Poor mental health triage record-keeping
Lack of comprehensive written records for triage decisions in mental health services, leading to gaps in accountability.
Source spread
Where this theme appears
This theme appears across 11 independent accountability sources, so the source mix matters as much as the headline total.
15 PFD reports
1 committee rec
3 CQC actions
5 PPO recs
2 IOPC recs
2 IMB recs
11 DHR recs
2 PHSO decisions
8 LGO/SPSO 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(15)
Sean Seabourne
Concerns: The coroner noted insufficient formal communication and clarity of roles between mental health teams, which meant critical information about a patient's settled plans to kill himself was not adequately shared or acted upon.
Overdue
Adam Withers
Concerns: The coroner identified insufficient recording of observations and interactions with psychiatric patients, noting some staff lacked understanding of record-keeping importance. Additionally, concerns were raised about non-contemporaneous notes made post-death without retrospective labelling.
Response (Department of Health): • The Department of Health stated its view that original paper records should not be destroyed if a patient's death may be subject to investigation. • The NHS Records Management … (AI summary)
Response (Adam WITHERS): • The Trust instigated a purposeful engagement process to improve staff interactions and timely record-keeping. • The Trust revised its Observation Policy to include clearer guidance on recording clinical interventions … (AI summary)
Response (CQC): • The CQC and NHS Improvement stated they would jointly design the approach the CQC will use to assess trusts' use of resources. • They indicated they would share revised … (AI summary)
Responded
Oliver Ford
Concerns: The coroner raised concerns regarding the telephone triage process, noting a need to include a risk assessment within it and ensure all risk assessments are documented. There were also concerns about the weekend cover for the PCLS service to prevent delays in patient follow-up.
Response (Avon and Wiltshire NHS Trust): • The telephone triage process now incorporates an Access Trigger Tool to conduct in-depth risk assessments. • Clinicians are required to document a full rationale for decision-making on RIO following … (AI summary)
Responded
Richard Walsh
Concerns: The coroner noted significant gaps in communication and information-sharing processes between custodial, health, police, court, and prison services. This led to crucial mental health information being lost or distorted, particularly due to a lack of automatic sharing for Mental Health Act assessments between agencies.
Response (Virgin Care Limited): • Virgin Care arranged additional ACCT awareness training for all current healthcare colleagues, to be completed by the end of January 2017. • An annual ACCT refresher training programme has … (AI summary)
Response (Department of Health): • The Department of Health brought the coroner's report to the attention of the Health and Care Professions Council (HCPC). • The Department of Health asked the HCPC to respond … (AI summary)
Response (Health Care Professions Council): • The Health Care Professions Council (HCPC) reviewed its criteria for Approved Mental Health Professional (AMHP) training and stated that they continue to set out appropriate requirements. • The HCPC … (AI summary)
Response (Hampshire County Council): • Hampshire County Council and Portsmouth City Council introduced a requirement in November 2016 for Approved Mental Health Professionals (AMHPs) to receive a written medical report from assessing doctors when … (AI summary)
Responded
Greg Hutchins
Concerns: The coroner noted a lack of clear purpose and documentation for telephone triage, including no notes, system updates, or staff recollection. There was also no national system for rapid information sharing for patients from outside the local area.
Overdue
Gregory Rewkowski
Concerns: Concerns included Pennine Care Trust's process for raising welfare concerns and escalating issues, North West Ambulance Service's limited investigation and inadequate telephone triage, and inter-agency confusion over police roles in Section 136 incidents.
Response (Pennine Care NHS Trust): • Staffing levels on wards have increased, and a memo has been issued to staff regarding seeking support from On-Call managers. • The Trust is seeking to update policies and … (AI summary)
Response (Greater Manchester Police): • Greater Manchester Police (GMP) has implemented a Control Room Triage (CRT) service, operational 24/7 since September 2018, which integrates mental health professionals with police staff to support responses to … (AI summary)
Response (GMCA): • A pan-Greater Manchester (GM) protocol for response has been developed to establish common understanding, shared risk assessment, and communication and escalation procedures. • Eight issues were identified, and task … (AI summary)
Responded
Natalie Hunter
Concerns: The coroner noted delays or absence of discharge summaries from the Isle of Wight NHS Trust to GPs, affecting continuity of care for mental health patients. Concerns were also raised about insufficient out-of-hours mental health staff due to funding limitations.
Overdue
Darrell Sharples
Concerns: The coroner noted that the clinician conducting a telephone triage assessment was unfamiliar with the Trust's Operational Policy and Triage guidance, emphasizing the need for a robust system to ensure future clinicians are familiar with relevant documents.
Response (Cornwall Partnership NHS Foundation Trust): • The Trust introduced a 24-hour response telephone line and appointed a Senior Operational Lead and six Band 7 Clinical Leads to the Initial Response Service. • The Single Point … (AI summary)
Response (Devon and Cornwall Police and Kernow NHS Clinical Commissioning Group): • Cornwall Partnership NHS Foundation Trust recruited a Mental Health Liaison Officer to provide advice and guidance on best practice for individuals with mental health disorders in a criminal justice … (AI summary)
Response (Further response and update from Cornwall Partnership NHS Foundation Trust): • The Trust launched an Initial Response Service and developed a standardised triage tool for adult mental health services. • A training package for clinicians undertaking triage assessment is being … (AI summary)
Responded
Keith Nottle
Concerns: The coroner identified a practice where telephone workers bypassed specialist mental health assessments, making risk judgments on limited criteria. Issues included a lack of care co-ordination and clarity in the multi-disciplinary team's discharge decisions and approach to re-referrals.
Response (Turning Point): • Turning Point reviewed and refreshed key factors for helpline workers, including referral escalation, training, supervision, monitoring, and audit. • Turning Point agreed a Standard Operating Procedure (SOP) with Nottinghamshire … (AI summary)
Response (NHS Nottinghamshire Healthcare): • The competency assessment for staff was updated, and local guidance for the UK Mental Health Triage Scale was reviewed to include a more robust escalation process. • The Standard … (AI summary)
Responded
Demet Akcicek
Concerns: A patient was not placed on the multi-disciplinary team meeting board for discussion, leading to no follow-up despite reporting distress. The welfare check documentation was also found to be insufficient, and the Trust provided no evidence of preventative steps.
Response (Camden and Islington NHS Foundation Trust): • The Trust updated the Complex Depression Anxiety and Trauma Team (CDAT) Operational Policy. • A daily duty sheet/tracker has been implemented to log all matters, with daily cross-checking by … (AI summary)
Responded
Jack Farrington
Concerns: The coroner raised concerns about the limited sharing of electronic mental health records between NHS trusts, hindering timely access to patient history. Within the mental health unit, issues included the recording and storage of handover information and the reliance on paper records.
Response (Solent NHS Trust): • The Trust's Clinical Leadership Team is attending handovers and undertaking quality audits of clinical records to mitigate risks. • Work is underway to transfer the handover process to SystmOne, … (AI summary)
Response (Portsmouth Hospitals University NHS Trust): • The Trust updated its Mental Health Primary Risk Assessment Survey Tool and introduced a twice-daily Plan of Care Mental Health Huddle. • The Trust implemented flagging of mental health … (AI summary)
Overdue
Leslie Swindells
Concerns: Concerns were raised regarding a mental health assistant practitioner's limited training, insufficient understanding of risk, and unclear supervision. The report also noted inadequate patient triage, challenges with telephone assessments, and poor documentation.
Response (GTD Healthcare): • GTD Healthcare ceased the employment of Assistant Practitioners in Mental Health. • The organisation introduced a digital front door system for patient triage and reviewed induction processes for agency … (AI summary)
Response (Department of Health and Social Care): • Departmental officials made enquiries with NHS England and the Care Quality Commission (CQC) regarding the concerns raised. • NHS England reviewed the concerns and provided information to the Department … (AI summary)
Responded
Jan Raciborski
Concerns: The coroner noted the absence of written records for risk assessments by the AMHT, which could lead to inadequate information sharing and hinder future investigations into deaths.
Response (Oxford Health NHS Foundation Trust): • The team manager initiated supervision training for supervisors and held a meeting to discuss documenting risk assessments. • The Trust developed a clinical audit tool in autumn 2024 to … (AI summary)
Responded
Paul Dunne
Concerns: Coroner noted insufficient knowledge and judgment among mental health professionals regarding high-risk assessment and Mental Health Act. Concerns also included Mental Health Trust staff's unawareness that A&E policies for risk assessment and monitoring applied.
Response (NHS England): • NHS England stated it provided funding for Electronic Patient Record (EPR) implementation across NHS Trusts and specified a core information standard for Shared Care Records (ShCRs). • King’s College … (AI summary)
Response (CQC): • The CQC stated it would incorporate the PFD report's information into its ongoing monitoring and assessment planning for the providers. • The CQC indicated it would ask Oxleas NHS … (AI summary)
Overdue
Edward Hands
Concerns: The coroner noted conflicting policies between the prison healthcare provider and prison staff regarding prisoners suspected of being under the influence of illicit substances. This resulted in confusion, a lack of awareness, and a prisoner's clinical deterioration not being recognised or escalated due to missed observations.
Response (Northamptonshire Healthcare NHS Foundation Trust): • A common local protocol for managing prisoners suspected to be under the influence of illicit substances has been agreed and implemented at HMP Bedford. • The UTI protocol and … (AI summary)
Response (HM Prison Probation Service): • HMP Bedford and Northamptonshire Healthcare Foundation Trust (NHFT) conducted a joint review of Under the Influence (UTI) policies and protocols. • A single, standardised UTI protocol has been implemented … (AI summary)
Response (HMP Bedford): • HMP Bedford implemented a local protocol outlining procedures for managing prisoners suspected of being under the influence of substances. • The protocol provides detailed guidance on staff response, welfare … (AI summary)
Responded
Select committee recommendations(1)
CQC inspection actions(3)
Northern General Hospital
The trust should implement systems to ensure all patients receive an initial mental health triage on arrival to the department.
Should Do
Sunnyside
Further improvement was required in the level of detail, particularly around what action staff had taken to de-escalate people's behaviour prior to the use of medication. Furthermore, no analysis of incidents had occurred in order to identify any potential trends …
Should Do
Verve Health
The service must ensure that observation records indicate the level of observation and reasoning for levels of observation.
Must Do
PPO death in custody recommendations(5)
The Head of Healthcare at The Mount
The Head of Healthcare at The Mount should ensure that the reasons for mental health referrals are clearly documented so that staff can assess any potential risks.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who need mental health support receive a full mental health assessment to determine if they need individual therapeutic intervention.
The Head of Healthcare
The Head of Healthcare should: • review the mental health referral and triage process to ensure that assessments are based on all available information; and • ensure that prison staff are involved in case discussions when they report concerns about …
The Head of Healthcare
The Head of Healthcare should ensure that mental health assessments are updated when there are changes in a prisoner’s clinical presentation and circumstances.
The Head of Healthcare
The Head of Healthcare should ensure that mental health staff consider the results of previous mental health assessments when completing the initial mental health assessment.
IOPC learning recommendations(2)
Recommendations - Northumbria Police, July 2024
The IOPC recommends that Northumbria Police provides guidance to the Street Triage Team (STT) around the importance of considering the particular circumstances faced by frontline officers when attending an incident, when making a decision about how best to resolve a …
Recommendation - Sussex Police, January 2025
The IOPC recommends that Sussex Police update its call-handling training and guidance to include clear direction on when Contact Officers should seek specialist medical advice or support, particularly in cases where a sudden death is suspected. This follows an IOPC …
IMB individual recommendations(2)
Exeter (2020)
Will the Secretary of State exert influence with colleagues to improve the transfer arrangements for those with severe mental health issues, to an environment more suitable to meet their mental health needs? The Board remains concerned about the difficulties encountered in transferring prisoners with severe mental health issues, often held in the segregation unit, to an environment where they can …
Ministry of Justice
In Progress
Elmley (2020)
The Board would ask the minister to review the effectiveness of the Criminal Justice Liaison and Diversion Service (CJLADS), given the number of prisoners that arrive at the establishment with a mental health diagnosis. Is the scheme working as it was designed to do, and is it properly resourced?
Ministry of Justice
Accepted
Health investigations(7)
Independent investigation: Anita Bawtree, Southampton (2011) — Rec 15
Ensure that the record of referral from Emergency Department re: mental health problems is included on the patient’s electronic mental health records by the mental health team receiving the referral, regardless of whether the patient is seen in Emergency Department, the Mental Health team refuse to see or patient self …
south_east
Multi-agency systems review to identify the learning following five homicides … — Rec 2
Mental health assessments carried out by L&D should include a narrative description of the mental state examination. L&D assessment forms should be restructured to provide more guidance in the mental health section of the form, ensuring it encompasses mental state examination.
south_west
Accepted
Independent investigation: Sally Poynton, Crowlas (2021) — Rec 5
The Trust must ensure that crisis team staff comply with policy expectations by recording their decisions and the actions taken or not taken as part of MHA assessment requests.
south_west
Independent investigation: Nicole TownshendJane Malkin, Leicester (2007) — Rec 5
The LPT crisis resolution and home treatment service needs to minimise the loss of information along the communication pathway from those making referrals to the assessing mental health practitioners. This investigation highlights the dangers of introducing too many variables in a communication pathway when service users are referred for assessment …
midlands
Independent investigation: Alan ScottStella Scott, Allerton, Liverpool (2008) — Rec 2
All clinical business units in Mersey Care NHS Trust need to implement a more dynamic approach to how it audits and reviews the quality of clinical documentation. The quality of documentation was not of the standard expected in Mr SU‟s community mental health records. In particular, there was no depth …
north_west
An independent investigation into the care and treatment of Darren … — Rec 2
Isle of Wight NHS Trust IAPT service must either develop a bespoke IAPT service risk assessment or utilise the community mental health risk assessment tool. The IAPT risk assessment must include the identification and assessment of : • All potential risk, including the patient’s risk to self and others • …
Isle of Wight NHS Trust
south_east
An independent investigation into the care and treatment of Darren … — Rec 12
The IAPT referral information requires further amendments in order to clarify the criteria of referrals, including any prohibitive risk histories.
Isle of Wight NHS Trust
south_east
PHSO casework decisions(2)
P-004151 — Norfolk and Suffolk NHS Foundation Trust
The Trust allegedly failed to communicate with Ms B's family, ignored distress, poorly managed records and suicide risk, misdiagnosed EUPD, and changed medication without consulting prior plans.
NHS in England
Partly Upheld
Oct 2025
P-004260 — Oxford Health NHS Foundation Trust
Dr J complained a mental health nurse from Oxford Health NHS Foundation Trust gave incorrect advice to police, resulting in her unnecessary removal from home under the Mental Capacity Act.
NHS in England
Nov 2025
LGO / SPSO decisions(8)
PSOW-201903330 — Cwm Taf Morgannwg University Health Board
Ms C complained about her daughter, H’s, management and care by Cwm Taf Morgannwg University Health Board’s “(the First Health Board’s”) Child and Adolescent Mental Health Services (“CAMHS”), including what Ms C felt was an unreasonable delay in diagnosing her daughter’s Borderline Personality Disorder (“BPD”). Ms C also complained about …
PSOW (Public Services Om…
Health
Upheld
Jun 2021
21-009-384d — Rotherham, Doncaster & South Humber NHS Foundation Trust …
Summary: Ms A complained about several organisations involved in her father, Mr D’s care, when his physical health and behaviour deteriorated towards the end of his life. Mr D had dementia. Ms A said failings in Mr D’s care meant his family were distressed by his deterioration. We found fault …
LGO (Local Government & …
Health
Not Upheld
Sep 2022
24-018-535b — Hampshire and Isle of Wight Healthcare NHS Foundation …
Summary: We will not investigate this complaint about the decision to apply for a warrant to gain entry to Miss D’s home and take her to a place of safety to assess her mental health. It is unlikely we would find fault and Miss D had a right of appeal …
LGO (Local Government & …
Health
Jun 2025
24-018-535a — Island City Practice (24 018 535a)
Summary: We will not investigate this complaint about the decision to apply for a warrant to gain entry to Miss D’s home and take her to a place of safety to assess her mental health. It is unlikely we would find fault and Miss D had a right of appeal …
LGO (Local Government & …
Health
Jun 2025
25-000-113b — NHS Cheshire and Merseyside ICB (25 000 113b)
Summary: Ms X complains the Council, Trust and ICB are not providing her with section 117 aftercare support which she is entitled to after being detained under Section 3 of the Mental Health Act 1983. We will not investigate this complaint because we have seen evidence all the organisations have …
LGO (Local Government & …
Health
Jul 2025
25-000-113a — Mersey Care NHS Foundation Trust (FT) (25 000 …
Summary: Ms X complains the Council, Trust and ICB are not providing her with section 117 aftercare support which she is entitled to after being detained under Section 3 of the Mental Health Act 1983. We will not investigate this complaint because we have seen evidence all the organisations have …
LGO (Local Government & …
Health
Jul 2025
24-021-993b — NHS Staffordshire and Stoke-On-Trent ICB (24 021 993b)
Summary: We will not investigate Ms X’s complaint about Staffordshire County Council, North Staffordshire Combined Healthcare NHS Trust and NHS Staffordshire and Stoke-on-Trent Integrated Care Board. She says they ignored her views when it moved her brother, Mr Y, to a care home, which cannot meet his mental health needs. …
LGO (Local Government & …
Health
Apr 2025
24-021-993a — North Staffordshire Combined Health Care NHS Trust (24 …
Summary: We will not investigate Ms X’s complaint about Staffordshire County Council, North Staffordshire Combined Healthcare NHS Trust and NHS Staffordshire and Stoke-on-Trent Integrated Care Board. She says they ignored her views when it moved her brother, Mr Y, to a care home, which cannot meet his mental health needs. …
LGO (Local Government & …
Health
Apr 2025
Domestic Homicide Reviews(11)
Croydon — recommendation 6.1.3.e
Complete internal review of level of contact detail recorded. Outcome: To ensure that AIR Network records sufficient level of information to more effectively support and review an individual’s progress and record any untoward or concerning behaviours that may indicate an increase or deterioration in mental health.
AIR Network
Ealing — recommendation 32
Consider how mental health diagnosis and domestic violence issues are coded or flagged within GP records.
Ealing ICB
Kent — recommendation 5
Where an agency expresses a view as to the decision a Mental Health Tribunal should consider, then, such a view must be supported with a rationale, either in person or in the form of documentary evidence.
SoS
Chorley and South Ribble — recommendation 1
Accurate recording of Mental Health referrals, assessment, and interventions.
Lancashire Teaching Hospitals NHS Trust
Lancashire Teaching Hospitals NHS …
Somerset — recommendation 5
Improve consistency of community mental health staff always clearly documenting source of disclosure of historic domestic abuse relevant details, whether or not the information can be substantiated.
Somerset NHS Foundation Trust
Taunton and Somerset NHS …
Leicester — recommendation 8
Discussion with AMHP manager to improve consistent use of paperwork and timely inputting of assessment onto LAS.
Leicestershire Adult Social Care
Leicestershire County Council
Bath and North East Somerset — recommendation R18
All patients on mental health register to have documentation of consideration of safeguarding issues
GP Practice
Bath and North East Somerset — recommendation R17
Baseline assessment of documentation of consideration of child and adult safeguarding issues for all patients on mental register
GP Practice
Epping Forest — recommendation 12.2
All Mental Health Service staff to continue to make attempts to obtain collaborative information and to indicate in progress notes the reason for not obtaining collaborative information from families and carers.
NELFT
North East London NHS …
Harrow — recommendation 8
That the standardised format is revised and issued for staff to use for session notes, incorporating prompts to identify and respond to and record safeguarding, substance use, violence and abuse and mental health issues of client
Each
Tower Hamlets — recommendation 2
Stepney and Wapping CMHT acknowledged the processing error on their part; the referral should have been discussed in their clinical meeting which took place on 21/12/20. Action: The following steps to prevent repeat incidents has already been commissioned: i) the victim’s referral was sent to Stepney and Wapping CMHT email …
Stepney and Wapping CMHT