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
GIRFT recommendation
100match
Children and Young People's Mental Health Services
There must be an effective and sufficiently resourced CYP urgent & emergency mental health pathway based on local needs and with effective data collection to drive QI. The pathway, as indicated in the Long Term Plan, will operate 24 hours a day, seven days a week. It will combine crisis assessment, brief response, and intensive home treatment functions....
Matched on
terms: crisi, health, mental
Inquiry recommendation
99match
73 - Reception health screen referral to mental health
The first reception health screen questionnaire should be revised so as to trigger a referral to a mental health professional on the healthcare team even if the prisoner has only self-harmed in prison. A referral should also be triggered where the prisoner’s behaviour is such that the healthcare officer completing the questionnaire considers it desirable.
Matched on
terms: health, mental, referral
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
GIRFT recommendation
95match
Mental Health – Adult Crisis and Acute Care
Trusts need to work with system partners to understand and mitigate increased demand on SMI services related to COVID-19. a Ensure the sustainability of new and/or modified practices such as rollout of 24/7 access lines, and wider use of remote working models and technology established during COVID-19 to improve or assist use of available capacity. b 24/7 crisis...
Matched on
terms: crisi, 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
CQC enforcement action
94match
Conditions Imposed: Croydon Health Services NHS Trust
The Care Quality Commission (CQC) told Croydon Health Services NHS Trust that it must improve the quality of care provided to patients in mental health crisis in its urgent and emergency services at Croydon University Hospital. Following an unannounced, focused inspection in October, CQC took enforcement action and imposed conditions against the trust registration. These conditions require the...
Matched on
terms: crisi, health, mental
PFD report
93match
Jacqueline Williams
The coroner noted insufficient systems for mental health referrals, allowing human error to go undetected. Emergency department staff could not confirm referral acceptance, nor could the Mental Health Liaison Team identify patients awaiting assessment.
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
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.
Matched on
terms: delay, health, mental, referral
PFD report
89match
Amanda Vickers
Insufficient availability of beds at the county's sole mental health crisis home meant a patient died while awaiting admission. The report notes the need for a review of facility provision.
Matched on
terms: crisi, health, mental
PFD report
89match
Barry Thraves
The report identifies significant delays in psychiatric follow-up appointments and a lack of planned community support, compounded by poor communication between mental health teams and other stakeholders. Insufficient information was provided to the patient and family regarding care teams and contact points.
Matched on
terms: delay, health, mental
PFD report
89match
Richard Grant
A patient's mental health referral was sent to the incorrect team and experienced an unexplained delay, while communication regarding the assessment outcome was not sent to the GP in a timely manner.
Matched on
terms: delay, health, mental, referral
PFD report
89match
Christopher Jones
Delays in completing Care Treatment Plans post-discharge meant patients might not see a consultant psychiatrist for up to sixteen months. Concerns were also raised about insufficient staff cover due to increasing demand on mental health services.
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
Kyle Ashley Smith
The coroner noted a delay in an urgent mental health referral from Mr Smith's GP reaching the Mental Health Assessment Team, and that the reason for this delay had not been investigated.
Matched on
terms: delay, health, mental, referral
PFD report
85match
Andrew Horgan
The coroner identified knowledge gaps among doctors and medical staff regarding referral procedures for mental health assessments and engaging Mental Health Partnership personnel, noting a need for improved training on effective communication pathways.
Matched on
terms: health, mental, referral
PFD report
85match
Sandra Bodrozic
Concerns were raised about delays in securing an informal hospital admission for the patient and a lack of exploration of private bed options. Further concerns noted delays in arranging Mental Health Act assessments, with no clear protocols for timeframe or communication regarding urgent assessment options.
Matched on
terms: delay, health, mental
PFD report
85match
Mark Daniels
The crisis team failed to adhere to Mr Daniels' visit plan or document non-compliance, and had communication issues. Concerns were also raised about delays in crisis house referrals and insufficient consideration of hospital admission despite high-risk factors.
Matched on
terms: crisi, delay, referral
PFD report
85match
Matthew Groom
The coroner noted delays in mental health assessment, medication not administered, and an absence of a clear plan if the patient left the department. Insufficient communication with hospital security and police regarding the patient's mental state was also a concern.
Matched on
terms: delay, health, mental
PFD report
85match
Rohan Fitzsimons
The coroner identified insufficient availability of in-patient mental health beds, leading to delays in Mental Health Act Assessments. These delays could result in individuals taking their own lives before assessment and bed provision.
Matched on
terms: delay, health, mental
Committee recommendation
85match
#89 - 1st Report - Cutting crime: better community sentences
Many people on probation suffer from mental health issues and from addiction to alcohol or drugs, which fuels their offending behaviour. Few of them are referred to a Community Sentence Treatment Requirement (CSTR). And yet, referrals exceed the availability of treatment, which may in itself deter sentencers from making referrals.
Matched on
terms: health, mental, referral
Committee recommendation
85match
#82 - 1st Report - Cutting crime: better community sentences
Even when treatment is available, witnesses told us about delays before it starts. Justin Russell said that âas with services for others living in the community, there are huge waiting lists at the moment for things like mental health treatment, and people on probation are joining a very long queue.â 154 The Criminal Justice Alliance added that âthe...
Matched on
terms: delay, health, mental
Committee recommendation
85match
#80 - 1st Report - Cutting crime: better community sentences
Witnesses told us that referrals exceed availability and that increasing availability âwould save livesâ, especially in respect of mental health. 145 Tom Franklin told us that âlocal services may not be availableâ to deliver treatment requirements, such that the Probation Service would not recommend them in Pre-Sentence Reports in the first place, adding that âthis is particularly the...
Matched on
terms: health, mental, referral
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
NCEPOD recommendation
83match
Mental Healthcare in Young People and Young Adults
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
GIRFT recommendation
82match
Mental Health Rehabilitation
1.3 All trusts, health commissioners and LAs should ensure timely access to rehabilitation services and introduce local 'access and wait times' data to optimise and monitor. This should include rehabilitation services accessing evidence-based interventions and services, in line with relevant NICE guidance. a Identification of all people who meet the criteria for rehabilitation services, including people with complex...
Matched on
terms: health, mental
CQC enforcement action
82match
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Greater Manchester Mental Health NHS Foundation Trust. This action followed a focused inspection in April of community-based mental health services for adults of working age. Inspectors found that patients and carers struggled to contact the service, and there were concerns regarding staffing levels and the monitoring of patients,...
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
Unqualified administrative staff categorised urgent mental health referrals without clinical review or re-prioritisation by nursing staff. The coroner also identified a lack of robust systems for tracking non-contact referrals and managing the high workload of Senior Nurse Practitioners.
Matched on
terms: health, mental, referral
PFD report
81match
Samiyo Farah
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.
Matched on
terms: health, mental, referral
PFD report
81match
Eve Cullen
The coroner noted a failure to action and treat mental health referrals as urgent, identifying a lack of service-wide definitions for terms like 'urgent' and no agreed timeframes for referral action. This represented a lost opportunity for timely intervention.
Matched on
terms: health, mental, referral
PFD report
81match
Barbara Mayer
The coroner noted a lack of continuity in crisis team care, where the patient repeatedly recounted personal history. Concerns also related to insufficient discussion of treatment options and efficacy, and a delay in providing urgent help.
Matched on
terms: crisi, delay
PFD report
81match
Vanessa Dadswell
The coroner highlights the need for an intermediate referral option between the existing '4-hour' and 'within 5-day' periods for urgent mental health service referrals, alongside effective management of this new category.
Matched on
terms: health, mental, referral
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