
Response (Dorset Healthcare University NHS Foundation Trust): • The Trust appointed a new full-time Band 4 epilepsy co-ordinator to support the two epilepsy specialist nurses. • The Trust is recruiting a part-time Band 7 specialist nurse for … (AI summary)
Response (Dorset Council): • Dorset Council implemented a new internal data reporting system to ensure initial AMHP reports are emailed to the GP within 72 hours. • A mandatory field was added to … (AI summary)
Response (Dorset Healthcare University NHS Foundation Trust): • The Trust is developing new procedures for supporting victims of sexual violence on inpatient units and for working with families and carers. • Guidance and training on the RiO … (AI summary)
Response (College of Policing): • The College of Policing provides medical knowledge through its first aid programme, which links to vulnerability training. • College standards require front-line responders to ask questions to understand the … (AI summary)
Response (Dorset Police): • Dorset Police reviewed and updated its Missing Person Policy and its call handling, deployment, and grading policy, with changes implemented. • The organisation has delivered vulnerability training since 2019 … (AI summary)
Response (Department of Health and Social Care): • The Trust introduced a Standard Operating Procedure in May 2022 covering information provision following Mental Health Act assessments. • NHS England established the Neurosciences Service Transformation Programme to develop … (AI summary)
Response (Royal College of Psychiatrists): • The Royal College of Psychiatrists' Neuropsychiatry Faculty has commenced work to establish relationships and initiate dialogue regarding access to health services for individuals with neurological conditions. • The College's … (AI summary)
Response (Association of British Neurologists): • The Association has asked its Epilepsy Advisory Group for comment on the numbers of epilepsy nurses and how the system could operate with more resources. • The Association has … (AI summary)
Response (Dorset Healthcare University NHS Foundation Trust): • The Trust's Safeguarding policy was updated to highlight the response needed when an adult discloses they have experienced sexual abuse. • Two appendix documents were added to the Safeguarding … (AI summary)
Responded
Gareth Williams
Concerns: The coroner noted insufficient support for the individual, who was transferred between mental health and ENT teams that did not communicate directly, resulting in them falling between services.
Response (Aneurin Bevan University Health Board): • A concise review was undertaken by the Mental Health and Learning Disabilities Division. • The 'Adferiad' service will receive recurrent funding from April 2023 to broaden its inclusion criteria … (AI summary)
Responded
Samuel Morgan
Concerns: The coroner raises concerns about the lack of integrated electronic records between alcohol and drug addiction services and primary community mental health teams. This hinders effective sharing of patient safety information, particularly for dual diagnosis cases, increasing the risk of important details being lost.
Response (Swansea Bay University Health Board): • For Swansea-based teams, technical changes will be completed to enable two-way information sharing via WCCIS, with implementation intended for the week commencing 7th August 2023. • For NPT-based teams … (AI summary)
Responded
Conrad Colson
Concerns: The coroner identified insufficient liaison and information sharing between specialist and step-down mental health services for a BDD patient on discharge. Concerns included a lack of risk communication regarding aesthetic treatments for BDD, and limited national resources and training.
Response (NHS England): • NHS England stated it would continue to monitor the need for greater capacity for treating Body Dysmorphic Disorder at primary and secondary mental healthcare levels. • The national Clinical … (AI summary)
Response (South London and Maudsley NHS Foundation Trust): • The Centre for Anxiety Disorders and Trauma (CADAT) updated its discharge policy to specify expectations for liaison between local teams and CADAT. • The updated CADAT discharge policy includes … (AI summary)
Response (NELFT): • NELFT stated it would develop a joint working protocol between specialist and step-down services to improve information sharing and risk management planning. • Learning events will be arranged on … (AI summary)
Response (Aesthetic Dermatology): • The clinic updated its Body Dysmorphic Disorder (BDD) policy to include formal screening for all new patients using the COPS questionnaire, with scores of 30 or more or clinical … (AI summary)
Responded
Marlene McCabe
Concerns: The coroner identified potential for a lack of understanding among clinicians regarding urgent mental health referrals, and inconsistent access to mental health records hindering information sharing. Concerns were also raised that drug/alcohol references or perceived intoxication could lead to missed mental health diagnoses or delayed identification of psychosis.
Overdue
Corinne Haslam
Concerns: Concerns were raised regarding barriers for mental health staff to access physical health specialists without emergency department use, incompatible electronic record systems hindering information transfer between trusts, and insufficient guidance for nursing staff on Venous Thromboembolism risk assessments.
Response (Department of Health and Social Care): • Primary and secondary care organisations have been able to share a subset of patient information within their integrated care board footprint since 2021. • Pennine Care NHS Foundation Trust … (AI summary)
Overdue
Donna Donnellan
Concerns: The coroner identified a lack of understanding between Acute and Mental Health Trust clinicians regarding the specific role of the Mental Health Liaison Team for eating disorder patients. There was also a lack of clarity on referral pathways to specialist eating disorder services.
Response (Northern Care Alliance NHS Foundation Trust): • The Trust finalised and ratified a policy, 'Management of Medical Emergencies in Adult Patients with Eating Disorders,' which is now in use. • The policy clarifies the roles and … (AI summary)
Response (Pennine Care NHS Foundation Trust): • Pennine Care NHS Foundation Trust and Northern Care Alliance NHS Foundation Trust reviewed policies and procedures to clarify referral processes. • The Trusts agreed to jointly review the policy … (AI summary)
Responded
Angela Collins
Concerns: Vulnerable adults under the care of secondary mental health services by East London NHS Foundation Trust receive very limited or no support despite being at risk of prescription drug overdose or mental health crisis.
Response (East London NHS Foundation Trust): • The Trust will conduct a robust review of the Duty Function across all Community Mental Health Teams in Bedfordshire and Luton, commencing in February 2024. • The Trust will … (AI summary)
Responded
Alice Litman
Concerns: The coroner identified gaps in the knowledge, training, and guidance for clinicians supporting transgender individuals in mental health and primary care. Concerns also include delays in accessing gender-affirming healthcare and a lack of mental health provision for those awaiting treatment.
Response (Surrey and Borders Partnership NHS Foundation Trust): • The Trust is developing a mandatory training package for all staff on supporting transgender individuals, co-produced with people with lived experience and their families, including age-specific training for clinicians … (AI summary)
Response (NHS England): • NHS England has established pilot services to increase capacity for gender dysphoria services, with some now operating under substantive contracts. • NHS England plans to refresh service specifications for … (AI summary)
Response (Royal College of Genereal Practitioners): • The Royal College of General Practitioners (RCGP) has worked with NHS England and other organisations to improve knowledge and understanding of the needs of transgender patients. • The RCGP … (AI summary)
Response (Travistock and Portman NHS Foundation Trust): • The Trust is working with NHS England and other providers to develop innovative ways of reducing the waiting list. • This work includes the development of new roles such … (AI summary)
Responded
Kirsty Taylor
Concerns: The coroner identifies insufficient connectivity between mental and physical health services, particularly for neurodivergent patients, and notes a lack of a comorbidity policy. Further concerns include the pace of developing a personality disorder pathway and ineffective communication with families of mental health patients.
Response (NHS England): • NHS England has provided funding since 2021/22 to develop and implement new models of integrated primary and community mental health care, including a dedicated offer for individuals with personality … (AI summary)
Response (Hampshire and Isle of Wight): • The ICB endorsed the recommendation for a new all-age community and mental health Trust, which is planned to go-live on 1 April 2024. • The ICB is re-commissioning ASC … (AI summary)
Response (Southern Health NHS Foundation Trust): • The Trust is progressing with Project Fusion to establish a new, single community and mental health provider by April 2024, and has established a Neurodiversity Clinical Delivery Group. • … (AI summary)
Responded
Katharine Fox
Concerns: The coroner identified a disconnection between hospital and community psychology services, with insufficient handover and long waiting times for community sessions. Concerns were also raised about clinicians potentially being unable to access patient notes across different computer systems.
Response (Essex Partnership University NHS Foundation Trust): • The Trust stated that a handover of care from inpatient to community psychological practitioners will occur for patients needing continued intervention post-discharge, and this process will be regularly audited. … (AI summary)
Responded
Amarnih Lewis-Daniel
Concerns: The coroner raised concerns about extensive waiting lists for Gender Identity Disorder clinics, insufficient local patient support, and unclear responsibility for wellbeing during this period. There was also a noted lack of specialist knowledge in local mental health services and clear guidance for GPs on bridging hormone prescriptions.
Response (NHS England): • NHS England developed five pilot services, transitioning two to substantive contracts, and launched the UK's first accredited training programme in gender identity healthcare to increase capacity. • Additional funding … (AI summary)
Response (Together UK): • Together UK has information sharing agreements with NELFT and ELFT, a Standard Operating Procedure for Liaison and Diversion, and will raise the possibility of direct access to East London … (AI summary)
Responded
Shahzadi Khan
Concerns: The coroner identified concerns regarding out-of-area mental health placements resulting from bed shortages, which impeded family contact and information sharing. Issues also included coordinating teams' insufficient understanding of local care pathways and effective discharge planning.
Response (Department of Health and Social Care): • Funding was made available to support discharge from mental health inpatient settings, and statutory guidance for discharge was published. • Capacity within the North-West Bed Bureau was strengthened, and … (AI summary)
Responded
Axel Price
Concerns: The coroner notes a lack of clear understanding and accountability between agencies when young people transition from CAMHS to adult services, compounded by a lack of national guidance and recognised pathways for support.
Response (Department of Health and Social Care): • The NHS is extending current service models to create a comprehensive mental health offer for 0-25 year olds. • Nearly 500 mental health support teams have been established across … (AI summary)
Responded
Jason Pulman
Concerns: The coroner raises concerns about a lack of clarity for CAMHS teams, patients, and parents regarding national referral mechanisms for gender services and the resources available to provide mental health support for young people on waiting lists. This situation may lead to extended wait times and potential risks while awaiting treatment.
Response (Arden and Greater East Midlands NHS Commissioning Support Unit): • The CSU confirmed that a process was established in April 2024 to contact all children and young people on the waiting list for CYP gender services and offer assessment … (AI summary)
Response (NHS England): • NHS England established a process from April 2024 to offer mental health assessments to all children and young people on the waiting list for gender services, supported by additional … (AI summary)
Responded
Evie Davies
Concerns: The coroner noted a lack of real-time information sharing between the cafe71 service and the mental health team, meaning cafe71 staff lack access to patient background and risk factors, and mental health teams are not notified of contacts.
Response (Cheshire and Wirral Partnership NHS Foundation Trust): • Crisis line staff received a reminder to ensure referrals between services contain contact information and to complete warm transfers with patient consent where possible. • Café 71 updated its … (AI summary)
Response (Cheshire and Merseyside Integrated Care Board): • The Integrated Care Board (ICB) confirmed it had liaised with Cheshire and Wirral Partnership NHS Foundation Trust (CWP) to confirm information sharing arrangements. • The ICB stated it would … (AI summary)
Response (Spider Project 1): • The respondent stated that the individual did not contact Cafe 71 directly. • The respondent clarified that Cafe 71 operates as a non-clinical safe cafe space, not a crisis … (AI summary)
Response (Spider Project Cafe): • Referral forms for Café 71 were made more detailed to include consent for leaving voicemails. • Referral forms now request information on other referrals or support provided to the … (AI summary)
Responded
Select committee recommendations(37)
#3 —
Recommendation: It is unacceptable that there are parts of the country where women cannot access the specialist menopause services they need. By 2024, there should be a menopause specialist or specialist service in every Clinical Commissioning Group area. The Menopause Taskforce, …
Response attribution not verified
#2 —
Recommendation: GPs will be the first port of call for many women who are experiencing perimenopause or menopause. It is vital that women can trust their GPs and that GPs feel confident and well-equipped in diagnosing a condition that affects half …
Response attribution not verified
#21 — Commission women's health hubs to include mental health support in core specification in underserved areas
Recommendation: Women’s health hubs situated in areas where access to appropriate mental health services is lacking should be commissioned to include mental health support as part of their core specification.
Response attribution not verified
#20 — Offer specialist mental health support to individuals with reproductive health conditions from first symptoms through treatment
Recommendation: Individuals with a suspected or diagnosed reproductive health condition should be offered specialist mental health support from when they start to report distressing and/or painful symptoms and throughout diagnosis and treatment. Delays at each step of the process and a …
Response attribution not verified
#8 — Ensure FGM Support Clinics offer specialist counselling with clear referral pathways
Recommendation: The Government should ensure that all FGM Support Clinics offer specialist counselling support to FGM survivors in appropriate settings, provided by counsellors who are trained in the specific challenges of FGM. There should be clear referral pathways to this counselling …
Response attribution not verified
#7 — Many FGM survivors lack access to appropriate specialist counselling services
Recommendation: FGM survivors often suffer psychosexual, emotional and mental health complications from undergoing FGM. However, many FGM survivors do not have access to appropriate counselling services, with many FGM services not offering any counselling to FGM survivors and others offering counselling …
Response attribution not verified
#9 — High number of care leaver deaths highlights poor transition coordination to adult services.
Recommendation: We asked the Department and other witnesses about the circumstances surrounding a young person recently taking their own life after turning 18 and facing the uncertainty of moving out of the children’s social care system. A situation which the Chief …
Response status not verified
#47 — Require Government to detail actions addressing complex health needs of women in custody
Recommendation: The Government should respond to this report setting out what action it is taking to address the complex health and wellbeing needs of the women it currently has in its custody. (Recommendation, Paragraph 212) 88
Response attribution not verified
#46 — System failing to meet complex health and wellbeing needs of women in prison
Recommendation: Women in prison often have acute and complex health needs, yet the system is failing to meet even their most basic requirements. We acknowledge the Government’s ambition to reduce the population in the female prison estate, and that change is …
Response attribution not verified
#21 — Expand Section 75 use to enable wider budget pooling, including housing and education services.
Recommendation: The Government should expand the use of Section 75 of the NHS Act 2006 by enabling and encouraging more widespread pooling of budgets between NHS bodies and local authorities. This expansion should support the inclusion of a broader range of …
Response attribution not verified
#15 — Community Mental Health Services fragmentation persists, requiring sustained investment for integrated support models.
Recommendation: Community Mental Health Services (CMHS) are integral to supporting people with severe mental illness across health, social care, and with their wider social needs. Evidence to this inquiry shows that integrated models of support within multi-disciplinary teams—such as co-located teams …
Response attribution not verified
#9 — Fragmented mental health system requires sustained investment and cultural shift for transformative community care.
Recommendation: Delivering real change and achieving parity of esteem in mental health care requires dismantling the current fragmented system and reimagining service design and delivery. The 24/7 Neighbourhood Mental Health Centre 75 pilots seem to be genuinely transformative. The experience from …
Response attribution not verified
#3 — Current mental health services fail to provide person-centred, holistic care
Recommendation: Service users, their families, carers and loved ones have been clear: high- quality care must be person-centred, responsive to the full range of needs individuals experience, and ensure involvement of their wider networks. Current services too often fall short—focusing narrowly …
Response attribution not verified
#2 — Lack of continuity of care fragments support for people with severe mental illness
Recommendation: Continuity of care is a necessity for people with severe mental illness. It is essential to the delivery of high-quality care. When it is present, it prevents crisis, builds trust, and supports recovery. When it is absent, it fragments support, …
Response attribution not verified
#5 — Set actions to improve perinatal mental health access within Family Hubs for ethnic minority women.
Recommendation: The Government should set out what actions it will take to improve access to perinatal mental health care within Family Hubs, supported by specific targets to improve access for women from ethnic minority backgrounds who have disproportionately poorer mental health …
Response attribution not verified
#4 — Perinatal mental health investment remains insufficient and geographically limited to address needs.
Recommendation: Perinatal mental health is as important as physical health, with poor mental health outcomes having potentially significant long-term consequences for both the mother and child. We were struck by how frequently mental health concerns were raised in evidence. Given that …
Response attribution not verified
#5 —
Recommendation: We recommend that the Government commits to removing dual prescription charges for oestrogen and progesterone, replacing it with a single charge for all women. We also recommend that the Government works with the NHS and the ‘HRT tsar’ to develop …
Response attribution not verified
#16 — Encourage firms to establish menopause policies and support to retain talent.
Recommendation: We recommend that Government continue to encourage firms to recognise the impact of menopause and to establish policies and support for those who are affected to ensure that their experience and talents are not prematurely lost from the industry. (Paragraph …
Response attribution not verified
#4 — Ensure all FGM survivors access timely, essential support and specialist care nationwide
Recommendation: The Government should ensure that all FGM survivors can access the essential support and care they need in a timely manner. While some variation in service provision may be necessary to reflect local prevalence rates, higher-prevalence areas should offer funded …
Response attribution not verified
#46 — Ministerial responsibility split leads to neglect and fragmentation of FE SEND policy.
Recommendation: SEND policy is currently overseen by the Minister for School Standards whilst further education policy lies with the Minister for Skills. This split in ministerial responsibility has led to the neglect of FE SEND policy, as well as inefficiencies, limited …
Response attribution not verified
#13 —
Recommendation: We are also persuaded that a new protected characteristic of menopause should be created, although we acknowledge this will need careful drafting and consultation. The Government should launch a consultation on how to amend the Equality Act to introduce a …
Response attribution not verified
#4 —
Recommendation: We are extremely disappointed that despite a clear Government commitment on a single-cost, annual pre-payment certificate for HRT, almost nine months later that commitment has not been realised. Progress has been further derailed by supply issues. We welcome the Health …
Response attribution not verified
#1 —
Recommendation: Menopause still carries significant social and cultural stigma, particularly for certain groups, including LGBT+ people and young and ethnic minority women. We are encouraged by the recent shift towards talking about menopause more openly, by the inclusion of menopause in …
Response attribution not verified
#32 — Develop and pilot a specific 'menopause leave' policy with a large public sector employer.
Recommendation: We endorse and support the recommendation by the Women and Equalities Committee that the Government should develop and pilot a specific ‘menopause leave’ policy with a large public sector employer.
Response attribution not verified
#15 — Progress in supporting employees affected by menopause requires further action.
Recommendation: Welcome progress has been made in recognising the effect of the menopause and in identifying ways of assisting those affected to overcome the challenges it presents without having to leave their jobs. That progress, as in other areas of this …
Response attribution not verified
#8 — Improve NHS website with interactive tools, guidelines, accessibility, and mental health support
Recommendation: To supplement improvements in the provision of information on the NHS website, we recommend the inclusion of an interactive tool which can help women to determine whether they might have a reproductive health condition. We further recommend that information on …
Response attribution not verified
#49 — Prioritise mental health support for children in care and pilot co-located CAMHS services.
Recommendation: The Department for Education should work with the Department of Health and Social Care to ensure that children in care and care leavers are prioritised for mental health support and improve training for mental health practitioners on the impact of …
Response attribution not verified
#46 — NHS England needs national menopause strategy to retain senior staff
Recommendation: NHS England should develop and implement a national menopause strategy focused on the retention of senior staff who may be reducing their hours, leaving management or supervisory roles, or retiring earlier than intended, because of a lack of support around …
Response attribution not verified
#12 —
Recommendation: The current law does not serve or protect menopausal women. Whilst the law rightly protects women from pregnancy and maternity discrimination, it does not specifically protect menopause. This is anomalous, given all women will experience menopause, whilst not all women …
Response attribution not verified
#7 — Government's 'Get Active' strategy remains inadequate for addressing midlife women's health barriers.
Recommendation: Women in midlife face specific health-related barriers to participation, including but not limited to the symptoms of perimenopause and menopause. These occur after many have experienced barriers at earlier life stages, including in early years and at school during puberty. …
Response attribution not verified
#16 —
Recommendation: We are aware that there has been a significant increase in the number of referrals to Gender Identity Development Services in recent years. We strongly believe that improved support is needed to help young people seeking to transition, especially mental …
Response attribution not verified
#9 —
Recommendation: Menopause symptoms can have a significant and sometimes debilitating impact on women at work. The Government should work with a large public sector employer 48 Menopause and the workplace with a strong public profile to develop and pilot a specific …
Response attribution not verified
#8 —
Recommendation: We recommend that the Government, in consultation with the Menopause Ambassador, produces model menopause policies to assist employers. The model policies should cover, as a minimum: how to request reasonable adjustments and other support; advice on flexible working; sick leave …
Response attribution not verified
#7 —
Recommendation: The Government has a key strategic role in helping businesses and should lead the way in developing and disseminating good practice. The Government should appoint a Menopause Ambassador to work with stakeholders from business (including small to medium enterprises), unions, …
Response attribution not verified
#6 —
Recommendation: Menopause is a workplace issue. There is a legal, economic, and social imperative to address the needs of menopausal employees. We are not persuaded that a legal requirement for every workplace to have a menopause policy would embed meaningful change. …
Response attribution not verified
#11 —
Recommendation: Wellbeing of Women’s period symptom checker should be added to the NHS app. The Government should work with Wellbeing of Women to determine whether conditions in addition to heavy bleeding and pain, such as irregular bleeding, depression and anxiety, might …
Response attribution not verified
#10 —
Recommendation: We congratulate Wellbeing of Women on developing and rolling out its period symptom checker. It is an excellent tool, which has the potential to be a major breakthrough in improving awareness and understanding of menstrual health problems and speeding up …
Response attribution not verified
HSSIB safety recommendations(2)
Care delivery within community mental health teams
HSIB recommends that the Royal College of Psychiatrists forms a working group with relevant stakeholders to identify ways in which menopause can be considered during mental health assessments.
Safety Recommendation
Care delivery within community mental health teams
HSIB recommends that the National Institute for Health and Care Excellence evaluates the available research relating to the risks associated with menopause on mental health and if appropriate, updates existing guidance.
Safety Recommendation
PPO death in custody recommendations(3)
The Head of Healthcare
The Head of Healthcare should conduct an urgent review of the following areas of mental healthcare delivery at Wakefield: ▪ develop a protocol for disseminating transfer handover information, within a centralised email system, not to an individual staff member’s email, …
The Heads of Healthcare at HMP Manchester and HMP Buckley …
The Heads of Healthcare at HMP Manchester and HMP Buckley Hall should ensure that: liaison between prisons takes place when prisoners with a history of severe and enduring mental illness are transferred to Manchester and that the outcome is fully …
The Head of Healthcare, the lead GP and the lead …
The Head of Healthcare, the lead GP and the lead manager of the mental health service should: • review the system for the follow up of patients who do not meet the threshold for input from the mental health team …
IMB annual reports(2)
Warren Hill (2023)
HMP Warren Hill, a Category C adult male prison with an operational capacity of 267, maintained a safe environment despite some low-level bullying. The Board noted improved use of safety interventions (CSIPs, ACCTs) and zero deaths in custody. Key challenges included persistent issues with food provision, the suspension of the ROTL pilot, and delays in progression caused by Secretary of State interventions. The IMB made recommendations regarding food quality, estate investment, digital skills for resettlement, and urges review of the ROTL suspension.
PRISON
Key concerns
Thorn Cross (2023)
HMP/YOI Thorn Cross is a Category D open prison that maintains a very safe environment with extremely low violence levels and effective drug reduction strategies. Relationships between staff and prisoners are generally positive, fostering a rehabilitative culture. While healthcare provision is deemed excellent and rehabilitation efforts are at the heart of the prison's operations, concerns remain regarding low transfer rates for long-sentence prisoners, property transfer issues, and limitations in internet and mobile phone access for prisoners.
PRISON
Key concerns
Health investigations(5)
Independent investigation into the care and treatment of Mr J — Rec 3
The Trust and NHS Newham CCG should develop guidelines for the integrated care and treatment of bipolar disorder across primary health and secondary mental health services, which includes guidance for GP’s action with regards to uncollected prescriptions in patients under secondary mental health care.
Mr J who committed a homicide in 2014. Mr J was in receipt of services from East London NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr J — Rec 3
The Trust and NHS Newham CCG should develop guidelines for the integrated care and treatment of bipolar disorder across primary health and secondary mental health services, which includes guidance for GP’s action with regards to uncollected prescriptions in patients under secondary mental health care.
Mr J, published on 25 August 2020. Mr J was in receipt of services from South London and Maudsley NHS Trust
london
Independent investigation: Dean Shorney, Bargoed (2006) — Rec 4
Gwent Healthcare NHS Trust and Caerphilly County Borough Council Social Services should ensure that integrated and co-ordinated services are provided for those experiencing mental health problems of whatever severity or duration. In particular: a) Effective management of CMHT MDTs including joint working arrangements within the CMHT should be reviewed and …
wales
An independent investigation into the care and treatment of patient … — Rec 4
The Integrated Care Board and Trust should develop services in line with the requirements of the community mental health framework for adults and older adults20 that avoid patients being subject to repeat referrals, screenings and assessments across multiple services. This methodology must describe the expectations for medical oversight for patients …
north_east_yorkshire
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 5a
Develop and publish a national service specification for perinatal mental health pathways covering common and moderate to severe mental health needs, services for fathers/partners, and parent–infant relationships.
wales
Accepted
PHSO casework decisions(4)
P-004551 — A practice in the Leeds area
Ms J complained the Practice did not appropriately treat her perimenopause symptoms, disregarded her concerns, refused HRT, and didn't advise its age-based HRT policy, significantly impacting her mental health.
NHS in England
Dec 2025
P-004580 — A practice in the Richmond upon Thames area
The Practice unnecessarily referred her for HRT, stated only female GPs could treat perimenopause, prescribed incorrect HRT, and wrongly advised antidepressants.
NHS in England
Jan 2026
P-003984 — A practice in the City of Nottingham area
Ms P complained the Surgery refused her required HRT dose, reduced it without notice, and failed to communicate with other organizations to support her prescription needs.
NHS in England
Sep 2025
P-004575 — Dorset Healthcare University NHS Foundation Trust
The Trust failed to return a voicemail, provided no ADHD care after private diagnosis, and did not inform him about a DBT referral transfer.
NHS in England
Jan 2026
Domestic Homicide Reviews(7)
Carmarthenshire — recommendation 7
Develop a 7 minute briefing on the links between Menopause and Domestic Abuse and distribute with the Guidance document56 via the Health Board’s Safeguarding Intranet, Primary Care Network and relevant forums
Hywel Dda University Health Board
Hywel Dda University Health …
Carmarthenshire — recommendation 6
To consider the links between menopause and domestic abuse within the development of the Health Board’s Menopause Pathway
Hywel Dda University Health Board
Hywel Dda University Health …
Lincoln — recommendation 10.3.5
Further develop improved partnership working and joint working with Mental Health Services across Lincolnshire.
Addaction
Exeter — recommendation R6
In managing structural and personnel changes, seek minimal effect on continuity of care for mental health clients, including liaison with other agencies involved with them. (#370)
Devon Partnership NHS Trust
Devon Partnership NHS Trust
Bradford — recommendation 1
The CCG will request that the template for the maternal mental health pathway includes an explicit enquiry in relation to domestic violence.
ICB
Carmarthenshire — recommendation 11
Develop a regional substance use, domestic abuse and mental health pathway for individuals who present with multiple needs
Regional Partnership Board
Middlesbrough — recommendation 2
The Middlesbrough Community Safety Partnership should seek assurances from health agencies and commissioners within the partnership that professionals are trained in recognising abuse, being alert to indicators and understanding the links between mental health and domestic abuse. Professionals should have clear understandings of pathways and when appropriate use routing enquiry …
Middlesbrough Community Safety Partnership