Therapy access barriers
Long waiting times and accessibility restrictions for vital psychological therapies for mental health inpatients.
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.
17 inquiry recs
54 PFD reports
79 committee recs
2 HSSIB recs
6 CQC actions
4 PPO recs
2 PHSO recs
16 IMB recs
1 detention investigation rec
59 PHSO decisions
9 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.
Inquiry recommendations(17)
FR-16 — Specialist Therapeutic Support
Recommendation: The Inquiry recommends that the UK government and the Welsh Government introduce a national guarantee that child victims of sexual abuse will be offered specialist and accredited therapeutic support. There should be sufficient supply of these services so that children …
Gov response: We accept that victims and survivors must be able to access effective systems for provision of therapeutic support. We will elicit views on the future of therapeutic support, including possible systemic changes to provision, through …
Accepted in Part
89 — Church funding policy for victim support
Recommendation: The Church of England and the Church in Wales should each introduce a Church-wide policy on the funding and provision of support to victims and survivors of child sexual abuse concerning clergy, Church officers or those with some connection to …
Gov response: On 7 April 2021, the Church in Wales stated that it had introduced Independent Sexual Violence Adviser (ISVA) support for survivors. The Church in Wales committed to offer funding towards counselling recommended by an ISVA …
Accepted
88 — Rehabilitation code for CSA civil claims
Recommendation: The International Underwriting Association of London should take the lead in the production of a code for the benefit of claimants who are bringing civil claims for child sexual abuse. The aim should be to produce a code, comparable to …
Gov response: On 23 February 2021, the International Underwriting Association of London stated that it had established a working party to develop a rehabilitation code. On 14 December 2021, the International Underwriting Association of London stated that …
Accepted
R97 — Funded access to primary care
Recommendation: The SPPG must ensure that commissioning includes provision for people with learning disabilities and autistic people cared for in any facility to have fully funded access to primary care services. These may be provided by LD nurse practitioners/LD nurse consultants. …
Response Pending
R96 — Access to mainstream mental health services
Recommendation: 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.
Response Pending
R29 — Psychology input to reduce restrictive practices
Recommendation: All facilities providing residential services for people with learning disabilities and autistic people should provide sufficient psychology input for each patient, to obviate the need for restrictive practices in all but the most exceptional circumstances.
Response Pending
R10 — Access to allied health professionals
Recommendation: It is critical for the wellbeing of people with learning disabilities and autistic people that they are well supported by, and have access to, AHPs including psychologists, speech and language therapists (SALTs), occupational therapists (OTs), podiatrists and dieticians. These AHPs …
Response Pending
86 — Review CSA support services expenditure (England)
Recommendation: The Chair and Panel recommend that the Department of Health and Social Care, the Department for Education, the Ministry of Justice and the Home Office work together to establish current levels of public expenditure, and the effectiveness of that expenditure …
Gov response: The Government agrees that more clarity is needed on the effectiveness of public expenditure on services for victims of child sexual abuse. The Government will present findings to the Inquiry within one year.
Accepted
81 — Revised damages guidelines for CSA cases
Recommendation: The Judicial College should revise its Guidelines for the Assessment of General Damages in Personal Injury Cases to include a freestanding section on the damages that may be appropriate in cases of child sexual abuse. This new section of the …
Gov response: The Judicial College informed the Inquiry that the revised edition of its Guidelines for the Assessment of General Damages in Personal Injury Cases was published on 11 April 2022. The Judicial College stated that the …
Accepted
79 — Codes of practice for civil CSA claims
Recommendation: The Local Government Association and the Association of British Insurers should each produce codes of practice for responding to civil claims of child sexual abuse. The codes should include recognition of the long-term emotional and psychiatric or psychological effects of …
Gov response: Association of British Insurers: In August 2021, the Association of British Insurers published a Code of Practice on Responding to Civil Claims of Child Sexual Abuse. It seeks to improve certain aspects of the civil …
Accepted
IR2-17 — Bespoke Psychological Service
Recommendation: I recommend that without delay steps be taken to provide a bespoke psychological service in England.
Gov response: With respect to recommendations 15 and 17 of the Second Interim Report, the Government acknowledges the immense psychological harm that has been caused as a result of this scandal, and is committed to offering psychological …
Accepted
IBI-A-8a — Supplementary Route for Affected Persons
Recommendation: The Minister give consideration to there being a supplementary route for people affected. This could include opening the supplemental award for severe psychological harm to people affected. He should involve parents, children, siblings, partners and carers, and their legal representatives …
Gov response: In his oral evidence to the Inquiry, the Minister for the Cabinet Office agreed to look again at how the Scheme compensates affected people through a supplementary route. The Government has accepted the Inquiry's recommendation …
Accepted in Part
IBI-A-5a — Severe Psychological Harm
Recommendation: The approach of the Infected Blood Psychology Service is adopted so that both a diagnosis made by a psychiatric professional and a formulation-based opinion of all qualified psychological and counselling professionals are accepted as sufficient evidence of severe psychological harm …
Gov response: The Government accepts more needs to be done to test with the community the severity level and evidential requirements for those applying with severe psychological harm under the severe health condition award. The Government has …
Accepted in Part
33 — Improve HMIP and IMB evidence gathering and reporting processes
Recommendation: HM Inspectorate of Prisons and Independent Monitoring Boards working within immigration removal centres must ensure that they have robust processes for: obtaining and reporting on an enhanced range of evidence and intelligence from detained people and those who represent or …
Gov response: The government stated it is considering its reliance on external scrutiny organisations. This recommendation was directed primarily at HMIP and IMBs.
Accepted in Part
HIA-8 — Specialist Care and Assistance Facilities
Recommendation: Sufficient funds should be made available by government on a ring-fenced basis for a fixed period of ten years, subject to a review after five years, to establish dedicated specialist facilities in Belfast, Derry and, if necessary, at other suitable …
Gov response: No formal government response published.
Accepted
BRIS-14 — Provide support for patients experiencing anxiety due to increased medical knowledge
Recommendation: Patients should be supported in dealing with the additional anxiety sometimes created by greater knowledge.
Unknown
IR2-15 — Support Services for Applicants
Recommendation: I recommend that the scheme should include provision of the following support services to be provided without charge to the applicant: a) an advice and advocacy service, supplemented where necessary by discretionary access to independent legal advice and representation, where …
Gov response: With respect to recommendations 15 and 17 of the Second Interim Report, the Government acknowledges the immense psychological harm that has been caused as a result of this scandal, and is committed to offering psychological …
Accepted
Prevention of Future Deaths reports(54)— showing 50 strongest matches
Michael Worrall
Concerns: The limited availability of psychological therapy at Avesbury House risks adverse outcomes for patients, particularly upon discharge to the community if prior therapy is discontinued.
Overdue
Graeme Kidd
Concerns: Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, patients lacked essential medication advice in the prescribing doctor's absence.
Overdue
Frances Andrade
Concerns: Vulnerable witnesses require clear advice on psychiatric counselling and timely explanations of trial proceedings. Additionally, better measures are needed to secure prescription medication from family members with a history of overdoses.
Response (Surrey and Borders Partnership NHS): The Trust has taken steps to ensure staff interactions with family carers recognise the risk of medication misuse and highlight it as an area to be considered. They have also …
Overdue
Roseanne Cooke
Concerns: Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for a vulnerable patient.
Response (5 Borough Partnership NHS): The Trust has looked into the concerns raised and has put an action plan in place after a period of no psychological input on the Grasmere Unit due to maternity …
Responded
Rowena Golton
Concerns: Critical shortages and significant waiting times for psychological services within crisis teams hinder adequate provision and timely access for vulnerable patients.
Response (North Central South Manchester Clinical Commissioning Groups): The CCGs are working with colleagues to review service provision across all services and develop care pathways for service users. An external review of psychological therapies (IAPT) has been completed …
Responded
Janette Insley
Concerns: Inpatients lacked access to psychological treatment due to unavailable psychologists and resources, with an overemphasis on community services, leaving vulnerable patients without support post-discharge.
Response (Department of Health): The Department of Health acknowledges the concerns but states that the issues raised are most appropriately addressed at a local level, while also noting national investment in psychological therapies and …
Responded
Craig Bell
Concerns: There was an unmet need for psychological therapies for prisoners with personality disorders, poor information sharing about self-harm risk, and a lack of senior clinician attendance at discharge reviews.
Overdue
Tania Hristova
Concerns: The patient received antidepressant medication for over five years without adequate review and was not offered additional psychological therapies such as counselling or CBT.
Response: The surgery has taken steps to ensure regular medication reviews are undertaken for patients on SSRIs and that patients are made aware of mental health support services, including raised awareness …
Responded
Guy Robinson
Concerns: The 'AWOL' protocol was improperly applied due to staff unfamiliarity, lacking Trust-wide implementation. A significant service gap exists with no inpatient clinical psychology access, disadvantaging vulnerable patients.
Response: The Trust reviewed and revised the Absence Without Leave (AWOL) policy, including additional guidance and a flowchart, and implemented it Trust-wide on April 1, 2015; Psychological therapies are available on …
Responded
William Higgleton
Concerns: A critical lack of psychotherapy services for patients with anti-social personality disorder means their primary treatment is unavailable, creating a risk of future deaths.
Response (William Higgleton): NELFT and CCGs will review care pathways for patients with anti-social personality disorder, ensuring support to access existing services per NICE guidelines and develop a communication plan. The review, commencing …
Overdue
Simon Klineberg
Concerns: Concerns include insufficient psychiatric bed availability, inadequate resourcing for home treatment teams, and significant waiting lists for psychological therapy, especially for high-risk patients.
Overdue
Emma Timbrell
Concerns: Patients with suicidal ideation were given a non-free out-of-hours crisis number, creating a financial barrier to accessing urgent mental health support for those with limited means.
Overdue
David Read
Concerns: After an initial urgent referral and a cancelled appointment, a new appointment for mental health services was scheduled after a delay of over 16 weeks, during which time the patient died.
Response (Norfolk and Suffolk NHS Trust): Norfolk and Suffolk NHS Trust has fully staffed its team and made amendments to practice. If a service user does not attend an appointment the team will have a phone …
Responded
Thomas Green
Concerns: A referral to Adult General Psychiatry for an inpatient was not considered or actioned, resulting in no psychiatric follow-up or treatment plan for complex PTSD upon discharge; a commissioning gap exists for complex PTSD services.
Response (Tameside and Glossop CCG NHS Trust): Tameside and Glossop CCG will clarify the Individual Funding Request process by 1/6/17, review and establish clear pathways into MH support for people with complex needs within four months, and …
Overdue
David Hamilton
Concerns: Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant an incomplete patient picture.
Response (Pennine Care NHS Trust): Healthy Minds service provides treatment options and offers advice. A log is kept on the system and patients can be "stepped up" during therapy. GPs can request consideration for assessment …
Response (Grosvenor Medical Centre): The practice escalated concerns about mental health support to the Clinical Commissioning Group. They escalated the matter to the Mental Health Clinical Lead and Head of Mental Health regarding the …
Responded
Linsay Bushell
Concerns: A significant lack of provision and priority for commissioning therapeutic psychological services for mentally disordered female patients with Emotionally Unstable Personality Disorder was identified.
Response (Department of Health): NHS England is investing in psychological therapies for people with personality disorders and developing guidance on high-quality services. Mersey Care NHS Foundation Trust has established a Personality Disorder Hub, devised …
Overdue
John Haines
Concerns: Mental health inpatients and those supported by Home Treatment Teams lack timely access to qualified psychological therapy, a repeated concern due to commissioning issues and long waiting lists.
Response (Heywood Middleton and Rochdale CCG): HMR CCG acknowledges concerns about access to psychological therapy and Healthy Minds, explaining investment decisions and waiting time performance. They note a new Primary Care Mental Health Pathway was commissioned …
Overdue
John Derwent
Concerns: Excessive waiting times for CBT (12 months) due to insufficient capacity and ineffective escalation mechanisms between commissioning and service providers prevented timely access to essential mental health treatment.
Overdue
Arun Viswambaran
Concerns: Excessive waiting times of up to 18 weeks for IAPT therapy and difficulties in contacting the team risked mental health deterioration and disengagement from services.
Overdue
Heather Carey
Concerns: Insufficient funding and staffing led to excessively long waiting times for urgent psychotherapy, which was not comparable to physical life-threatening illnesses, causing distress and increasing suicide risk.
Response (Tameside Metropolitan Borough): The CCG has invested £600,000 to improve staffing on inpatient mental health wards. The service's waiting times have improved due to internal actions, with the current waiting time for Cognitive …
Response (Department of Health and Social Care): NHS England will test four-week waiting times to appropriate care and is expected to publish a Community Mental Health Framework to support local areas in the transformation of community mental …
Responded
Stephen Kennedy
Concerns: A patient couldn't access recommended psychological therapy due to internal service barriers and long waiting lists. Additionally, a severe lack of acute inpatient mental health beds led to further self-harm and suicide attempts.
Response (Department of Health and Social Care): The Department of Health and Social Care highlights national initiatives to improve mental health services, including expanding CRHTTs, integrating primary and secondary care, and establishing a national single point of …
Response (Birmingham and Solihull Mental Health NHS Trust): The Trust is developing training and guidance for staff on Personality Disorder and patients with Personality Disorder, to be mandated for all staff working within our Home Treatment Teams during …
Response (NHS Birmingham and Solihull ICB): The CCG acknowledges the coroner's concerns and is unable to identify any correlation between funding and this death, but has recognised the need to continually improve its quality monitoring function …
Responded
Jack May
Concerns: Inadequate university mental health services, characterized by long waits and limited appointments, combined with patchy, poorly trained pastoral support from personal tutors, allowed students to "slip through the net."
Response (Cardiff University): Cardiff University acknowledges the coroner's concerns and provides a detailed explanation of its student support services, personal tutoring policies, and local pastoral care. They state they are not complacent and …
Responded
Danyon Chesters
Concerns: Significant delays in accessing NHS mental health services led to fragmented private care, lack of information sharing between professionals, and private therapists not reviewing medication, impacting the deceased's treatment.
Response (Department of Health and Social Care): The Department acknowledges the concerns raised and explains the NHS's role in commissioning services and targets for psychological therapies. They reference guidance for therapists on managing client confidentiality and risk, …
Responded
Kerry Hunter
Concerns: The proposed in-house Borderline Personality Disorder service access pathway may inadvertently exclude patients due to their condition's characteristics, like avoidance and previous negative treatment experiences.
Response (Norfolk and Suffolk NHS Trust): The Trust is implementing a new Personality Disorder Service with a phased approach, including needs-based interventions, crisis support, peer support workers, and training for all staff, with regular review points …
Response (Norfolk and Suffolk NHS Foundation Trust): The Trust has co-produced patient-facing information, is reviewing its personality disorders strategy, has rolled out a training program, upskilled community teams, and is supporting MHPs to offer evidence-informed approaches, and …
Responded
Patricia Ferguson
Concerns: Community Mental Health Teams in Nottinghamshire have inadequate clinical psychologist staffing, leaving some patients without access to essential psychological services, which poses a risk of preventable deaths.
Response (Bassetlaw Clinical Commissioning Group): The CCG is working with Nottinghamshire Healthcare NHS Trust on a transformation programme to meet the NHS Long Term Plan requirements over the next 5 years, with increased access to …
Response (Nottingham and Nottinghamshire CCG): The CCG is working with Nottinghamshire Healthcare NHS Trust on a transformation programme to meet the NHS Long Term Plan requirements over the next 5 years, with standardised service delivery …
Responded
Carole Mitchell
Concerns: Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant placements. Health professionals also misunderstood patient confidentiality, hindering crucial information gathering from families.
Response (Greater Manchester Health and Social Care Partnership): Learning from the case will be presented to the Greater Manchester Quality Board and shared with commissioners of services. The partnership is also working to improve bed capacity and information …
Response (Dept of Health and Social Care): The Department is providing targeted funding to local areas for suicide prevention and bereavement support, aiming for every area to receive funding by 2023/24. The Zero Suicide Alliance is developing …
Responded
Sean Kay
Concerns: A critical gap in mental health service provision in Norfolk and Waveney meant high-risk patients did not meet criteria for available support, leaving them without appropriate care.
Response (NHS Norfolk and Waveney CCG): NHS Norfolk and Waveney CCG has contacted Norfolk and Suffolk NHS Foundation Trust, which confirmed they have improved communication and education between teams to ensure people receive the help they …
Responded
Joanna Leven
Concerns: Gaps exist in national therapeutic pathways for Personality Disorders and trauma support services. Separate computer systems between hospital and mental health liaison create a risk of critical information loss.
Response (Dept. of Health Social Care): The Department acknowledges the concerns and outlines national initiatives to improve mental health services and suicide prevention, including investments in community mental health care and digital information sharing. It notes …
Responded
Dyllon Milburn
Concerns: The current repeat prescription system lacks automated alerts to remind patients to request and collect medication, contributing to non-compliance for those with mental illness.
Response (National Institute for Health and Care Excellence): NICE acknowledges the concerns but states it cannot influence changes to the EMIS system. They highlight existing guidelines on medicines adherence (CG76) and depression management (CG90) that contain relevant recommendations.
Response (Royal College of General Practitioners): The RCGP will open a dialogue with the Royal Pharmaceutical Society to consider in more detail the issue of patients not collecting prescriptions, and recommends that much greater integration of …
Response (EMIS): EMIS confirmed that their software was working as designed and complies with NHS Digital requirements and are presently considering a number of potential digital tools to aid further patient compliance; …
Response (GPs): The practice uses EMIS Web software and outlines the three methods by which patients can request repeat prescriptions, also noting that there is no system to alert them if a …
Responded
Kelly Hewitt
Concerns: There is an inadequate provision of mental health support for prison officers, which needs urgent review.
Response (HM Prison and Probation Service): HMPPS employs an Employee Psychological Support Services Clinical Lead. They launched a staff suicide prevention campaign, "Reach Out, Saves Lives" in September 2020, and are working with Remploy to provide …
Responded
Todd Salter
Concerns: A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek treatment by committing criminal acts.
Response (HM Prison and Probation Service): The identified lack of knowledge and training gaps have been and continue to be dealt with at an individual level, briefing sessions on suicide prevention and processes have been updated …
Responded
Jane Bush
Concerns: Persistent delays in mental health assessments and access to psychological therapy are driven by ongoing staff recruitment and retention issues, hindering the Trust's ability to manage increased demand for complex cases.
Response (Hellesdon Hospital): Hellesdon Hospital has implemented several actions including increasing capacity of the Central Youth Team, developing a locality model, developing a transition service, and recruiting senior nurses and consultant psychologists. They …
Responded
Joy Burgess
Concerns: Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.
Response (Department of Health and Social Care): The Department of Health and Social Care references NHS England's consultation on new waiting time standards for mental health services and states they are working on the next steps following …
Responded
Daniel France
Concerns: A vulnerable young person known to the County Council and Mental Health Trust did not receive timely support, facing a long wait for psychological therapy, potentially dangerous given the risk of impulsive acts; there were also considerable delays in obtaining appointments for the Gender Identity Clinic and a shortage of psychological therapies.
Overdue
Marjorie Walker
Concerns: A DNA CPR was not completed according to protocols, and significant delays affected access to specialist pain clinics. Furthermore, health professionals showed a lack of understanding regarding kidney function monitoring for pain medication like Gabapentin, increasing overdose risk.
Response (Greater Manchester Integrated Care): NHS Greater Manchester Integrated Care highlights actions taken including presenting findings to learning forums, introducing electronic white boards in patient areas, completing analgesic dosing audits, distributing a Pharmacy Safe Bulletin …
Response (Department of Health and Social Care): The government plans to spend over £8 billion from 2022-23 to 2024-25 to support elective recovery and reduce waiting times, and the NHS is developing Community Diagnostic Centres. The MHRA …
Responded
Amanda Hesketh
Concerns: The practice failed to systematically review patients on multiple repeat analgesics or create individual plans, relying on repeat prescriptions without specialist input. There were also concerns about limited access to specialist pain clinics and underutilization of practice pharmacists for complex pain management.
Response (Department of Health and Social Care): The Department of Health and Social Care highlights existing support for pharmacists in General Practice via Primary Care Networks (PCNs) and the Additional Roles Reimbursement Scheme (ARRS). It also mentions …
Response (Donneybrook Medical Centre): Donneybrook Medical Centre has categorised and prioritised patients receiving repeat prescriptions of multiple analgesics with assistance from the Medicines Optimisation Team. A plan has been put in place to introduce …
Responded
Neil McDougall
Concerns: Military debriefs lack individual trauma support and promote alcohol use over discussion. The resettlement process for leavers fails to provide mandatory comprehensive mental health assessments, leaving ex-personnel reliant on external services.
Response (Ministry of Defence): The Army has current policies and procedures to minimise the risk of suicide within the ranks of serving military personnel and the veteran community including education to tackle stigma, providing …
Responded
James Tice
Concerns: There is a critical lack of beds for informal mental health admissions for older adults and insufficient community psychotherapy services for their needs.
Response (Greater Manchester Integrated Care): Learning from the case will be presented to the Greater Manchester System Quality Group and cascaded to professionals through governance forums. The Regulation 28 report will be shared with mental …
Responded
Aleksandra Markowska
Concerns: Patients receiving services from BPAS lack direct, confidential access to NHS perinatal psychiatry teams for pregnancy-related mental health decline, hindering timely and private support.
Overdue
Lucy Jones
Concerns: Significant delays in providing Cognitive Behavioural Therapy and inadequate follow-up by the Community Psychiatric Nurse after discharge, including limited contact attempts, were identified.
Response (Aneurin Bevan University Health Board): The health board has developed a Disengagement and Did Not Attend policy to guide clinicians when a person does not attend appointments, balancing duty of care with the patient's right …
Response (Rosedale Surgery): The Rosedale Surgery will add a sentence to patient records giving no more controlled medication than is needed for 48 hours when recording a diagnosis of an overdose. If a …
Responded
Michelle Jennings
Concerns: Critically long national waiting lists for mental health therapy, inconsistent application of referral/discharge policies, and a lack of proper consideration for mental health vulnerabilities during prosecutions, with no clear mechanism for sharing lessons.
Response (Department of Health and Social Care): The Department of Health and Social Care is increasing investment in mental health services by £2.3 billion by 2023/24. They are also working to improve joined-up working across the NHS, …
Overdue
Angela Collins
Concerns: Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health crisis receive insufficient or no support.
Response (East London NHS Foundation Trust): The Trust is planning to review discharge and de-escalation pathways, work with system partners to review 'Multi-Agency Vulnerable Adult Return Home Interview Practice Guidance', ensure staff attend 'Think Family' training, …
Responded
Alice Litman
Concerns: Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient mental healthcare provision for those awaiting gender-affirming treatment.
Response (Surrey and Borders Partnership NHS Foundation Trust): The Trust is developing a mandatory training package for all staff on working with people from the transgender community, co-produced with people with lived experience and their families. It is …
Response (NHS England): NHS England acknowledges concerns about the death of Alice Litman and outlines its role as commissioner of gender dysphoria services. They note improvements being made to the NCMD alert system …
Response (Royal College of Genereal Practitioners): The RCGP expresses condolences and describes its existing work to improve care for transgender individuals, including e-learning packages and a transgender policy document. They highlight long waiting lists for specialist …
Response (Travistock and Portman NHS Foundation Trust): The Tavistock and Portman NHS Foundation Trust acknowledges concerns about services for patients on the GIC waiting list. They describe the role of the GIC, noting the HA60 classification, and …
Responded
Amarnih Lewis-Daniel
Concerns: Extremely long waiting lists for Gender Identity Clinics, coupled with a severe lack of local support and specialist knowledge in mental health services, and unclear responsibilities for patient welfare, are intensifying distress.
Response (NHS England): NHS England expresses condolences and acknowledges the concerns raised. The response focuses on the NHS pathway of care for adults with gender dysphoria, national policy on mental health services for …
Response (Together UK): Together UK has information sharing agreements with NELFT and ELFT and follows a Standard Operating Procedure for Liaison and Diversion. The agency social worker would have received risk management, information …
Responded
Jessica Eastland-Seares
Concerns: Critically inadequate community provision and insufficient financial investment for autistic individuals force unnecessary inpatient admissions and A&E attendances due to a severe lack of suitable support placements.
Response (Department of Health and Social Care): The Department of Health and Social Care is prioritising updating the Autism Act statutory guidance to support the NHS and local authorities to deliver improved outcomes for autistic people. They …
Responded
[REDACTED]
Concerns: Significant delays in IAPT counselling and an unclear, difficult-to-follow electronic record system with poorly defined risk assessment protocols raised concerns for patient safety.
Response (Midlands Partnership NHS Foundation Trust): Midlands Partnership NHS Foundation Trust is redesigning counselling services to reduce waiting times, with completion planned within six months. The Trust is also further developing the Rio system to improve …
Responded
Amina Ismail
Concerns: Delays in transferring mental health patients from independent providers resulted from underfunded local beds, an over-reliance on external services, and a national shortage of specialist rehabilitation units.
Response (NHS England): NHS England highlights the Mental Health, Learning Disability and Autism Inpatient Quality Transformation programme, designed to localize and realign care. They have published a Commissioning Framework and required ICBs to …
Response (Department of Health and Social Care): The DHSC acknowledges concerns about mental health service funding, reliance on independent providers, and availability of specialist units. They highlight existing initiatives to improve patient flow, localise care, and ensure …
Responded
Isobel Stapleton
Concerns: Mental health practitioners lack easy access to complete patient records across Wales and NHS England. Acute and home treatment teams also suffer from a lack of clinical psychologists and lengthy psychotherapy waiting lists.
Response (Welsh Government): Digital Health and Care Wales is developing a business case for the introduction and deployment of mental health systems across health boards in NHS Wales, with a phased approach anticipated …
Response (Cwm Taf Morgannwg University Health Board): CTMUHB has made a dedicated psychological professional available for direct assessment and treatment in all three CRHTTs, eliminating the waiting list. They also contact people on the waiting list for …
Responded
Paul Chase
Concerns: There is a critical lack of mental health, alcoholism, and addiction support for veterans, both serving and after release. Resources are extremely limited, leading to extensive waiting times for essential treatment and therapy.
Response (Ministry of Defence): The Ministry of Defence expresses sympathy and highlights existing mental health support for service personnel and veterans, stating that the deceased received treatment for addiction issues before discharge, but requests …
Responded
Imogen Nunn
Concerns: A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial proceedings for deaf patients and witnesses.
Response (NHS England): NHS England will hold a meeting to brief stakeholders on the plan to publish a refreshed version of the Accessible Information Standard (AIS), and regional Patient Safety colleagues are engaging …
Response (Department of Health and Social Care): The Cabinet Office’s Disability Unit, alongside members of the Government’s BSL Advisory Board, met with the National Registers of Communication Professionals working with Deaf and Deafblind People (NRCPD).
Response (National Register of Communication Professionals working with Deaf and Deafblind peopl): NRCPD will focus on improving access to appropriately qualified BSL interpreters, update their CPD guidance to registrants, develop a closer relationship with NHS England to support a clear pathway for …
Responded
Select committee recommendations(79)— showing 50 strongest matches
#42 — Make FCDO security and mental health expertise accessible to local NGOs upon request.
Recommendation: Beyond funding, the FCDO should explore how it might make its in- house security and mental health expertise, particularly at diplomatic mission level, accessible to local NGOs as requested as appropriate. (Recommendation, Paragraph 81)
Gov response: 113. Mental health and security support is designed specifically to meet the needs of staff and their families for whom HMG holds a legal duty of care obligation. An extension of these services to third …
Position Not Stated
#41 — Provide flexible funding to local organisations for culturally appropriate aid worker psychological support.
Recommendation: Psychological support and wellbeing strategies need to be appropriate to the context and culture of the aid workers in question. Sufficient flexibility in funding must be built in to ensure that local organisations are supported in designing and implementing their …
Gov response: 108. FCDO takes seriously issues of health and safety, including mental health and safeguarding, for our partners. FCDO internal guidance on Mental Health and Psychosocial Support (MHPSS) advises that funding to meet mental health needs …
Position Not Stated
#40 — Underfunding of security risk management jeopardises aid worker mental health and welfare.
Recommendation: Constrained budgets and competition for funding may incentivise the over- promising of delivery by international NGOs at the risk of underfunding security risk management. This runs the risk of subjecting aid workers to unnecessary pressures, and of their welfare being …
Gov response: Agree 108. FCDO takes seriously issues of health and safety, including mental health and safeguarding, for our partners. FCDO internal guidance on Mental Health and Psychosocial Support (MHPSS) advises that funding to meet mental health …
Response Not Attributed
#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 …
Gov response: the Department for Health and Social Care to pilot this approach. We recognise the importance of prioritising mental health support for children in care and care leavers. Working with DHSC, NHSE, and MoJ, we are …
Position Not Stated
#48 — Mental health support for children in care is currently falling far short of needs.
Recommendation: Children in care have experienced trauma, abuse and neglect, and they are over four times more likely to suffer from emotional or mental health problems than their peers. It is therefore essential that there is a strong system in place …
Gov response: We recognise the importance of prioritising mental health support for children in care and care leavers. Working with DHSC, NHSE, and MoJ, we are piloting a multi-disciplinary approach within the South-East Regional Care Co-operative in …
Accepted
#30 — Reduce visibility of security guards in Jobcentres, ensuring a more welcoming entry experience.
Recommendation: Jobseekers are not criminals and shouldn’t be greeted at Jobcentres by security guards. DWP should make security guards much less visible in Jobcentres, with a more welcoming presence when people enter. (Recommendation, Paragraph 133)
Gov response: DWP recognises the importance of a supportive and welcoming environment for our customers, however we also need to strike the right balance to ensure safety for customers and colleagues. This approach does not remove our …
Partially Accepted
#27 — Jobcentre environments often lack accessibility and welcome, undermining efforts to support claimants.
Recommendation: Jobcentres are not places that people want to go to. They are often run-down and lack basic facilities, including accessibility features. An intimidating security presence can create additional barriers for some. It will be important that when people walk through …
Gov response: Accept Through capital investment, DWP is committed to transforming our Jobcentre spaces so that our physical infrastructure is adaptable and responsive to the needs of our customers, colleagues, and local and national partners. The Workplace …
Response Not Attributed
#26 — Introduce Jobcentre outreach work as a core service, taking support into local communities.
Recommendation: DWP needs to break Jobcentres out of their four walls. It should make outreach work, with staff taking Jobcentre services into the community and to locations that people trust, a core part of the new service. DWP should include larger-scale …
Gov response: DWP recognises the value of working collaboratively within communities, operating from a range of locations, to deliver timely, tailored support to customers. We are developing and testing a Flexible Delivery Network model to address economic …
Accepted
#24 — Jobcentres require deeper integration with voluntary and community sectors to address complex employment barriers.
Recommendation: Many people who use Jobcentres have multiple and complex needs, which can act as barriers to them securing employment. Too often, issues that prevent people from finding jobs go unaddressed. Jobcentres and Jobcentre staff will not be able to address …
Gov response: Partially accept DWP recognises the invaluable part played by the voluntary and community sector in supporting customers alongside DWP and agrees that forming a more coherent view of the current position is useful. As part …
Response Not Attributed
#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 …
Gov response: Response: Integrated Care Boards and NHS Trusts commission FGM support clinics which offer a range of services to support women affected by FGM including physical treatment, counselling and further referrals to urology, gynaecology etc. depending …
Partially Accepted
#42 — Improve access to CAMHS and adult mental health services for young people with severe conditions.
Recommendation: 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 …
Gov response: PLANS ALREADY IN PLACE This government has already taken significant steps to stabilise and improve NHS mental health services but there is much more to do. Transforming the system will take time, but we are …
Position Not Stated
#41 — Accelerate Mental Health Support Team rollout for 100% post-16 coverage by 2029-30, publishing impact data.
Recommendation: The Government’s pledge of 100% MHST coverage by 2029–30 must be met and must include all post-16 students and trainees. We recommend that Government accelerates the rollout of Mental Health Support Teams with a particular focus on expanding coverage for …
Gov response: UNDER REVIEW Around six in ten pupils and learners in FE will have access to a mental health support team (MHST) by March 2026, and the government has committed to full coverage by 2029–30. This …
Position Not Stated
#40 — Slow rollout of Mental Health Support Teams leaves most post-16 students unsupported
Recommendation: 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 …
Gov response: The government is committed to improving mental health support for FE students, promoting a whole-college approach through guidance and the Acol Mental Health Charter. Polly Harrow, appointed as the first FE Student Support Champion in …
Not Addressed
#21 — Ensure NHS provides culturally competent therapy and fund tailored support for Muslim communities.
Recommendation: The Government should set out steps to ensure that the NHS can provide religiously and culturally competent, trauma-informed, and accessible therapy for those in need, including Muslim communities. 52 The Government should also fund local support services tailored to the …
Gov response: 56. NHS staff should feel safe at work in an environment free of racism and discrimination. Every NHS organisation has a duty to protect staff from racism, sexism and religious hatred and will have their …
Position Not Stated
#18 — Muslim women in frontline services endure anti-Muslim abuse and face mental health barriers.
Recommendation: It is deeply saddening that Muslim women working in frontline services such as healthcare settings are having to endure anti-Muslim abuse while performing their duties in helping others. Reports of a lack of support from colleagues and employers are also …
Gov response: 56. NHS staff should feel safe at work in an environment free of racism and discrimination. Every NHS organisation has a duty to protect staff from racism, sexism and religious hatred and will have their …
No Published Response
#30 — Ensure all victims needing counselling and pre-trial therapy can access it.
Recommendation: The Government must ensure that counselling and therapy, including pre-trial therapy, can be accessed by all victims and survivors who need it. We welcome the Government’s funding for Independent Sexual Violence Advisors (ISVAs) but are mindful of Rape Crisis England …
Gov response: The Government is committed to ensuring that all victims receive appropriate support, whether they are engaged in the criminal justice system or not. We acknowledge that the provision of pre-trial therapy has been inconsistent to …
Position Not Stated
#28 — Ask Law Commission to publish early recommendations on pre-trial therapy and disclosure of notes.
Recommendation: We welcome the fact that the Law Commission’s project will be covering access to counselling and therapy notes and records. However, we are concerned that, as the Law Commission will not be reporting until summer 2023, victims and survivors could …
Gov response: We recognise the importance of ensuring that only evidence about the victim pertinent to the case is used at court. That is why the Ministry of Justice asked the Law Commission to conduct a landmark …
Position Not Stated
#26 — Rape victims fear accessing mental health support due to disclosure concerns.
Recommendation: We were particularly concerned to hear that victims and survivors of rape may feel they need to—or are advised to—put off accessing mental health support as they fear that their counselling or therapy notes and records could be disclosed to …
Gov response: In October 2020 the CPS completed a public consultation exercise on draft pre-trial therapy guidance. In February 2022, the CPS published the Pre-trial Therapy Fundamental Principles which confirmed its commitment to a number of fundamental …
Response Not Attributed
#18 — Publish and implement urgent national access and waiting time standards for integrated care.
Recommendation: We heard that one way to track progress on integration would be through the establishment of national access and waiting time standards. The absence of national standards contributes to inconsistent access and undermines parity with physical health. NHS England should …
Gov response: The government partially accepts this recommendation. Improving access and reducing waiting times for mental health services is essential to achieving equality with physical health and ensuring people receive timely, high- quality care wherever they live. …
Partially Accepted
#1 — Severity gap reveals unacceptable failing in timely access to mental health care
Recommendation: 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. …
Gov response: The government accepts this recommendation. Embedding the voice of people with lived experience is fundamental to delivering person-centred mental health care. We are committed to ensuring that NHS services reflect what matters most to those …
Response Not Attributed
#5 —
Recommendation: We continue to believe that achieving parity of esteem between physical and mental health requires sustained investment in mental health services and recommend that meeting, rather than just reporting on, the Mental Health Investment Standard should be a statutory requirement …
Response Pending
#21 —
Recommendation: The Government must introduce a dedicated, trauma-informed health pathway for all those affected by historical forced adoption. This should include improved access to specialist psychological support for birth mothers and adult adoptees, national clinical guidance recognising the heightened prevalence of …
Gov response: PARTIALLY ACCEPT The Government recognises the significant mental health impacts associated with historic forced adoption practices. We will work with NHS England and DHSC to strengthen access to trauma-informed care through existing NHS pathways by: …
Partially Accepted
#1 — Northern Ireland's public services remain in crisis across health, education, and justice.
Recommendation: Northern Ireland’s public services remain in crisis. Its health service is under immense pressure, with long waiting lists, a struggling primary care sector and an acute mental health situation, in part due to Northern Ireland’s recent history. There are severe …
Gov response: We welcome your assessment on the state of public services, one year on from the previous Committee’s initial report, and recognise that improving public services will not be quick or easy. There are very real …
Not Addressed
#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 …
Gov response: Response: Integrated Care Boards and NHS Trusts commission FGM support clinics which offer a range of services to support women affected by FGM including physical treatment, counselling and further referrals to urology, gynaecology etc. depending …
Not Addressed
#31 — Ensure comprehensive mapping of sexual violence services assesses counselling and therapy provision.
Recommendation: Any comprehensive mapping and monitoring exercise, covering the provision of specialist sexual violence and abuse services in England and Wales, that the Government undertakes (as we recommend) must take account of the need for and availability of counselling and therapy …
Gov response: We will continue to work with our partners to understand the provision of specialist sexual violence and abuse services and identify where improvements need to be made. This will include joint working with the NHS …
Position Not Stated
#29 — Legal advice pilot for complainants must consider support for therapy record applications.
Recommendation: The pilot of the provision of legal advice to complainants—which we recommended at paragraph 125 above—should take account of support in relation to applications for counselling or therapy records.
Gov response: The Ministry of Justice’s legal support consultation explored options to enhance rape victims’ access to legal support or advice relating to all police or prosecutor requests for personal information. We aim to ensure victims of …
Position Not Stated
#27 — Work with CPS to enable urgent publication of pre-trial therapy guidance.
Recommendation: We recommend that the Government work with the Crown Prosecution Service so that it is possible for the organisation to publish its guidance on pre-trial therapy as soon as possible. We understand the Crown Prosecution Service has been waiting on …
Gov response: In October 2020 the CPS completed a public consultation exercise on draft pre-trial therapy guidance. In February 2022, the CPS published the Pre-trial Therapy Fundamental Principles which confirmed its commitment to a number of fundamental …
Position Not Stated
#19 —
Recommendation: Dismissal of women’s period problems and the normalisation of period-related pain in primary care is now recognised as a concern by the healthcare sector. However, there is little evidence of systemic improvement. Young women and girls are still reporting their …
Gov response: The Government acknowledges the Committee’s concerns regarding the dismissal of women’s period problems and the normalisation of period-related pain in primary care. The Government agrees that there is a need for systemic improvement in this …
Accepted
#2 — Expand Youth Hub eligibility for economically inactive young people not claiming Universal Credit
Recommendation: DWP Youth Hubs offer vital services to young people and the provision of mental health support services in all Youth Hubs is a critical part of that. However, not all young people who need this support are currently able to …
Gov response: The Government announced in the Spring Budget that it would be expanding access to the Youth Offer to enable more young people on Universal Credit to see a work coach in a Youth Hub or …
No Published Response
#1 — Integrate mental health support and job readiness training into future DWP programmes for young people
Recommendation: The pandemic has led to a steep rise in mental health problems among young people. Whilst maintaining steady employment often helps people to sustain good mental health, problems with mental health are a principal barrier to employment for many 16-to-24-year-olds. …
Gov response: The department works closely with DHSC and the NHS, in recognition of the fact that many people find mental ill health a barrier to employment, which is especially true for young people. There are a …
No Published Response
#49 — Ensure comprehensive and affordable insurance covers aid workers' legal, medical, and psychological support.
Recommendation: The FCDO needs to make sure that insurance provided to aid workers by their employers covers legal advice and longer-term medical, including physiological support. The FCDO should work with insurance providers and delivery partners to ensure that appropriate and affordable …
Gov response: 126. We agree that insurance provided to aid workers through FCDO partners should meet a range of identified needs, including legal, mental and physical health provision where applicable. FCDO’s funding guidelines are flexible, allowing for …
Position Not Stated
#37 — Adopted children's early trauma impact on education receives insufficient recognition and support.
Recommendation: There is too little recognition of the impact of the early trauma and separation experienced by adopted children, and of the support they need to thrive in education and beyond, with over half of adopted children feeling that they didn’t …
Gov response: Supporting adopted children to thrive is a key government priority. We remain committed to providing high-quality adoption support from the point of placement and throughout childhood. The £50 million Adoption and Special Guardianship Support Fund …
Response Not Attributed
#164 — Revise drug testing policy for dual response: disciplinary action and treatment referral.
Recommendation: The MoJ and HMPPS must revise the drug testing policy to ensure that positive test results consistently trigger a dual response: swift and certain disciplinary action (with a rehabilitative element) and an immediate, 60 mandatory referral for a clinical needs …
Gov response: The existing adjudications policy already allows Governors the discretion to award a suspended punishment in guilty findings, on the condition that the prisoner undertakes a rehabilitative activity, such as engagement with drug and alcohol treatment …
Partially Accepted
#19 — Commission research into providing better mental health support and guidance for terminally ill people.
Recommendation: There is a pressing need to understand how to better provide mental health support, and guidance, for people who are living with a terminal diagnosis. We therefore recommend that the Government commission such research and report back to Parliament.
Gov response: The Department, through the National Institute for Health and Care Research, is investing £3 million in a new Palliative and End of Life Care Policy Research Unit. This will help build the evidence base on …
Position Not Stated
#26 —
Recommendation: The renewed Women’s Health Strategy should include a specific objective on improving the menstrual wellbeing of disabled and Deaf girls and young women. This should include provision of information and advice in suitable formats, including in Easy Read for girls …
Response Pending
#24 —
Recommendation: Girls and young women with disabilities and sensory impairments face additional barriers to menstrual wellbeing. Taboos around periods are compounded by those around disability. Disabled and Deaf girls’ period- related needs are routinely ignored or dismissed. We were shocked to …
Response Pending
#20 —
Recommendation: The Government must introduce a nationally funded and regulated intermediary service to ensure that all adoptees and birth relatives have access to skilled, trauma-informed professionals who can support them in navigating contact, reunion, or information-sharing processes safely and sensitively. As …
Gov response: PARTIALLY ACCEPT The Government recognises the value of intermediary services in supporting sensitive contact, tracing, and information sharing. We will: Expand access to funded intermediary services for historical adoption cases where access is currently most …
Partially Accepted
#28 — Establish DEFRA working group to explore leave and support options for rural workers.
Recommendation: Although it will be challenging for the Government to address this given such occupations can involve lone workers in often isolated rural locations, we recommend that DEFRA sets up a working group to: a) explore options to establish or expand …
Gov response: Government works closely with the veterinary profession, including the Royal College of Veterinary Surgeons (RCVS) and the British Veterinary Association (BVA). Defra officials regularly engage with both these organisations as well as the wider profession. …
Accepted
#27 — Address occupational demands and cultural barriers preventing rural workers taking time away.
Recommendation: The Government should look at how to respond to the occupational demands placed on farmers, agricultural and veterinary workers and any cultural barriers that: prevent these workers from taking time away from work, are detrimental for mental health without opportunity …
Gov response: Government works closely with the veterinary profession, including the Royal College of Veterinary Surgeons (RCVS) and the British Veterinary Association (BVA). Defra officials regularly engage with both these organisations as well as the wider profession. …
Accepted
#19 — Identify farming and veterinary mental health as priorities and develop specific NHS staff training.
Recommendation: It is very important for the farming and veterinary communities to feel that their circumstances are understood by NHS staff when seeking to access, or receiving, support (otherwise this may work against help-seeking behaviours). Charities with specialist-knowledge can gain people’s …
Gov response: The government recognises the critical importance of good mental health and wellbeing to the agricultural and veterinary communities and notes with concern the evidence contained in the report. Defra’s Farming and Countryside Programme works with …
Position Not Stated
#7 — Create clear objectives and actions for agricultural and veterinary workers in national suicide prevention strategy
Recommendation: We are very concerned by the evidence indicating that agricultural and veterinary workers have a higher-than-average suicide rate compared to the rest of the population. Although more accurate information is needed, a clear enough picture Rural Mental Health 77 was …
Gov response: Our Suicide Prevention Strategy for England: 2023 to 2028, was published on 11 September 2023. This strategy sets out our ambitions over the next five years to: reduce suicide rates, improve support for people who …
Response Not Attributed
#6 — Joined-up public health approach essential for preventing suicide among agricultural and veterinary workers
Recommendation: Adopting a more joined-up approach to public health focused on early intervention could make a positive contribution to preventing suicide amongst agricultural and veterinary workers. It would need to ‘wrap-around’ people at potential risk, incorporating the NHS, other key public …
Gov response: Our Suicide Prevention Strategy for England: 2023 to 2028, was published on 11 September 2023. This strategy sets out our ambitions over the next five years to: reduce suicide rates, improve support for people who …
Response Not Attributed
#5 — Require DEFRA to establish a clear and active role in national suicide prevention strategy
Recommendation: DEFRA should be an active stakeholder in any national suicide prevention strategy, as the Department is responsible for populations and occupational groups arguably at higher-than-average risk of poor mental health and death by suicide. However, DEFRA does not appear to …
Gov response: Our Suicide Prevention Strategy for England: 2023 to 2028, was published on 11 September 2023. This strategy sets out our ambitions over the next five years to: reduce suicide rates, improve support for people who …
Response Not Attributed
#4 — Addressing risks and stressors for farming and veterinary workers represents an immediate priority.
Recommendation: In particular, the long list of risks and stressors affecting the farming community and veterinary workers is perhaps the immediate priority, not least because there are real opportunities for substantial gains in this area with significant levers for change in …
Gov response: Our Suicide Prevention Strategy for England: 2023 to 2028, was published on 11 September 2023. This strategy sets out our ambitions over the next five years to: reduce suicide rates, improve support for people who …
Response Not Attributed
#6 — Significant mental health support will be required for Gaza's aid workers and population post-conflict.
Recommendation: Unfortunately, little can be done from the UK to support the mental health of aid workers at this time, but no one should lose sight of the scale of care that will be needed for these people - as well …
Gov response: Agree 31. We are conscious of the social and psycho-social dimensions of recovery for Gazan individuals and society. We have long-standing partnerships with Palestinian civil society organisations and, per our White Paper and past commitments …
Response Not Attributed
#11 — Require Government to set out plans for reducing autistic detentions and improving community alternatives.
Recommendation: In response to this report, the Government should set out: • The reasons why the number of autistic people detained in mental health hospitals has increased; and how it plans to reduce that number, and by when. • The steps …
Response Pending
#10 — Accelerate progress in reducing detentions by increasing support for community-based alternatives.
Recommendation: The Government must make more progress in reducing the number of people with learning disabilities and/or autism detained in mental health settings. To achieve this the Government needs to learn from previous failings and increase support for community-based alternatives to …
Response Pending
#22 — Counselling notes' therapeutic purpose requires strict enforcement of reasonable disclosure grounds.
Recommendation: The primary purpose of counselling is therapeutic not investigative. The law should still allow for disclosure of those notes where their probative value merits it; but the reasonable grounds test must be respected and enforced effectively if victim confidence in …
Gov response: 31. We thank the Committee for their recommendation, which reflects the Government’s existing position. The recently published CPS pre-trial therapy guidance makes it clear that this type of third-party material should only be considered when …
Position Not Stated
#21 — Consider providing independent legal advice for vulnerable victims facing disclosure requests.
Recommendation: The decision whether to accede to a disclosure request of counselling notes and third-party material should not rest solely on the shoulders of victims, many of whom are vulnerable and traumatised. There is a case for providing independent legal advice …
Gov response: 30. The Government launched a public consultation on police requests for third party material in June 2022 which closed in August 2022. The Government has considered the responses to the consultation and will shortly publish …
Position Not Stated
#18 — Victim participation in parole risks retraumatisation without effective counselling support provision.
Recommendation: The Government’s Root and Branch Review of the Parole System merits more consideration than we have had opportunity to give to it during our scrutiny of the draft Victims Bill. It is a policy area we are likely to return …
Gov response: 25. The Government is committed to ensuring that victims who observe parole hearings have access to emotional support if they need it and we are putting measures in place to deliver it – we therefore …
Position Not Stated
HSSIB safety recommendations(2)
Medication not given: discharge from an acute hospital to the community
How does your organisation make sure that patients have access to specialist diabetes support including out of hours?
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
It is recommended that NHS England, within the ‘Long-Term Plan’, works with partners to identify and meet the needs of young adults who have mental health problems that require support but do not meet the current criteria for access to …
Safety Recommendation
CQC inspection actions(6)
Birmingham Children's Hospital
The trust must ensure patients have timely access to mental health services.
Must Do
Taplow Manor
The service must ensure that young people have access to the recommended psychological therapy as outlined in best practice guidance and that young people have access to meaningful activities seven days a week.
Must Do
Crown Street Surgery
Review and improve access.
Should Do
Bousfield Surgery
Take action to improve patients experience of being able to get through to the practice by telephone.
Should Do
The Croft
The service had no contacts with advocacy services to support people who may need help to make decisions about their lives, and defend and promote their rights.
Should Do
Lotus Home Care Worksop
The provider should put in place information available on independent advocacy for people to access.
Should Do
PPO death in custody recommendations(4)
The Head of Healthcare of HMP Holme House
The Head of Healthcare should ensure that prisoners have access to appropriate therapy services, such as physiotherapy and occupational therapy, following major surgery.
The Head of Healthcare
The Head of Healthcare should create an assertive outreach policy for patients who are repeatedly referred to the MHIRT but decline to engage, which should include a flexible assertive method utilising the multidisciplinary team with an early intervention and recovery …
The Head of Healthcare
Staff consider whether a prisoner’s neurodiversity presents a barrier to them self-referring to services such as IAPT and psychosocial substance misuse support.
The Head of Healthcare of HMP Holme House
The Head of Healthcare should ensure that prisoners with complex pain management needs have access to a local specialist pain service.
PHSO ombudsman recommendations(2)
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or seek answers after an incident.
Ignoring the alarms: How NHS eating disorder services are failing patients
The Department of Health and NHS England should review the existing quality and availability of adult eating disorder services to achieve parity with child and adolescent services.
IMB individual recommendations(16)
Altcourse (2020)
As mentioned in last year’s report, many men convicted of sexual offences will still be unable to access treatment programmes as a number are considered unfit for transfer to other prisons which run these programmes.
HMPPS
In Progress
Grendon (2023)
The Board recommends that the Prison Service outlines its plan to address the growing problem of men who are Out Of Therapy (OOT) and unable to move out of Grendon.
HMPPS
In Progress
Grendon (2024)
There continues to be an ongoing issue regarding men who remain too long at Grendon following the completion of their therapy, due to the lack of space at other prisons. There are very few opportunities at Grendon for these men to build on their experiences once they are OOT. What is being considered to address this matter?
HMPPS
In Progress
Grendon (2024)
The Board continues to be concerned about how men who are out of therapy cannot move on to another prison due to overcrowding, which can have a major impact on the effective running of a therapeutic community. How are specialist prisons, such as Grendon, factored into considerations on prison sentencing policies?
Ministry of Justice
In Progress
Foston Hall (2021)
Are there plans to address: the lack of interview rooms, which seriously undermines the delivery of rehabilitative work, in particular healthcare, mental health and offender management
HMPPS
In Progress
Foston Hall (2021)
Are there plans to address: the inadequate provision for mental health throughout the criminal justice system, which is a serious concern? This is manifested in Foston Hall in a high level of unmet need for mental health treatment and delays in transferring prisoners to secure hospitals
Ministry of Justice
In Progress
Heathrow Immigration Removal Centre (2022)
The Home Office should improve the access and capacity of the interpreting and translation services in HIRC; this is especially important given the number of detainees in HIRC whose first language is not English.
Home Office
Channings Wood (2022)
What measures are planned to address the backlog in the provision of offending behaviour programmes? What is being done in order to minimise the detrimental effect on men awaiting courses prior to parole board hearings while at the same time ensuring that public safety requirements are met?
Ministry of Justice
Foston Hall (2021)
The IMB is concerned about: lack of support to foreign national prisoners who do not speak English
Governor / Director
The Mount (2022)
The Board is concerned at the lack of category D places. Prisoners are being assessed and approved but then face months waiting for a place. Some are released before being allocated a category D placement. Increasing the period that a prisoner can apply from two to three years with no extra places will increase the frustration of prisoners.
Ministry of Justice
Swansea (2022)
The Board acknowledges the prison's efforts to locate speakers of the same language on the same wings wherever feasible and especially during this period when there were no formal ESOL courses available The Board has noted that whilst there has been an increase in the use of ‘thebigword’ interpretation service across the prison, its usage at relatively low levels and …
Governor / Director
Grendon (2023)
The Board looks forward to a resolution to the problems of men being pulled from education to attend therapy specials, and lessons being cancelled because of staff training.
Governor / Director
Littlehey (2023)
The waiting lists for attendance on offending behaviour programmes, which are often a requirement for consideration for parole, remain long. The Board would like to understand whether there are any plans to increase Programme provision to improve prisoner access to such programmes.
HMPPS
Maidstone (2024)
Improve access to translation services for foreign nation prisoners, so that papers served, and information served, can be viewed in their native languages.
HMPPS
Partially Accepted
London STHF (2023)
Delays and the unavailability of certain languages in the Big Word translation service need to be addressed.
Home Office
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
We reiterate our recommendation, which was accepted, for Border Force and Immigration Enforcement to implement standardisation of the use of translation devices across all facilities.
Home Office
Detention investigations(1)
PHSO casework decisions(59)
P-002767 — Hampshire and Isle of Wight Integrated Care Board
Mrs A complained the ICB failed to implement agreed SEND tribunal recommendations and delayed addressing her sons' mental health needs, causing significant family impact.
NHS in England
Jul 2024
P-002779 — Cumbria, Northumberland, Tyne And Wear Area Team
Mrs K complained about excessive waiting times for gender identity clinic services and NHS England's failure to meet treatment standards, causing emotional distress and financial burden.
NHS in England
Jul 2024
P-002886 — Devon Partnership NHS Trust
Ms I complained about long waiting lists at a gender identity clinic and NHS England's failure to reduce wait times, causing distress and private costs.
NHS in England
Aug 2024
P-003047 — Cornwall Partnership NHS Foundation Trust
The Trust failed to provide him with an Emotional Coping Skills Course despite referral and improperly managed his complaint, changing the outcome without explanation, impacting his mental health.
NHS in England
Upheld
Sep 2024
P-004647 — Leicestershire Partnership NHS Trust
Mrs A complained her mother received insufficient therapy, was poorly managed during a transfer (no medication/food, left unattended), and communication about her discharge was inadequate.
NHS in England
Upheld
Jan 2026
P-001349 — Buckinghamshire Clinical Commissioning Group
Mr A complained Buckinghamshire CCG delayed his hip surgery for 11 months by forcing him through a specialist service and not offering choice of hospital or surgeon.
NHS in England
Upheld
Mar 2022
P-001605 — A medical practice in the Cambridgeshire area
Mrs P complained the GP failed to refer Mr P to the neurological rehabilitation team for Botox injections, causing a significant delay and severe deterioration of his arm.
NHS in England
Nov 2022
P-002305 — Cheshire and Wirral Partnership NHS Foundation Trust
Trust delayed providing mental health therapy for four years, allegedly ignoring GP letters and discriminating against Mr O for wanting in-person appointments.
NHS in England
Nov 2023
P-002477 — Kent and Medway Integrated Care Board
Mr O complained the ICB failed to provide recommended adapted cognitive behavioural therapy (CBT), negatively impacting his mental health and education.
NHS in England
Feb 2024
P-003016 — A practice in the City of Southampton area
Ms E complained the Practice failed to support her autism assessment referral, including providing insufficient information and not referring appropriately. She also alleged a delayed orthopaedic referral and dismissive staff attitude.
NHS in England
Oct 2024
P-003118 — Tavistock and Portman NHS Foundation Trust
Ms D complained about the Clinic's lack of care and significant four-year waiting times for an appointment following an accepted referral.
NHS in England
Nov 2024
P-003457 — Kent and Medway NHS and Social Care Partnership …
Miss A complained the Trust failed to offer appropriate therapy for borderline personality disorder for many years and did not provide a safe environment in group therapy sessions.
NHS in England
Mar 2025
P-003438 — South East London Integrated Care Board
Ms K complained that an ICB policy requiring GP referrals through physiotherapists delayed her hyperparathyroidism diagnosis, causing distress.
NHS in England
Mar 2025
P-003545 — South East London Integrated Care Board
Ms A complained the ICB declined mental health therapy, then failed to explain why her comprehensive assessment was inadequate, causing distress and health decline.
NHS in England
May 2025
P-003568 — Oxford Health NHS Foundation Trust
Mrs Y complained the Trust failed to support her daughter after an ARFID diagnosis, leading to hospital admission for liver damage and continued deterioration, despite the Trust not being commissioned for ARFID treatment.
NHS in England
May 2025
P-003577 — A practice in the Rushcliffe area
Mr G complained the Practice made an incorrect referral, introduced testosterone therapy, refused blood monitoring, and wouldn't enter a shared care agreement for his transgender care, causing health risks and distress.
NHS in England
May 2025
P-003562 — An independent provider in the North East Lincolnshire …
Mr O complained an independent provider inaccurately completed his son's ADHD assessment and refused a second opinion, resulting in an incorrect diagnosis and worsened symptoms.
NHS in England
May 2025
P-003569 — Herefordshire and Worcestershire Health and Care NHS Trust
Miss J complained the Trust failed to refer her son for paediatric occupational therapy, delaying sensory interventions and contributing to his pencil grip difficulties.
NHS in England
May 2025
P-003615 — Guy's and St Thomas' NHS Foundation Trust
Ms R complained about insufficient appointments and the Trust's refusal to refer her for water therapy or osteopath services, causing considerable pain and distress.
NHS in England
Jun 2025
P-003712 — Lancashire and South Cumbria NHS Foundation Trust
Miss P complained the Trust wrongly discharged her son from the ADHD pathway and rejected subsequent referrals, worsening his condition and causing academic and behavioral problems.
NHS in England
Not Upheld
Jul 2025
P-003753 — A dental practice in the Wandsworth area
Mr J complained the dental practice refused to complete his orthodontic treatment, falsely recorded treatment as complete, and failed to provide dental records.
NHS in England
Jul 2025
P-003784 — New Victoria Hospital
Mr T complained that multiple NHS organisations failed to provide him appropriate healthcare access and treatment for recurrent urinary tract infections, severely impacting his quality of life.
NHS in England
Aug 2025
P-003932 — A practice in the Exeter area
Miss B complained the Practice failed to arrange timely specialist support for her mother, and a GP was unprofessional and rude. She also complained about the Practice's poor complaint handling.
NHS in England
Partly Upheld
Sep 2025
P-004076 — Humber and North Yorkshire Integrated Care Board
Mr R complained about the lack of NHS-commissioned local services for his son's ARFID, leading to severe health issues and wheelchair reliance.
NHS in England
Sep 2025
P-004782 — Central and North West London NHS Foundation Trust
Mr and Mrs R complained their son's psychiatrist didn't fully consider his history, incorrectly concluded he wasn't depressed, and inappropriately increased his sertraline dose.
NHS in England
Partly Upheld
Feb 2026
P-004755 — Lancashire and South Cumbria NHS Foundation Trust
Mr H complained about an inaccurate EUPD diagnosis, lack of appropriate medication and community mental health support, leading to negative impacts on his mental and physical health.
NHS in England
Jan 2026
P-004756 — A practice in the St. Helens area
Miss A complained that the medical centre incorrectly stated she could only be referred to the local NHS ADHD assessment service, and failed to refer her to her chosen ADHD provider.
NHS in England
Jan 2026
P-004762 — Avon and Wiltshire Mental Health Partnership NHS Trust
Mr Q complained the Trust did not explore more treatment options for his anxiety, worsening his condition.
NHS in England
Jan 2026
P-001120 — Bury CCG
Mrs E complained that Bury CCG refused granted therapy sessions, denied mental health service access, and poorly handled her complaint, severely affecting her mental health.
NHS in England
Sep 2021
P-001596 — A medical practice in the Hartlepool area
Mr R complained GPs refused to prescribe eye drops for a flare-up in May 2021, causing impaired vision, blurry floaters, light sensitivity, and an inability to drive at night.
NHS in England
Nov 2022
P-001897 — A practice in the North Tyneside area
Mr O complained the Practice failed to manage his back and neck pain, inaccurately listed symptoms, ordered unnecessary scans, and did not refer him for needed surgery.
NHS in England
Mar 2023
P-003837 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mr A complained a Trust therapist failed to follow PTSD treatment guidelines, was often late, and the Trust handled his subsequent complaint poorly.
NHS in England
Jul 2023
P-003905 — Cheshire and Wirral Partnership NHS Foundation Trust
Mr O complained the Trust denied him 'Step Four' mental health therapy since 2019, ignored GP requests, and added six months to his waiting time.
NHS in England
Jul 2023
P-002324 — A practice in the City of Plymouth area
Ms A complained the Practice delayed prescribing testosterone and arranging blood tests for menopause symptoms, and failed to refer her to a gynaecologist.
NHS in England
Nov 2023
P-002401 — West Yorkshire Integrated Care Board
Ms H complained the ICB failed to provide suitable electrolysis providers or funding for private treatment, causing her distress and delays.
NHS in England
Jan 2024
P-002490 — A practice in the Barnet area
Miss I complained her GP delayed referring her for an ADHD/autism assessment and denied her 'right to choose' a service provider, causing mental health deterioration.
NHS in England
Mar 2024
P-002633 — An independent provider in the West Berkshire area
Mr A complained about the Practice's failure to book timely appointments and provide adequate pain relief for dental pain, resulting in an abscess, emergency surgery, and removal of four teeth.
NHS in England
May 2024
P-002701 — Leeds and York Partnership NHS Foundation Trust
Mr L complained about long waiting times for ADHD assessment, failure to inform him of alternative pathways, and lack of coping advice, negatively impacting his mental health and employment.
NHS in England
Jun 2024
P-002871 — Central and North West London NHS Foundation Trust
Miss E complained the Trust provided inadequate mental health care, including inappropriate discharge, insufficient therapy, poor facilities, and isolation during a complaint, causing mental deterioration.
NHS in England
Jul 2024
P-003098 — Sussex Partnership NHS Foundation Trust
Miss K complained her EMDR therapy was unsuccessful due to the Trust not ordering buzzers, lack of continuity, her therapist's authoritative manner, and refusal to refer her to the crisis team.
NHS in England
Sep 2024
P-003034 — Essex Partnership University NHS Foundation Trust
Miss R complained the Trust wrongly removed her from the care coordination service and delayed a psychiatry review, causing suicidal thoughts, self-harm relapse, anxiety, and distress.
NHS in England
Oct 2024
P-003021 — Mersey Care NHS Foundation Trust
Mr E complained a talking therapy course was unsuitable and not personalised, and the Trust failed to refer him to a psychologist or discuss other support options, contributing to his mental health deterioration.
NHS in England
Oct 2024
P-003046 — South East London Integrated Care Board
Miss R complained the ICB failed to diagnose her with ADHD in 2006. This caused difficulties at school, mental struggles, and significant debt from university due to a lack of support.
NHS in England
Oct 2024
P-003104 — An independent provider in the Colchester area
Miss A complained the Service wrongly decided she did not meet criteria for a full ADHD assessment due to inappropriate methods, delaying her access to treatment and causing distress.
NHS in England
Nov 2024
P-003322 — County Durham and Darlington NHS Foundation Trust
The Trust allegedly provided no clear diagnosis or treatment for Dr V's CRPS, made him feel ignored, and handled his complaint poorly, causing chronic pain and distress.
NHS in England
Feb 2025
P-004213 — Mersey Care NHS Foundation Trust
Mr D complained Mersey Care NHS Foundation Trust's resolution for his C-PTSD support was inadequate, citing delays in starting and lack of ongoing talk therapy.
NHS in England
Nov 2025
P-004718 — Tower Hamlets GP Care Group CIC
Mrs K complained her trans-daughter was wrongly turned away from A&E, mis-recorded, and faced insensitive comments, leading to a 36-hour delay in diagnosing Burkitt's Lymphoma and her death.
NHS in England
Jan 2026
P-001567 — A medical practice in the Birmingham area
The complainant alleged poor GP communication and the recording of incorrect, deeply hurtful personal information on her referral form, causing significant distress.
NHS in England
Oct 2022
P-001616 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mr A complained the Trust failed to advise them of BMI criteria and delayed scans for IVF treatment, causing them to miss eligibility. He also complained the consultant ignored a GP letter.
NHS in England
Nov 2022
P-001907 — Mersey Care NHS Foundation Trust
Mrs E complained her son's OCD worsened because the Trust declined a funding letter for treatment and discharged him without a plan between April and November 2021.
NHS in England
Mar 2023
LGO / SPSO decisions(9)
21-018-709 — Royal Borough of Greenwich
Summary: the Council failed to make arrangements for Mr F’s son B’s Occupational Therapy in September 2021. However, the Council has apologised and refunded Mr F for the therapy he arranged instead. This is a suitable remedy.
LGO (Local Government & …
Education
Upheld
Jul 2022
23-012-818 — Royal Borough of Kingston upon Thames
Summary: Ms Y complained the Council decided Placement H was a suitable setting for her child, X, despite concerns from Ms Y and Placement H. Ms Y said this led to X losing education and therapy provision. Ms Y also complained the Council delayed agreeing to her proposed education arrangements …
LGO (Local Government & …
Education
Upheld
Mar 2024
21-016-344 — Suffolk County Council
Summary: there was delay by the Council arranging Speech and Language Therapy for Mr F’s daughter, G, but the Council has offered an appropriate remedy. There are no grounds for the Ombudsman to recommend the Council refund Mr F’s legal expenses.
LGO (Local Government & …
Education
Upheld
Jun 2022
23-020-868 — Brighton & Hove City Council
Summary: Mrs X complains about the care and support provided to her daughter after her autism diagnosis. I have found fault by the Trust and the Council. However, they have accepted this and provided a suitable remedy for most of the complaint. We have recommended the Trust apologises for distress …
LGO (Local Government & …
Children S Care Services
Upheld
Dec 2025
23-020-868b — Sussex Partnership NHS Foundation Trust (23 020 868b)
Summary: Mrs X complains about the care and support provided to her daughter after her autism diagnosis. Based on current evidence I have found fault by the Trust and the Council. However, they have accepted this and provided a suitable remedy for most of the complaint. We have recommended the …
LGO (Local Government & …
Health
Upheld
Dec 2025
23-020-868a — Sussex Partnership NHS Foundation Trust (23 020 868a)
Summary: Mrs X complains about the care and support provided to her daughter after her autism diagnosis. Based on current evidence I have found fault by the Trust and the Council. However, they have accepted this and provided a suitable remedy for most of the complaint. We have recommended the …
LGO (Local Government & …
Health
Upheld
Dec 2025
25-003-682 — Broadway Lodge
Summary: We will not investigate this complaint about the actions of Mr X’s Care Provider. This is because the actions
LGO (Local Government & …
Adult Care Services
Aug 2025
21-016-339 — Royal Borough of Kingston upon Thames
Summary: We will not investigate this complaint about a lack of advocacy support for the complainant. This is because the complaint does not meet the tests in our Assessment Code on how we decide which cases to investigate. There is not enough evidence of fault by the Council.
LGO (Local Government & …
Other Categories
Feb 2022
25-003-125 — London Borough of Lewisham
Summary: We will not investigate this complaint about an unsuccessful blue badge application. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Aug 2025