Mental Health Crisis Referral Delays
Procedural gaps preventing direct referral of acutely unwell patients to emergency Crisis Resolution and Home Treatment Teams.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
100match
Safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care...
HSSIB recommends that the Department of Health and Social Care urgently reviews the current legal framework and addresses the current legislative gaps in emergency care for people in mental health crisis and clarify the extension of legal powers for health professionals to hold someone in the emergency department. This will safeguard people who are currently arriving at the...
Matched on
terms: crisi, health, mental
HSSIB recommendation
100match
Investigation report: Mental health inpatient settings - out of area placements
Crisis resolution and home treatment teams can improve patient safety by joining quality networks for crisis resolution and home treatment teams and could consider using continuous clinical reviews of mental health acute inpatients. This can ensure that appropriate patients are discharged early and could maximise acute care bed availability for patients in the community who are at high...
Matched on
terms: crisi, health, mental
Committee recommendation
99match
#26 - 3rd Report - Legislative Scrutiny: Mental Health Bill
It is crucial that prisoners experiencing serious mental health crises are promptly moved to a hospital environment where they can receive the treatment they need. Delays in such moves risk exposing individuals to inhuman or degrading treatment in breach of Article 3 ECHR. The Bill’s introduction of a statutory 28 day time frame for hospital transfers represents, therefore,...
Matched on
terms: delay, health, mental
Committee recommendation
98match
#28 - Eighth Report - Children and young people’s mental health
In order to achieve this shift towards community-based care, every area should have a community service for children in crisis which is available 24 hours a day, seven days a week. A clear map is needed of where current gaps in this provision are and a plan should be in place to ensure these services are available in...
Matched on
terms: crisi, health, mental
Committee recommendation
95match
#11 - Extend 24/7 Neighbourhood Mental Health Centre pilot programme with funding and finalise metrics.
The design of these centres must be informed by the learnings from the pilot programme so they can be tailored to the needs of their communities. In order for the learnings to be robust, the 24/7 Neighbourhood Mental Health Centre pilot programme must be extended by at least 12 months beyond April 2026, with additional service development funding...
Matched on
terms: delay, health, mental
Committee recommendation
95match
#1 - Severity gap reveals unacceptable failing in timely access to mental health care
Timely access to mental health care is not just a matter of convenience— it is a matter of safety, dignity, and equity. Delays in care can lead to preventable crises, greater distress, poorer outcomes, and higher costs to the system. The severity gap, where people fall between high and low intensity services, reflects an unacceptable failing of the...
Matched on
terms: crisi, delay, health, mental
Committee recommendation
94match
#40 - Slow rollout of Mental Health Support Teams leaves most post-16 students unsupported
Poor mental health is a growing crisis for young people, with rising rates of anxiety, depression and eating disorders—particularly for those aged 17 to 19. The Government has pledged specialist mental health support in all schools and colleges, but the rollout of Mental Health Support Teams (MHSTs) has been slow—only 41% of post-16 students are currently covered. There...
Matched on
terms: crisi, health, mental
PPO recommendation
94match
The Head of Healthcare and Mental Health Clinical Manager
The Head of Healthcare and Mental Health Clinical Manager should ensure that referrals to the mental health team, reporting that a prisoner feels suicidal, prompts an additional mental health assessment within 48 hours.
Matched on
terms: health, mental, referral
PFD report
93match
Vanessa Dadswell
Mental health services lacked an intermediate referral option between 4-hour A&E assessment and 5-day appointments, preventing timely intervention for patients requiring urgent but not emergency care.
Matched on
terms: health, mental, referral
IMB recommendation
93match
Swansea (2025)
Prisoners with significant mental health needs are being held for lengthy periods, often in segregated conditions, whilst waiting for specialist hospital care. Given that demand for inpatient care appears to exceed healthcare capacity, what specific actions will the Minister take to reduce delays, prevent the use of segregation for acutely unwell prisoners and ensure timely access to appropriate...
Matched on
terms: delay, health, mental
HSSIB recommendation
91match
Provision of mental health care to patients presenting at the emergency department
It is recommended that NHS England ensures there is a sustainable funding model to support 24/7 urgent and emergency mental health liaison services in acute general hospitals with emergency departments.
Matched on
terms: health, mental
Committee recommendation
90match
#10 - Eighth Report - Children and young people’s mental health
We welcome and support the proposals in the recent access and waiting times consultation that concluded on 1st September, including crisis response times and a four-week waiting time limit for children and young people, and call on NHS England to publish a detailed roadmap as to how it will be delivered including the additional funding requirements.
Matched on
terms: crisi, health, mental
PHSO casework decision
90match
P-003355 - Birmingham and Solihull Mental Health NHS Foundation Trust
Mr R complained Birmingham and Solihull Mental Health NHS Foundation Trust incorrectly rejected his referrals to its Community Mental Health Team, leaving him without vital mental health support.
Matched on
terms: health, mental, referral
PFD report
89match
Matthew Dunham
Failures in mental health care included delayed emergency referrals, unclear team roles, inadequate assessment of suicide risk, and critical breakdowns in information sharing and coordination among professionals.
Matched on
terms: delay, health, mental, referral
PFD report
89match
Barry Thraves
Significant delays in psychiatric follow-up, lack of community support, and poor communication between mental health teams and GPs led to unaddressed patient deterioration.
Matched on
terms: delay, health, mental
PFD report
89match
Jacqueline Williams
The mental health referral system was prone to human error, failing to provide ED staff with confirmation of accepted referrals or assessment times. The Mental Health Liaison Team also lacked a process to identify patients awaiting assessment.
Matched on
terms: health, mental, referral
PFD report
89match
Richard Grant
Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment outcomes. This risked the patient not receiving timely mental health support.
Matched on
terms: delay, health, mental
PHSO casework decision
89match
P-002499 - Avon and Wiltshire Mental Health Partnership NHS Trust
Ms E complained the crisis team did not listen or offer support options, and as an inpatient, she was denied free movement, proper toilet facilities, correct diet, and a discharge plan.
Matched on
terms: crisi, health, mental
Committee recommendation
89match
#15 - 1st Report - Black people’s experiences of homelessness
We welcome the government’s programmes to increase access to mental health support for people in the homelessness system. We would like to see improved access to referral pathways between health and housing services in areas with high levels of Black homelessness. In these areas, health, mental health and hospital discharge policies should include clear responsibilities for identifying homelessness...
Matched on
terms: health, mental, referral
Committee recommendation
86match
#9 - 3rd Report - Legislative Scrutiny: Mental Health Bill
To help ensure that mental health needs are properly identified before they reach crisis point, we recommend that the Government considers introducing an English equivalent to the right to a mental health assessment that appears in the Mental Health (Wales) Measure 2010. (Recommendation, Paragraph 64)
Matched on
terms: crisi, health, mental
PFD report
85match
Keward Guy Domonic Harding
An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.
Matched on
terms: delay, health, mental
PFD report
85match
Kyle Ashley Smith
An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the reason for this critical communication failure remaining unknown and uninvestigated.
Matched on
terms: delay, health, mental, referral
PFD report
85match
Michael Irlam
A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in care, risking patient abandonment.
Matched on
terms: crisi, health, mental
PFD report
85match
Andrew Horgan
Doctors lacked clear understanding and training on mental health referral procedures, leading to inadequate patient assessment processes.
Matched on
terms: health, mental, referral
PFD report
85match
Samiyo Farah
Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric referrals from A&E.
Matched on
terms: health, mental, referral
PFD report
85match
Stephen Ward
The mental health crisis team lacked a clear protocol for following up with police after requesting a welfare check, leading to delays when police did not respond.
Matched on
terms: crisi, delay, health, mental
PFD report
85match
Paul Hyde
Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a deteriorating condition, despite anxieties being raised by community mental health workers.
Matched on
terms: health, mental, referral
PFD report
85match
Matthew Groom
Significant delays occurred in mental health assessment and prescribed medication administration. Staff failed to plan for patient elopement, did not involve hospital security, and inadequately communicated the patient's detention need to police.
Matched on
terms: delay, health, mental
PFD report
85match
Anna Masson
A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice across the Trust's mental health teams.
Matched on
terms: health, mental, referral
PFD report
85match
Rohan Fitzsimons
Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals taking their own lives while awaiting necessary detention.
Matched on
terms: delay, health, mental
Committee recommendation
85match
#4 - Eighth Report - Children and young people’s mental health
During the pandemic, children and young people’s mental health has significantly worsened and the scale of the backlog mean that the NHS will not be able to treat its way out of this crisis. The need for early intervention and prevention in children and young people’s mental health has been consistently overlooked by successive governments and although there...
Matched on
terms: crisi, health, mental
IMB recommendation
85match
Downview (2025)
Acutely mentally unwell prisoners continue to arrive at the prison. They often face long delays in transfer to secure psychiatric units, following assessment and referral (6.1). How confident is the Minister that the statutory 28-day time limit for transfer from prison to hospital, envisaged by the Mental Health Bill, will be achievable, given the low number of suitable...
Matched on
terms: delay, health, mental, referral
IOPC learning recommendation
84match
Recommendations - Northumbria Police, July 2024
The IOPC recommends that Northumbria Police should work with Cumbria, Northumbria Tyne and Wear NHS (CNTW) to review and revise the referral points discussed in the Street Triage Team (STT) Operational Policy document around when a member of the public may require CRISIS intervention or home based treatment, to ensure that the referral points and guidance to staff...
Matched on
terms: crisi, health, mental, referral
Inquiry recommendation
83match
R96 - Access to mainstream mental health services
SPPG must ensure that people with learning disabilities and autistic people have access to mainstream (i.e. the same services that are available to those without a learning disability) mental health services, with appropriate adjustments for their disabilities.
Matched on
terms: health, mental
Committee recommendation
83match
#17 - Create clear, actionable plan to deliver comprehensive mental health offer for 0-25 year olds.
Despite nearly a decade of commitments, the transition from Children and Young People’s Mental Health Services (CYPMHS) to Adult Mental Health Services (AMHS)—including Community Mental Health Services (CMHS)— remains a cliff edge and continues to fall short of what young people need. The Government, NHS England, and Integrated Care Boards must treat this issue as a national priority....
Matched on
terms: health, mental
Committee recommendation
83match
#10 - Establish a 24/7 Neighbourhood Mental Health Centre in every community.
We believe there should be a 24/7 Neighbourhood Mental Health Centre in every community. (Recommendation, Paragraph 92)
Matched on
terms: health, mental
Committee recommendation
82match
#42 - Improve access to CAMHS and adult mental health services for young people with severe conditions.
The Government must improve access to Children and Adolescent Mental Health Services (CAMHS) and adult mental health services for those children and young people with more severe mental health conditions and whose education is often interrupted for months or years at a time by the long waits for services and treatment. (Recommendation, Paragraph 161)
Matched on
terms: health, mental
Committee recommendation
82match
#26 - Eighth Report - Children and young people’s mental health
Inpatient units have a role to play in treating some of the most severe and complex mental health conditions, especially those that are resistant to community treatment. However, in most cases the most compassionate and effective care for children and young people is provided in the community–and increasing its provision must be the overall aim of the Department...
Matched on
terms: health, mental
PFD report
81match
Simon Sankey
The categorisation of mental health referrals was done by an unqualified administration assistant, with no subsequent review of the urgency category, and the electronic system for prioritising referrals was not available to all senior nurse practitioners.
Matched on
terms: health, mental, referral
PFD report
81match
Sandra Bodrozic
Significant delays occurred in securing a hospital bed and arranging Mental Health Act assessments, exacerbated by a lack of urgency, protocol, and exploration of private bed options.
Matched on
terms: delay, health, mental
PFD report
81match
Eve Cullen
Referrals from hospital were not actioned or treated as urgent due to a lack of service-wide definition for "urgent" and no agreed timeframes. The process led to lost opportunities for timely intervention in mental health care.
Matched on
terms: health, mental, referral
PFD report
81match
Sian Armstrong
A significant delay occurred in providing Cognitive Behavioural Therapy (CBT) for a child, Sian Armstrong, who was assessed as needing it, highlighting a lack of timely access to critical mental health support.
Matched on
terms: delay, health, mental
PFD report
81match
Barbara Mayer
Carer fatigue was not followed up, inconsistent crisis team contacts prevented establishing trust, and urgent help was delayed due to increased demand. Treatment options were also not adequately discussed with the patient.
Matched on
terms: crisi, delay
PPO recommendation
81match
The Head of Healthcare
The Head of Healthcare should ensure there is an effective system for urgent mental health referrals to be tracked and carried out within a reasonable timescale.
Matched on
terms: health, mental, referral
CQC action
81match
Birmingham Children's Hospital
The trust should consider effective pathways are fully embedded between the Child and Adolescent Mental Health Service (CAMHS) and the emergency department. Where the CAMHS team do not respond within agreed timescales, the service should ensure staff are escalating these concerns so that patients receive care and treatment in a timely manner.
Matched on
terms: health, mental
IMB recommendation
81match
Thameside (2021)
Delays in transferring severely mentally ill prisoners to secure establishments that provide more specialist treatment have been a longstanding concern of the Board. While the government’s positive response to Sir Simon Wessely’s mental health review is noted, transfer wait times for these vulnerable individuals have remained this year overall in excess of NHS England guidelines.
Matched on
terms: delay, health, mental
IMB recommendation
81match
Downview (2023)
As commented on last year, the considerable rise in the number of prisoners being transferred to the prison, often from HMP Bronzefield, who exhibit more challenging mental health symptoms and consequent behavioural issues is causing safety concerns. Prison is not an appropriate environment for these women and staff do not have the appropriate training to manage them. The...
Matched on
terms: delay, health, mental
Scottish FAI
81match
Clare Shannon
(i) NHS Lothian should ensure that the Royal Edinburgh Hospital (or one of its associated services) is in a position to offer adult psychiatric inpatient care for patients diagnosed with EUPD who require admission (beyond the average 10 to 14 day period of stabilisation and assessment which is offered on acute wards) in a safe, secure and therapeutic...
Matched on
terms: health, mental
PPO recommendation
81match
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff at Pentonville understand that referrals to secure mental health units should only be made through the prison’s mental health Inreach team.
Matched on
terms: health, mental, referral
PPO recommendation
81match
The healthcare provider and the NHSE quality team
The healthcare provider and the NHSE quality team should consider whether the behaviour of the nurse who cancelled multiple mental health referrals requires discussion with the appropriate regulator.
Matched on
terms: health, mental, referral