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 18 independent accountability sources, so the source mix matters as much as the headline total.
20 inquiry recs
54 PFD reports
86 committee recs
2 HSSIB recs
19 CQC actions
4 PPO recs
2 PHSO recs
16 IMB recs
1 detention investigation rec
76 DHR recs
59 PHSO decisions
9 LGO/SPSO decisions
4 CQC enforcement actions
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(20)
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 …
No response yet
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 …
No response yet
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. …
No response yet
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.
No response yet
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.
No response yet
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 …
No response yet
82 — Awareness of support resources
Recommendation: Ensuring that relatives are aware of the full range of counselling/support resources available including those external to the hospital and bringing these matters to the attention of the relatives.
Unknown
81 — Discuss counselling and support
Recommendation: Discussing counselling or long-term support needs with relatives, including the needs of wider family members and making contact with appropriate counselling/support agencies if requested.
Unknown
35 — Lists of psychiatrists and psychologists
Recommendation: Area Child Protection Committees should prepare lists of psychiatrists and psycholgists available to give professional advice when required (15.82).
Unknown
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: 63. The Government agrees that more clarity is needed on the effectiveness of public expenditure on services for victims of child sexual abuse. The recently published Victims Strategy includes commitments to undertake deep dives into …
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 …
No response yet
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: This ABI Code of Practice: Responding to Civil Claims of Child Sexual Abuse has been produced with the aim of improving certain aspects of the civil claims process that are within insurers’ control for victims …
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: 6.10.1. The Home Office has considered its reliance on external scrutiny organisations and the effectiveness of existing internal inspection mechanisms.
Accepted, fully or in part (not specified)
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. The Inquiry reported on 20 January 2017, the month the Northern Ireland Executive collapsed; the report The Executive Office and the Northern Ireland Office laid before Parliament in September 2019 …
Unknown
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 coroner noted the limited availability of psychological therapy at Avesbury House, raising concerns about potential adverse consequences for patients discharged into the community after discontinuing therapy.
Overdue
Graeme Kidd
Concerns: Concerns included locum doctors lacking access to electronic records and awareness of mental health support teams. Additionally, GPs faced delays in referring patients to mental health services due to mandatory physical checks, and medication advice was unavailable.
Overdue
Frances Andrade
Concerns: The coroner noted insufficient provision of psychiatric counselling advice for vulnerable witnesses and timely explanations to complainants about criminal trial directions. Additionally, measures are needed to secure prescribed medication from family members at overdose risk.
Response (Surrey and Borders Partnership NHS): • Staff interactions with family carers and service users now recognise and highlight the risk of medication access, with comprehensive risk management care plans required for identified risks. • The … (AI summary)
Overdue
Roseanne Cooke
Concerns: The coroner noted a lack of inpatient psychological support and confusion regarding outpatient referrals. Concerns were also raised about the Recovery Team's attendance at discharge meetings and insufficient communication of family concerns about the deceased's suicidal thoughts to the team.
Response (5 Borough Partnership NHS): • The Trust produced an action plan to improve the process for managing extended leave, including reviewing psychology provision and ensuring detailed electronic record entries. • The Borough's Leadership Team … (AI summary)
Responded
Rowena Golton
Concerns: The coroner noted the lack of availability of psychological services within crisis teams and that not all teams have access to a psychologist. Concerns were raised about significant waiting times for psychological therapy, highlighting a need to prioritise cases.
Response (North Central South Manchester Clinical Commissioning Groups): • The CCG requested a diagnostic review of Citywide IAPT services and is working with providers to implement the report's recommendations. • The CCG is working with the Trust to … (AI summary)
Responded
Janette Insley
Concerns: The coroner identified a service gap in inpatient psychological therapy due to a lack of qualified practitioners and resources. This resulted in an inability to refer inpatients to a psychologist, and long wait times for community referrals post-discharge left patients vulnerable.
Response (Department of Health): • The Government is investing over £400 million to expand the choice of psychological therapies across England. • The Department of Health's 2014-15 Mandate to NHS England sets objectives for … (AI summary)
Responded
Craig Bell
Concerns: The coroner noted insufficient information sharing between clinical teams and HMPS staff regarding prisoner risk, and the absence of a senior clinician at discharge case reviews. There was also an identified unmet need for psychological therapies for prisoners with personality disorders.
Overdue
Tania Hristova
Concerns: The coroner noted the patient was prescribed antidepressant medication for over five years without adequate review and was not offered additional therapies such as counselling or CBT.
Response: • The practice undertook an audit to identify patients due for SSRI antidepressant reviews and contacted them to arrange appointments. • The repeat prescribing system was upgraded to electronic prescribing, … (AI summary)
Responded
Guy Robinson
Concerns: Insufficient application and staff familiarity with the AWOL protocol were noted. The coroner also raised concerns about the absence of an inpatient Clinical Psychology service, creating a gap in direct referral options for hospital clinicians.
Response: • The Absence without Leave (AWOL) Policy was reviewed, updated with additional guidance and a flowchart, and implemented Trust-wide on 1st April 2015. • The Trust stated that Psychological Therapies … (AI summary)
Responded
William Higgleton
Concerns: The coroner noted a lack of service provision for psychotherapy care for individuals with anti-social personality disorder. This gap in provision was identified as posing a risk of future deaths.
Response (William Higgleton): • The North East London NHS Foundation Trust (NELFT) and Clinical Commissioning Groups (CCGs) agreed to review care pathways for patients with anti-social personality disorder. • A communication plan will … (AI summary)
Overdue
Simon Klineberg
Concerns: Availability of psychiatric beds, resource allocation for the home treatment team's support threshold, and the management of psychological therapy waiting lists, particularly for high-risk patients, were noted as areas of concern.
Overdue
Emma Timbrell
Concerns: Concerns were raised that the out-of-hours telephone number provided for suicidal ideation might be inaccessible to individuals with limited finances due to call charges. The coroner suggested that crisis telephone numbers should be freephone numbers.
Overdue
David Read
Concerns: The coroner identified significant delays in Mr. Read's access to the Community Mental Health Team, noting that a re-referral after a cancelled appointment resulted in a waiting time exceeding 16 weeks.
Response (Norfolk and Suffolk NHS Trust): • The Trust reported that the team is currently fully staffed following recruitment to vacancies. • The Trust stated it would implement a policy to make a phone call to … (AI summary)
Responded
Thomas Green
Concerns: The coroner noted an unactioned psychiatric referral during an inpatient stay and a subsequent unsuitable referral to Healthy Minds for complex PTSD due to insufficient detail. A commissioning gap for complex PTSD services was also identified.
Response (Tameside and Glossop CCG NHS Trust): • The CCG met with Pennine Care NHS Foundation Trust staff to identify actions for service improvements. • The CCG will clarify the Individual Funding Request process and brief Pennine … (AI summary)
Overdue
David Hamilton
Concerns: The coroner identified a lack of documentation for therapy selection, unclear triggers for referrals, and limited information sharing among health professionals. There was also no formal process for escalating health professional concerns.
Response (Grosvenor Medical Centre): • The practice circulated the report to all colleagues and raised concerns about mental health support with the Clinical Commissioning Group. • The practice escalated concerns regarding the psychiatrist referral … (AI summary)
Response (Pennine Care NHS Trust): • A process will be initiated to clearly state in patient clinical records that a patient has completed a treatment options session, identifying the selected treatment and allocated pathway. • … (AI summary)
Responded
Linsay Bushell
Concerns: The coroner noted that psychological therapies for Emotionally Unstable Personality Disorder (EUPD) had not been commissioned for the deceased despite her extensive history.
Response (Department of Health): • NHS England committed to investing in psychological therapies and developing guidance for personality disorder services. • Mersey Care NHS Foundation Trust established a Personality Disorder Hub to coordinate community … (AI summary)
Overdue
John Haines
Concerns: Mental health in-patients and those under Home Treatment Teams lack access to therapy from a qualified psychologist. Timely access to the Healthy Minds service, an alternative, is also hindered by long waiting times.
Response (Heywood Middleton and Rochdale CCG): • Heywood, Middleton and Rochdale CCG invested in safer staffing initiatives and recruited a qualified psychologist for inpatient therapy. • The provider is reviewing inpatient service provision and has an … (AI summary)
Overdue
John Derwent
Concerns: The coroner noted significant waiting times for CBT, reaching 12 months against a 6-week target due to insufficient capacity. The report also described ineffective escalation mechanisms between the commissioning body and service provider to address the increasing waiting list.
Overdue
Arun Viswambaran
Concerns: The coroner noted long waiting times for IAPT therapy, ranging from 12 to 18 weeks, which may lead to mental health deterioration or disengagement. Difficulties in contacting the IAPT team by telephone were also identified as a potential barrier to individuals seeking assistance.
Overdue
Heather Carey
Concerns: The coroner identified long waiting times for urgent psychotherapy, noting a 24-week wait exceeding the 18-week target due to insufficient funding and staffing. Concerns were raised that an 18-week target is too long for urgent mental health needs, potentially leading to further deaths while patients await treatment.
Response (Tameside Metropolitan Borough): • The Tameside and Glossop Strategic Commissioning Board committed additional funding to increase access to psychological therapies, with an initial £271,000 agreed in 2018/19. • A review of psychological therapy … (AI summary)
Response (Department of Health and Social Care): • NHS England and Health Education England are working to expand the Improving Access to Psychological Therapies - Severe Mental Illness (IAPT-SMI) programme. • Funding has been made available to … (AI summary)
Responded
Stephen Kennedy
Concerns: The coroner identified insufficient access to psychological therapy for the deceased due to internal service structures and long waiting lists, alongside a lack of available inpatient acute beds when needed.
Response (Department of Health and Social Care): • The Department committed an additional £2.3 billion investment in mental health services by 2023-24, as outlined in the NHS Long Term Plan. • Over £400 million in supporting investment … (AI summary)
Response (Birmingham and Solihull Mental Health NHS Trust): • The Trust plans to invest in clinical psychology capacity within Home Treatment Teams, aiming to recruit 0.5WTE Clinical Psychologists for each team from September 2019. • A tiered training … (AI summary)
Response (NHS Birmingham and Solihull ICB): • The CCG stated its intention to formalise changes through a Service Development and Improvement Plan (SDIP) for 2019/20, which will require providers to ensure access to psychological therapies. • … (AI summary)
Responded
Jack May
Concerns: The coroner noted inadequate provision of counselling and wellbeing services at Cardiff University, citing long waiting times and a reapplication process after four appointments. There are also concerns about inconsistent pastoral support from Personal Tutors, with limited training and varying levels of student contact.
Response (Cardiff University): • The university is evaluating its approach to managing student mental health crises, reviewing related policies, and has allocated £150,000 for new posts to risk assess and triage these situations. … (AI summary)
Responded
Danyon Chesters
Concerns: Delays in accessing NHS mental health services led the individual to private therapy, resulting in a lack of joined-up care and information sharing. Concerns were also raised that private therapists have no obligation to obtain information about medication prescribing.
Response (Department of Health and Social Care): • The Department committed to expanding Improving Access to Psychological Therapies (IAPT) services to increase access for an additional 600,000 people annually. • The Department confirmed an additional £2.3 billion … (AI summary)
Responded
Kerry Hunter
Concerns: The coroner raises concerns that the proposed requirement for individuals with Borderline Personality Disorder to agree to a transfer to an Integrated Delivery Team may prevent some patients from accessing new in-house treatment, given the nature of BPD and past treatment experiences.
Response (Norfolk and Suffolk NHS Trust): • The Trust outlined an eight-element plan for a new Personality Disorder Service. • Recruitment for a personality disorder strategy lead has commenced, supported by an implementation team. • The … (AI summary)
Response (Norfolk and Suffolk NHS Foundation Trust): • The Trust has increased staffing and upskilled community teams to improve access to evidence-based treatment, aiming to reduce the need for service users to be referred to specialist services. … (AI summary)
Responded
Patricia Ferguson
Concerns: Community Mental Health Teams in Nottinghamshire have insufficient clinical psychologist staffing, with many teams having only one or part-time roles, leading to patients lacking access to clinically indicated psychological support, contrary to guidance.
Response (Bassetlaw Clinical Commissioning Group): • Bassetlaw Clinical Commissioning Group is working with Nottinghamshire Healthcare NHS Trust on a five-year transformation programme to meet NHS Long Term Plan requirements. • Funding was provided in 2019/20 … (AI summary)
Response (Nottingham and Nottinghamshire CCG): • The CCG included funding for additional Clinical Psychology posts in 2019/20. • The CCG is working with Nottinghamshire Healthcare NHS Trust on a transformation programme to meet NHS Long … (AI summary)
Responded
Carole Mitchell
Concerns: Significant delays in accessing psychology services and a lack of local mental health inpatient beds were identified. The coroner also noted health professionals' reluctance to gather family information due to a misunderstanding of patient confidentiality.
Response (Greater Manchester Health and Social Care Partnership): • The partnership has invested £2.8m in a Delayed Transfer of Care programme, mobilising thirty-six schemes to reduce bed blockage and Out of Area Placements. • A bespoke workforce strategy/plan … (AI summary)
Response (Dept of Health and Social Care): • The Department of Health and Social Care (DHSC) has provided targeted funding for suicide prevention and bereavement services and committed to further funding by 2023/24. • NHS England has … (AI summary)
Responded
Sean Kay
Concerns: The coroner identified a significant gap in mental health service provision in Norfolk and Waveney for patients identified as At Risk Mental State (ARMS). These patients, despite high risk, did not meet criteria for existing services and consequently received no appropriate care.
Response (NHS Norfolk and Waveney CCG): • Norfolk and Suffolk NHS Foundation Trust confirmed it had improved communication channels and education between its teams. • Norfolk and Suffolk NHS Foundation Trust stated it had a policy … (AI summary)
Responded
Joanna Leven
Concerns: A lack of a national therapeutic pathway for Personality Disorders was identified, alongside gaps in statutory provision of trauma-informed mental health services. Separate computer systems used by hospital and mental health liaison staff in Emergency Departments also risked information loss.
Response (Dept. of Health Social Care): • The Department stated it would invest almost £1 billion in community mental health care for adults by 2023/24, including for personality disorders. • The Department committed an additional £500 … (AI summary)
Responded
Dyllon Milburn
Concerns: The EMIS system for repeat prescriptions does not provide automated alerts to remind patients, particularly those with mental illness, to request and collect their medication. This feature could encourage compliance without increasing staff workload.
Response (National Institute for Health and Care Excellence): • NICE stated it is unable to influence changes to the EMIS system. • NICE referenced existing guideline CG76, which recommends considering the use of prescription records to identify potential … (AI summary)
Response (Royal College of General Practitioners): • The Royal College of General Practitioners recommended opening a dialogue with the Royal Pharmaceutical Society to consider the matter of prescription collection alerts. (AI summary)
Response (EMIS): • EMIS undertook an internal review of its repeat medication and compliance functionality. • EMIS is considering the development of potential digital tools to aid patient compliance. • EMIS indicated … (AI summary)
Response (GPs): • The practice uses EMIS Web and EMIS Web EPS for electronic prescriptions. • Patients can request repeat prescriptions through three methods: via pharmacy, online, or paper slip, with a … (AI summary)
Responded
Kelly Hewitt
Concerns: The coroner identified a lack of mental health support available to prison officers and recommended a review of its provision.
Response (HM Prison and Probation Service): • The service employs an Employee Psychological Support Services Clinical Lead to oversee mental health support for staff. • A staff suicide prevention campaign was launched in September 2020 in … (AI summary)
Responded
Todd Salter
Concerns: The coroner noted a lack of knowledge among Probation officers regarding available mental health services, which resulted in Mr Salter resorting to criminal acts to obtain treatment. There was also poor engagement and collaboration with agencies and family.
Response (HM Prison and Probation Service): • The identified lack of knowledge and training gaps were addressed at an individual level, and briefing sessions on suicide prevention were delivered to staff. • Processes in the EQUIP … (AI summary)
Responded
Jane Bush
Concerns: The report highlights delays in accessing mental health assessments and psychological therapy due to challenges in balancing service capacity with increasing demand, and difficulties in recruiting and retaining skilled staff within the Trust.
Response (Hellesdon Hospital): • The Trust increased assessment capacity by supplementing existing clinicians with agency nurses and extended their contracts. • It secured additional funding for six staff for the Central Youth Team, … (AI summary)
Responded
Joy Burgess
Concerns: The coroner noted that mental health ward environments could be chaotic and unsuitable for patient recovery due to resource constraints, alongside lengthy waits for psychological therapies, averaging one year locally.
Response (Department of Health and Social Care): • The government stated it is investing over £400 million up to 2024/25 to eradicate dormitory accommodation and £150 million for improvements to the mental health estate. • An extra … (AI summary)
Responded
Daniel France
Concerns: The coroner identified a significant gap in support for vulnerable young people awaiting substantive mental health treatment, exacerbated by long waiting lists for psychological therapies and difficulties meeting urgent intervention criteria. This situation poses risks for individuals at chronic risk of impulsive acts.
Overdue
Marjorie Walker
Concerns: The coroner noted that DNA CPR protocols were not followed and highlighted significant delays in accessing specialist pain clinics. Concerns were also raised about insufficient monitoring of kidney function when prescribing pain medication, increasing the risk of overdose.
Response (Greater Manchester Integrated Care): • Electronic whiteboards were introduced in patient areas to improve oversight of patient needs, including DNACPR status, and a trust-wide DNACPR audit was completed. • Analgesic dosing audits were completed, … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care has committed over £8 billion from 2022-23 to 2024-25 to increase elective activity and reduce waiting lists, aiming to eliminate waits of … (AI summary)
Responded
Amanda Hesketh
Concerns: The coroner noted a lack of systematic review and individual care plans for patients on repeat multiple analgesics within general practice, alongside difficulties in accessing specialist pain clinics due to long waiting lists. Concerns were also raised regarding GP practices not universally engaging practice pharmacists for patients with complex analgesia regimes.
Response (Department of Health and Social Care): • NHS England updated the Structured Medication Review (SMR) and medicines optimisation service in March 2022 to expand eligibility for patients on specific addictive medications, with implementation to be monitored. … (AI summary)
Response (Donneybrook Medical Centre): • The practice collaborated with the Medicines Optimisation Team to categorise patients on multiple analgesics by risk and urgency. • A plan was implemented to review patients on the red … (AI summary)
Responded
Neil McDougall
Concerns: The coroner raised concerns about post-tour debriefing for serving personnel, which lacks 1-to-1 sessions. There is also no mandatory mental health assessment during the Army resettlement process for those leaving service.
Response (Ministry of Defence): • The Ministry of Defence (MOD) stated that a Structured Mental Health Assessment is conducted at the mandatory discharge medical for all service personnel, indicating that comprehensive mental health assessments … (AI summary)
Responded
James Tice
Concerns: The coroner identified insufficient availability of beds for informal admissions to older adults mental health wards and a lack of psychotherapy services for older adults in the community.
Response (Greater Manchester Integrated Care): • Learning from the case will be presented and shared with the Greater Manchester System Quality Group. • Shared learning from this and similar cases will be cascaded to professionals … (AI summary)
Responded
Aleksandra Markowska
Concerns: The coroner noted insufficient direct and confidential access for British Pregnancy Advisory Service (BPAS) patients with pregnancy-related mental health decline to perinatal psychiatry teams, as BPAS lacks direct access and GP referrals are not viable for those seeking anonymity.
Overdue
Lucy Jones
Concerns: The coroner noted a significant delay in the individual receiving Cognitive Behavioural Therapy after hospital discharge. There were also concerns regarding inadequate community follow-up, with limited contact attempts by the Community Psychiatric Nurse and no physical sighting of the individual prior to her death.
Response (Aneurin Bevan University Health Board): • The Health Board has invested in psychological input to acute treatment areas and is piloting an embedded psychological care model. • The Adult Mental Health and Specialist Services Directorate … (AI summary)
Responded
Michelle Jennings
Concerns: Lengthy waiting lists for mental health therapy due to therapist shortages, and prosecuting authorities may not fully consider mental health vulnerability when making prosecution decisions. There is no clear national mechanism to share learning on these issues.
Response (Department of Health and Social Care): • The Department committed to increasing investment in mental health services by £2.3 billion by 2023/24, aiming for 2 million more people to access services. • It stated that all … (AI summary)
Overdue
Angela Collins
Concerns: Vulnerable adults under the care of secondary mental health services by East London NHS Foundation Trust receive very limited or no support despite being at risk of prescription drug overdose or mental health crisis.
Response (East London NHS Foundation Trust): • The Trust will conduct a robust review of the Duty Function across all Community Mental Health Teams in Bedfordshire and Luton, commencing in February 2024. • The Trust will … (AI summary)
Responded
Alice Litman
Concerns: The coroner identified gaps in the knowledge, training, and guidance for clinicians supporting transgender individuals in mental health and primary care. Concerns also include delays in accessing gender-affirming healthcare and a lack of mental health provision for those awaiting treatment.
Response (Surrey and Borders Partnership NHS Foundation Trust): • The Trust is developing a mandatory training package for all staff on supporting transgender individuals, co-produced with people with lived experience and their families, including age-specific training for clinicians … (AI summary)
Response (NHS England): • NHS England has established pilot services to increase capacity for gender dysphoria services, with some now operating under substantive contracts. • NHS England plans to refresh service specifications for … (AI summary)
Response (Royal College of Genereal Practitioners): • The Royal College of General Practitioners (RCGP) has worked with NHS England and other organisations to improve knowledge and understanding of the needs of transgender patients. • The RCGP … (AI summary)
Response (Travistock and Portman NHS Foundation Trust): • The Trust is working with NHS England and other providers to develop innovative ways of reducing the waiting list. • This work includes the development of new roles such … (AI summary)
Responded
Amarnih Lewis-Daniel
Concerns: The coroner raised concerns about extensive waiting lists for Gender Identity Disorder clinics, insufficient local patient support, and unclear responsibility for wellbeing during this period. There was also a noted lack of specialist knowledge in local mental health services and clear guidance for GPs on bridging hormone prescriptions.
Response (NHS England): • NHS England developed five pilot services, transitioning two to substantive contracts, and launched the UK's first accredited training programme in gender identity healthcare to increase capacity. • Additional funding … (AI summary)
Response (Together UK): • Together UK has information sharing agreements with NELFT and ELFT, a Standard Operating Procedure for Liaison and Diversion, and will raise the possibility of direct access to East London … (AI summary)
Responded
Jessica Eastland-Seares
Concerns: The coroner identified inadequate community provision for autistic individuals, leading to unnecessary hospital admissions. There is an acute shortage of suitable placements and support services for these individuals.
Response (Department of Health and Social Care): • The Department of Health and Social Care made available up to £8.6 billion in additional funding over this financial year and next to support adult social care and discharge. … (AI summary)
Responded
[REDACTED]
Concerns: Sub-optimal delays in accessing IAPT counselling were noted. Concerns were also raised about the clarity and accessibility of electronic patient records, particularly regarding the updating and function of risk assessments and progress notes.
Response (Midlands Partnership NHS Foundation Trust): • The Trust changed IAPT commissioning arrangements in January 2019 to centralise provision and is redesigning the service to a locality-based model. • The Trust is updating 'how to guides' … (AI summary)
Responded
Amina Ismail
Concerns: The coroner noted underfunding for local mental health beds and a national scarcity of specialist Personality Disorder rehabilitation units, which contributed to delayed patient transfers and prolonged stays in unsuitable out-of-area placements.
Response (NHS England): • NHS England launched the Mental Health, Learning Disability and Autism Inpatient Quality Transformation programme, which included publishing a commissioning framework and requiring Integrated Care Boards to develop 3-year plans … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care stated it would continue to work with NHS England to maximise mental health capacity. • The Department of Health and Social Care … (AI summary)
Responded
Isobel Stapleton
Concerns: Coroner noted mental health practitioners faced difficulties accessing full clinical records, including those from NHS England, and a lack of clinical psychologists for direct assessment and treatment in inpatient and home treatment teams.
Response (Welsh Government): • A business case is being developed for the introduction and deployment of mental health systems across NHS Wales. • Officials are working with Cwm Taf Morgannwg University Health Board … (AI summary)
Response (Cwm Taf Morgannwg University Health Board): • The Health Board developed and implemented a Clinical Information Access and Recording Matrix (CIARM) in August 2023 to inform staff on accessing patient clinical records across multiple systems. • … (AI summary)
Responded
Paul Chase
Concerns: The coroner identified insufficient mental health, alcoholism, and addiction support, treatment, and therapy for veterans while serving, during intensive combat training, and after release. This includes limited availability of resources, leading to significant wait times for ex-veterans.
Response (Ministry of Defence): • The Ministry of Defence stated it has been working to provide support for mental health and addiction issues among service personnel and veterans. • The Ministry of Defence noted … (AI summary)
Responded
Imogen Nunn
Concerns: The coroner noted a lack of available British Sign Language interpreters for Deaf mental health patients, particularly when urgent assessments were required in a crisis. This also caused delays to the inquest proceedings.
Response (NHS England): • NHS England will hold a meeting in May 2025 to brief stakeholders on the plan to publish a refreshed Accessible Information Standard. • The revised Accessible Information Standard is … (AI summary)
Response (Department of Health and Social Care): • Department officials made enquiries with NHS England regarding the concerns raised. • The Cabinet Office’s Disability Unit and the BSL Advisory Board met with the National Registers of Communication … (AI summary)
Response (National Register of Communication Professionals working with Deaf and Deafblind peopl): • NRCPD distributed a survey to its registrants and consulted with key stakeholder organisations to understand issues in healthcare interpreting. • NRCPD committed to supporting the development of person-centred procurement … (AI summary)
Response (DHSE): • The department committed to publishing a new 10 Year Workforce Plan. • The Minister stated an expectation that NHS Trusts and other care providers would ensure appropriate staffing arrangements, … (AI summary)
Responded
Select committee recommendations(86)— showing 50 strongest matches
#140 —
Recommendation: People wish to have a mix of provisions on the high street. The provision of public services, including health services, is increasingly seen by local authorities, the NHS and communities as having a role on the high street.
Response attribution not verified
#136 —
Recommendation: As well as boosting footfall to the benefit of local businesses, high streets are also a practical location for the delivery of the services themselves as they are often more accessible to local communities. 274 In 2021, the Stockport NHS …
Response attribution not verified
#134 —
Recommendation: Public services, including libraries and health services, can draw people onto their local high street: “They may go to the doctors and then maybe to the library, they may do some shopping and buy some food, and then they go …
Response attribution not verified
#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)
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#49 — Prioritise mental health support for children in care and pilot co-located CAMHS services.
Recommendation: The Department for Education should work with the Department of Health and Social Care to ensure that children in care and care leavers are prioritised for mental health support and improve training for mental health practitioners on the impact of …
Response attribution not verified
#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 …
Response attribution not verified
#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)
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#7 — Many FGM survivors lack access to appropriate specialist counselling services
Recommendation: FGM survivors often suffer psychosexual, emotional and mental health complications from undergoing FGM. However, many FGM survivors do not have access to appropriate counselling services, with many FGM services not offering any counselling to FGM survivors and others offering counselling …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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. …
Response attribution not verified
#15 —
Recommendation: Women entering the Criminal Justice System in England and Wales are often the victims of abuse and discrimination, or suffering from trauma, addiction, and mental health issues. Many of them have caring responsibilities. These issues, acknowledged by the Government in …
Response attribution not verified
#10 —
Recommendation: The Government should invest in the services that underpin community orders to satisfy sentencers of their efficiency and availability. The emphasis should be put on intensive treatment, the effectiveness of which is established.
Response attribution not verified
#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 status not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#8 — Ensure FGM Support Clinics offer specialist counselling with clear referral pathways
Recommendation: The Government should ensure that all FGM Support Clinics offer specialist counselling support to FGM survivors in appropriate settings, provided by counsellors who are trained in the specific challenges of FGM. There should be clear referral pathways to this counselling …
Response attribution not verified
#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 …
Response attribution not verified
#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.
Response attribution not verified
#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 …
Response attribution not verified
#35 —
Recommendation: The Government should set out whether they intend to encourage moving more NHS health services to the high street, including the new mental health crisis centres announced in the Autumn 2024 Budget, and, if so, how they will do so.
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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. …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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
#144 —
Recommendation: New public services including libraries, diagnostic centres and local government buildings should be located on the high street in the first instance, with the same sequential test applied to retail being applied to these services. The Government should amend the …
Response attribution not verified
#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 status not verified
#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 status not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
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
NCEPOD recommendations(8)
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
CQC inspection actions(19)
The York Hospital
The trust should ensure that psychology services are made available for patients.
Should Do
Scarborough Hospital
The trust should ensure that psychology services are made available for patients.
Should Do
John Radcliffe Hospital
The trust should ensure the unit meets National Institute for Health and Care Excellence guidelines regarding intensive care access to speech and language therapists (SALT).
Should Do
The Royal Orthopaedic Hospital
The service should consider providing access to a speech and language therapist during weekends.
Should Do
Royal Sussex County Hospital
The trust should continue to develop plans and policies to strengthen the provision of mental health services to patients in the critical care unit.
Should Do
Royal Sussex County Hospital
The trust should review the provision of psychological support provided to patients during their stay in critical care.
Should Do
Westmorland General Hospital
The trust must ensure that, patients with mental health concerns are seen in a timely way
Must Do
The York Hospital
The trust should ensure that patients on the acute stroke ward 23 received their daily 45 minutes of rehabilitation.
Should Do
The York Hospital
The trust must ensure that that care meets the needs of service users by improving referral to treatment times.
Must Do
The York Hospital
The trust must ensure that that care meets the needs of service users by improving referral to treatment times.
Must Do
Mount Vernon Cancer Centre
The trust should ensure that a pathway to specialist mental health support is implemented and staff are aware of it.
Should Do
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
Scarborough Hospital
The service should ensure ED staff recognise or make reasonable adjustments to meet patient needs such as those with mental health issues or anxiety.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that all CCU patients should have access to follow up clinics.
Should 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
Health investigations(115)
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (xiv)
The Trust should carry out a review of the process of referral of patients from the Out-patients Clinic to the Day Hospital, psychotherapy services and voluntary counselling organisations so as to ensure that sufficient and suitable use is made of these facilities.
london
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 9
Access to appropriate family interventions should be available to services users under the care of the CMHT. CMHT staff should receive training and supervision in appropriate family work and interventions. The Trust should monitor the provision of this service, including using regular audits, to ensure that those individuals who might …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 4
In line with the recent developments in the provision and delivery of Psychological Therapies in the Trust, together with its commissioners, the Trust should review this provision to ensure that it complies with the recommendations of relevant NICE guidelines. In particular the Trust should ensure that those individuals with more …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 3
South West Yorkshire Partnership NHS Foundation Trust should review, with its commissioners, the provision of services for individuals with a diagnosis of personality disorder. This review should identify how a comprehensive service, complying with the relevant NICE guidelines, will be established. Any plans should ensure that there is equity of …
north_east_yorkshire
Independent investigation: Richard Marden, Towcester (1999) — Rec 7
That the Trust take steps to publicise the range of services available though NHS Direct, and in particular the fact that it is a service which can be relevant even for patients with mental health problems.(Para 19.5)
midlands
Independent investigation: Philip Ellison, Preston (2008) — Rec 3
The Trust should ensure that a full range of therapeutic interventions are available to clinical teams including behavioural approaches (for example Cognitive Behavioural Therapy).
north_west
Independent investigation: Michael Kahan, Manchester (2008) — Rec 2
The Trust should ensure that the care and treatment options for people with schizophrenia meet the expectations of the National Institute of Clinical Excellence (NICE) guidelines. The Trust should ensure that Cognitive Behaviour Therapy and appropriate psychological therapies are made available to all service users when clinically indicated.
north_west
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 21
Trusts should review the provision and availability of “talking therapies”, including dialectic behavioural therapy in the trust area and encourage clinicians to actively consider whether the needs of a patient should be addressed by psychotherapy or psychology. This is particularly important where a patient (such as Louisa Ovington) has suffered …
north_east_yorkshire
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.k
The Trust and social services authority should give active consideration to the provision of an independent mental health advocacy scheme to assist patients and their carers make comments about the service they receive, and to articulate their own needs and preferences.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 1.vii
We understand that there is an independent Mental Health Advocacy service in Tameside, where the Trust’s Headquarters is based, but we are aware that independent advocacy input into Bury and Rochdale, for example, has been substantially reduced. We recommend that Bury (this is the focus for our enquiry) should receive …
north_west
Independent investigation: John Stevens, Woking (2001) — Rec 10
We recommend that the North West Surrey Mental Health Partnership NHS Trust review its plans for a specialist day service, taking account of evidence based practice and acknowledging the difficulty of engaging and treating people with severe personality disorders in such units.
south_east
Independent investigation: Ian LawsonSimon Richardson, Sunderland — Rec 1
The inquiry panel recommends that mental health services in Sunderland develop a strategy which recognises the need to engage those individuals who are reluctant to access services. Within such a strategy, policies and procedures should be put in place, which allow the identification of those unwilling to work with services …
north_east_yorkshire
Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009) — Rec 3.19
The Mental Health Programme Board for Wales must ensure that there is sufficient NHS low secure provision in Wales.
wales
Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009) — Rec 3.18
Aneurin Bevan Health Board must ensure that a comprehensive range of local in-patient mental health services is available to all patients.
wales
Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009) — Rec 3.15
Aneurin Bevan Health Board and Caerphilly County Borough Council must ensure that services’ eligibility criteria do not exclude patients with complex needs. Eligibility criteria must be flexible, with the core emphasis focused on individuals’ needs.
wales
Independent investigation: Vincent Francis, Wells (2009) — Rec 8
Research and development of new treatment approaches should be encouraged and supported to examine the needs of patients and carers who have previously been considered difficult to engage and treat e.g. young people and people with personality disorders in the community.
south_west
Independent investigation: Valerie Thomas, Cardiff (2005) — Rec 1
The Welsh Assembly Government should ensure that commissioners and providers of mental health services in Wales examine the current provisions for the care and treatment of those suffering from a personality disorder and that commissioners put in place relevant services where there are currently none provided (Related Healthcare Standard3 2).
wales
Independent investigation: Steven Hoskin, St. Austell (2006) — Rec R11
Northamptonshire Healthcare NHS Trust and Cornwall Partnership NHS Trust should ensure that where an assessment of ‗personality disorder‘ is made, it should not exclude the person from access to services. Local service need and provision should be reported to their boards, reflecting the DH guidance issued in 2003 and the …
south_west
Independent investigation: Stephen Rees, Cardiff (2011) — Rec 4
The Health Board and Local Authority should review the adequacy of the arrangements currently in place to provide psychiatric services for homeless, vulnerable people. This review should consider arrangements that are in place in other areas of the UK.
wales
Independent investigation: Shivani Taneja Kapoor, Northwood (2013) — Rec R3
The clinical director should review the size of caseloads with H ABT consultants to ensure they have time to offer priority appointments and appropriate intervals between routine appointments.
london
Independent investigation: Sharon Stokes, Exmouth (2007) — Rec 3.7.4.1.
The Devon Partnership NHS Trust should review the availability of psychological therapy service. The adequacy of the overall level of resourcing of this service with reference to current National Institute for Health and Clinical Excellence (NICE) guidelines for the treatment of mental health problems commonly encountered in secondary mental health …
south_west
Independent investigation: Michael Martin, Almondsbury, (1999) — Rec 6
We make recommendations aimed at improving mental health services to users who have lost contact with services. We recommend a local policy targetted at the care of this group of patients. We also suggest that the Department of Health consider how new mental health legislation might best be drafted to …
south_west
Independent investigation: Michael Martin, Almondsbury, (1999) — Rec 2
It should have been simple and understandable with one single point of access.
south_west
Independent investigation: Keziah Flux Edmonds, East Cowes, IoW (2016) — Rec 1
To ensure that Isle of Wight NHS Trust’s IAPT service is fully accessible to meet the diverse needs of the population the IAPT therapist must, at the initial assessment, assess what support and aids may be required by the patient.
south_east
Independent investigation: Karen Welsh, Cardiff (2010) — Rec 3.14
In view of the issues arising in this case, Welsh Government should review access to Mental Health Services for individuals deemed homeless or have no fixed abode, with particular attention given to those not willing to register with a GP.
wales
Independent investigation: Karen Welsh, Cardiff (2010) — Rec 3.8
The Health Board should review its provision of services for patients diagnosed with personality disorder in line with NICE26 guidance; people diagnosed with personality disorder should not be excluded from any health or social care services because of their diagnosis.
wales
Independent investigation: Joyce Lovell, Donhead St Mary, Wilts (2008) — Rec 1
The Trust action plan should include a specific action on raising the awareness of mental health and accessibility to mental health services with other agencies such as the GP and the Police.
south_west
Independent investigation: John Redhead, Potters Bar (2007) — Rec 25
Commissioners should undertake a review of the provison of psychological therapies within the relevant GP surgery to ensure that practice, referral and uptake rates are consistent with national standards.
east_of_england
Independent investigation: Jim Ward, Ayr (2007) — Rec 9
NHS Board A must ensure that all teams dealing with people with severe and enduring mental health problems have access to evidence-based family interventions. Where teams are viewed as too small in their own right to support a worker trained in a structured family intervention, there must be clear arrangements …
scotland
Independent investigation: Janet Keegan, Enfield & Harringay (1997) — Rec 10
The Trust should revise the current system within the psychology department of offering patients assessment appointments only when treatment places are available.
london
Independent investigation: Janet Keegan, Enfield & Harringay (1997) — Rec 9
Social Services should consider allocating resources to offer counselling and support in cases of serious domestic violence.
london
Independent investigation: Jane WheatleyGary Gardiner, Sheffield (2007) — Rec 7
The Trust should produce a policy on the provision of Cognitive Analytical Therapy (CAT) within the Trust and the policy should include clear criteria as to who is qualified to provide CAT and how staff providing CAT are to be trained and supervised. A centralised waiting list should also be …
north_east_yorkshire
Independent investigation: Halimah Ahmed, Derby (2007) — Rec Three
Post Traumatic Stress Disorder assessment and treatment, and trauma focused therapy requirements should be ascertained by the Derbyshire City Primary Care Trust and appropriate commissioning arrangements should be put into place to ensure that specialist services are available to compliment the services currently provided by the Mental Health Trust.
midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 36
As comprehensive a register of counsellors as possible should be available, setting out the type of counselling they are prepared to offer.
midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 28
The central organisation of all counselling services should be further strengthened so as to support effective use and to co-ordinate appointment and training.
midlands
Independent investigation: Edward Shaw, Ladbroke Grove (2006) — Rec Two
It is recommended that the Trust follow through their ambition to provide Dual Diagnosis services in-house and training to all staff.
london
Independent investigation: Edward Miles, Tower Hamlets (2003) — Rec 5
The Trust must develop and implement a strategy to increase the range of therapeutic options available to patients in Tower Hamlets, moving beyond a narrow medical focus. This should include greater access to psychological therapies, social interventions, and vocational support. The Trust must ensure that staff are trained in and …
london
Independent investigation: Dorothy Shepherd, Winchcombe (2010) — Rec 3
The Trust should ensure that psychological therapies are offered to all service users diagnosed with psychosis in line with the NICE Schizophrenia Guidance 2009.
south_west
Independent investigation: Colin Ricketts, Laindon, Essex (2009) — Rec R1
The commissioners should satisfy themselves that the period from referral to assessment and then treatment for psychology services is within acceptable time parameters.
east_of_england
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 11
In appropriate cases, arrangements for the provision of psychological assessment and/or treatment should include the provision of a fast track route to psychological services (whether at secondary or tertiary level). Such arrangements reflect the reality that in cases of PTSD there is a window for the provision of psychological therapy: …
north_east_yorkshire
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 9
The trust should have clear pathways from diagnosis of post traumatic stress disorder (PTSD) to treatment. The panel understands that during this period (January 2001 to April 2006) no specialist resource for dealing with PTSD existed in the region. There is now a tertiary level regional service however it has …
north_east_yorkshire
Independent investigation: Chloe Sutherland (8 mnths), Edinburgh (2015) — Rec 2
Review the PNMHS referral criteria to ensure that there is enough flexibility so that women with significant histories who have been seen within the service can be re-referred until the child is one year of age.
scotland
Independent investigation: Chloe Sutherland (8 mnths), Edinburgh (2015) — Rec 2
Ensure that there are clear pathways to access specialist perinatal mental health expertise within their board area, including pathways for urgent assessment by local mental health teams as appropriate.
scotland
Independent investigation: Chloe Sutherland (8 mnths), Edinburgh (2015) — Rec 1
ensure that there is enough flexibility in referral criteria so that women with significant histories who have been seen within the service can be re-referred until the child is one year of age.
scotland
Independent investigation: Beatrice Hughes, Harrow (1997) — Rec a.
ensure that Department of Health Circular LAC(93)2 and subsequent central guidance on Drug and alcohol misuse issues relating to community care assessments and service provision are being fully implemented, and that past barriers to service provision identified in this Inquiry have been removed;
london
Independent investigation: Beata Slomiana, Finchley (2010) — Rec R1
The trust should ensure that guidelines for the use of opt-in forms should set out when additional processes such as phone follow-up are needed to effectively assess a person’s willingness to engage with the service. Opt-in forms must be clearly written and available in other relevant languages.
london
Independent investigation: Anthony Kellman, Brixton (1994) — Rec R2
WE RECOMMEND THAT the Trust should offer to provide appropriate therapy as a matter of course to all those who may have been directly or indirectly affected following events such as these.
london
Independent investigation: Anthony Harrison, Andover (1998) — Rec 4
Together with partner agencies, the Health Authority and PCGs should investigate the most appropriate way to provide mental health and substance misuse services to people who are homeless and who may find difficulty accessing regular services.
south_east
Independent investigation: Abdullah Jama, Blackheath (2009) — Rec 11
Sheffield PCT should review the services commissioned from Sheffield Health and Social Care NHS Foundation Trust with specific emphasis on access to talking therapies and in-reach drug and alcohol misuse therapies.
north_east_yorkshire
Independent review of the care and treatment of Mr G — Rec 9
The Trust should prioritise psychological therapy for high risk patients likely to benefit from it.
Mr G published on the 16 th November 2021. Mr G was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust
london
Accepted
Detention investigations(1)
Independent reviews(16)
Mental Health Taskforce 2016 — Rec 15
By 2020/21, NHS England should support at least 30,000 more women each year to access evidence-based specialist mental health care during the perinatal period. This should include access to psychological therapies and the right range of specialist community or inpatient care so that comprehensive, high quality services are in place …
Health & Social Care
Mental Health Taskforce 2016 — Rec 14
NHS England should invest to increase access to integrated evidence-based psychological therapies for an additional 600,000 adults with anxiety and depression each year by 2020/21 (resulting in at least 350,000 completing treatment), with a focus on people living with long-term physical health conditions and supporting 20,000 people into employment. There …
Health & Social Care
Shaw Detention Review — Rec 57
Recommendation 57: I recommend that talking therapies become an intrinsic part of healthcare provision in immigration detention.
Immigration
Selous Review — Rec 89
The Armed Forces/Military Charities to: • continue to facilitate access for Serving personnel and their families across all three Services to independent, professional relationship support services outside the Chain of Command • promote through-life support and encourage Serving personnel and their families to seek timely and appropriate help.
Other
Selous Review — Rec 82
The Ministry of Defence and the Armed Forces to work in partnership with an established helpline, such as ChildLine, to set up a confidential helpline specifically for children and young people from military families.
Other
Taylor Youth Justice Review — Rec 1
Health commissioners and providers in England and Wales should seize the opportunity presented by additional investment in children and young people's mental health services to rethink the way that mental health support is provided to children who are at risk and who currently do not get the access they need …
Justice & Legal
Wessely Review — Rec 112
Every inpatient child or young person should have access to an IMHA who is trained to work with young people and their families.
Health & Social Care
Accepted
Wessely Review — Rec 35
There should be more accessible and responsive mental health crisis services and community-based mental health services that respond to people's needs and keep them well.
Health & Social Care
Accepted
Stevenson/Farmer Review — Rec 36
We recommend that online platforms with large reach amongst self-employed workers link up with NHS-approved health and wellbeing support to provide mental health support and advice which can be accessed by those working through their technology.
Employment & Work
Accepted
Stevenson/Farmer Review — Rec 30
We recommend that the Government and NHS bodies enable and encourage IAPT and other mental health services to provide quick and convenient access to care to fit around employment.
Employment & Work
Accepted
Cass Review — Rec 4
When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.
Health & Social Care
Accepted
Wessely Review — Rec 74
There should be better access to long-term support for everyone to keep them well and prevent admission.
Health & Social Care
Accepted
Wessely Review — Rec 67
As set out in our chapter on Advocacy, IMHA services should be commissioned specifically for people on CTOs that requires providers to proactively approach the patient and offer their services.
Health & Social Care
Accepted
Sayce Review — Rec 2
Access to Work should be transformed from being the best kept secret in Government to being a recognised passport to successful employment, doubling the number of people helped. Government should improve equity of access, use innovation to create efficiencies, remove unnecessary waste and mobilise the power of peer support.
Other
Black Review on Health and Work — Rec 8
When appropriate models for the Fit for Work service are established, access to the service should be open to those on incapacity benefits and other out-of-work benefits. Government should fully integrate health support with employment and skills programmes, including mental health support where appropriate. Government should expand the provision of …
Health & Social Care
Wessely Review — Rec 120
Health and social care commissioners should have a duty to collaborate to ensure provision of community based support and treatment for people with a learning disability, autism, or both to avoid admission into hospital and support a timely discharge back into the community.
Health & Social Care
Accepted
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
Domestic Homicide Reviews(76)— showing 50 strongest matches
Sheffield — recommendation 18
STHFT should ensure patients are signposted for specialist support when they are exhibiting evidence of alcohol and drug misuse.
STHFT
Oxford — recommendation 2
Addaction will explore creative options for re-engaging young people who don’t want to engage or who drop.
Young Addaction Oxfordshire
Oxford — recommendation 2
The OSCB to seek assurance from the relevant health and children’s services commissioning agencies that suitable services are available for young people with complex emotional and behavioural problems who do not meet current CAMHS thresholds.
Oxfordshire Safeguarding Children Board
Cheltenham — recommendation 3A
Carry out a review of the local Futures in Mind plan* in the light of this DHR and consider how well young people access emotional health and wellbeing support and services in a timely manner.
Cheltenham Strategic Leadership Group
Plymouth — recommendation 18
Health to review the existing communications strategy in relation to informing members of the public regarding mental health service access and gateways.
Health
Wiltshire — recommendation R41
For staff to be advised to use the term “signposted” rather than “referred” when discussing the outcome of discussions about Turning Point and LIFT /IAPT which require the service user to be proactive to access such services. By Service Managers by 31 May 2016.
Wiltshire Quality Director
Nottingham — recommendation Notts SVS 1
In any situation where clients request online or telephone counselling, however they cannot access a confidential space for counselling, Notts SVS Services will ensure that face-face counselling is delivered in a venue and location that meets the client’s needs e.g., GP, Community Venue, Notts SVS Services counselling rooms. Face-face counselling …
Nottingham Sexual Violence Support Service
Leicester — recommendation Multi-agency - 4
All Northants MARAC victims to be signposted to specialist domestic abuse informed counselling
Northants MARAC
Epsom and Ewell — recommendation 7
The Epsom & Ewell Community Safety Partnership should work with relevant agencies and other strategic partnerships to examine methods for reaching into local communities that encourage adults (particularly adult males) to seek support about emotional or mental health worries or any mental distress they may be troubled by.
Epsom & Ewell Community Safety Partnership
Lincoln — recommendation 7
For the Trust’s to identify a pathway for trauma informed care for people with secondary mental health diagnoses which is commensurate and accessible to all, aligned to NICE guideline [NG116] Post-traumatic stress disorder. This should include how to manage trauma in people currently experiencing abuse.
Lincolnshire Partnership (NHS) Foundation Trust
Lincolnshire Partnership NHS Foundation …
Somerset — recommendation 20.10
Somerset Drug and Alcohol Service to consider alternative ways to engage with clients who highlight at referral that they are unable to engage in their standard treatment options; Mon-Fri 09:00 - 17:00.
Somerset Drug and Alcohol Service
Brent — recommendation 6.6.1
That all Talk Wandsworth clinicians are reminded of the NHS England guideline and the commitment of the service to prioritise war veterans for treatment at Steps 2 and 3 thereby ensuring minimal waiting times for clients in this group.
South West London and St George’s …
South West London and …
Tower Hamlets — recommendation A16
Tower Hamlets CAMHS to ensure clinicians are aware of the systems for accessing telephone interpreting services if face to face interpreter is not possible.
Tower Hamlets CAMHS
Tower Hamlets Social Services
Tower Hamlets — recommendation A15
Tower Hamlets CAMHS to review systems to ensure that interpreting services are booked routinely for initial assessment if referral states that the clients cannot speak English. Giving the patient the option to refuse if not needed.
Tower Hamlets CAMHS
Tower Hamlets Social Services
Tower Hamlets — recommendation A1
Health Advocates should be used for all pregnancy appointments, particularly the booking appointment.
Barts Health NHS Trust
Barts Health NHS Trust
Sheffield — recommendation b
in cases of ongoing low mood, and misuse of medication, talking therapies should always be offered by the General Practitioner
Sheffield Clinical Commissioning Group
Sheffield Clinical Commissioning Group
Cwm Taf — recommendation 2
Agencies should consider how to support a community in relation to the aftermath of trauma, both in the short term and in the longer term.
Cwm Taf Community Safety Partnership | …
Stoke-on-Trent — recommendation NPS_Staffs_Stoke_1
When a referral has been accepted by the Criminal Justice Mental Health Team and an offender chooses to later decline these services, even though the officer assesses there is ongoing need, the officer should attempt to set up dissonance/motivate in an attempt to ensure services are taken up.
National Probation Service – Staffordshire and …
Solihull — recommendation 3
General Medical Practitioners to be reminded of the limitations of the service provided by Healthy Minds which is a primary health service and further training to be provided in respect of Improving Access to Psychological Therapy (IPT)
Solihull Clinical Commissioning Group
Kingston upon Thames — recommendation 5
Commissioners and providers of counselling and psychological services should ensure that services are appropriately designed to enable service users to have a face to face assessment of their needs.
Mental Health Trust | Clinical Commissioning …
Hammersmith and Fulham — recommendation WLT8
Recovery teams to offer family intervention and individual CBT to all patients with schizophrenia in line with the NICE guideline on psychosis and schizophrenia. If the service is not funded to be able to provide this, this is to be brought to the attention of the commissioners.
West London NHS Trust
West London NHS Trust
Hammersmith and Fulham — recommendation 9
West London NHS Trust and local CCGs to encourage social prescribing for patients in receipt of mental health services.
West London NHS Trust | local …
West London NHS Trust
Croydon — recommendation GP1-R2
Healthcare professionals to have a lower threshold to make referral on behalf of a patient to counselling services where appropriate (instead of patient’s being asked to self-refer) and ensure they follow-up with those asked to self-refer.
GP 1
Welwyn Hatfield — recommendation c
Hertfordshire Children Services contacts the carers of the three children in this case and establishes whether they have access to the therapeutic resources needed to support the three children. If this is not the case that they establish a fund to enable the children to access the support, they need.
Hertfordshire Children’s Services
Welwyn Hatfield — recommendation e
Information is passed to all victims of domestic abuse about domestic abuse support services and victims are encouraged to contact services for support.
Hertfordshire Constabulary
Hertfordshire Constabulary
Welwyn Hatfield — recommendation 12
Hertfordshire Domestic Abuse Partnership to review services across the County with a view to ensuring therapeutic support is available to all survivors of domestic abuse, including children.
Hertfordshire Domestic Abuse Partnership
Welwyn Hatfield — recommendation 4
Police, Health Services and Children’s Social Care increase their awareness of the role of the different third sector and specialist organisations in Hertfordshire, including therapeutic trauma services and ensure they refer their clients/patients/service users appropriately into these services.
Hertfordshire Constabulary | East and North …
Hertfordshire Constabulary
Welwyn Hatfield — recommendation 3
Hertfordshire Domestic Abuse Partnership to publish, publicise, and maintain updated lists of organisations who can offer help and support to victims and survivors, ensuring these are available to communities across the County.
Hertfordshire Domestic Abuse Partnership
Welwyn Hatfield — recommendation 1
An allocated lead at the Home Office is responsible for establishing a national fund to enable a package of therapeutic and advocacy support to be put in place for child survivors of Domestic Homicide and suicide linked to domestic abuse. The Home Office to report back to Hertfordshire County Council …
Home Office
Home Office
Waverley — recommendation 2
Surrey County Council Adult Social Services together with all Surrey Clinical Commissioning Groups and all Surrey Health Services, Domestic Abuse Outreach Services and Surrey Police, embark on a publicity campaign advertising with posters and seminars etc., the opportunities for older victims of domestic abuse, their friends and family members in …
Surrey County Council Adult Social Services …
Surrey Clinical Commissioning Group
Nottingham — recommendation 6
The Nottingham Crime and Drugs Partnership should collaborate with the Police, Children’s Social Care and other agencies to ensure that victims of abuse, particularly child victims of abuse are offered pre-trial therapy. The Partnership should seek assurance that pre-trial therapy is not delayed on account of an ongoing Police investigation …
Nottingham Crime and Drugs Partnership
Pendle — recommendation 6
That Pendle Community Safety Partnership ensures that access to information on support services which can respond to concerns regarding an individual’s mental health, whether the concerns are in relation to the individual’s own mental health or for someone they know, is available for all members of the community.
Pendle Community Safety Partnership
Bristol — recommendation 3
Improve the understanding of the specific needs of the local Somali Community (SC) in respect of Mental Health that includes; - what enables/hinders the SC accessing support and that clearly identifies the gaps in provision.
Public Health
Basildon — recommendation 11.12.1
That consideration of referral to specialist services needs to form part of every assessment where there are identified concerns about substance misuse.
North East London Foundation Trust (NELFT)
Manchester — recommendation Bridges 1
All Bridges referrals that disclose low mood/ suicidal ideation will be referred to the Jigsaw Support Wellbeing Navigator team for support and signposting.
Bridges Domestic Abuse Support Services
Sheffield — recommendation 17
SYP should ensure any person arrested for a ‘trigger’ offence should be the subject of a mandatory drug test and assessment, we well as being offered the support of a drug referral worker.
SYP
South Yorkshire Police
Doncaster — recommendation 11
That the Safer Stronger Doncaster Partnership ensures that agencies referral pathway for victims of sexual abuse is accessible for all victims.
Safer Stronger Doncaster Partnership
Kent — recommendation 7
In exercising their responsibility in assisting young adults leaving care, Social Services should endeavour to ensure such individuals are registered with a GP, (none of the Rose Brothers were registered with a GP at the time they attacked Joyce).
Kent and Medway Social Services
Plymouth — recommendation 18
Health to review the existing communications strategy in relation to informing members of the public regarding mental health service access and gateways.
Health
Tower Hamlets — recommendation A4
Ensure that that it is clearly stated in policy or standard operating procedure (SOP) and staff to be reminded of: The need to verify address and contact details at every time the family are seen and EMIS record updated accordingly. The need to establish at initial contact whether an interpreter …
Tower Hamlets GP Care Group
Tower Hamlets GP Care …
Tower Hamlets — recommendation A3
Ensure that the family health needs assessment includes, but is not limited to: Establishing immigration status; Recording both parents’ religion; Household finances; Housing status; Bonding / attachment and barriers to this; Knowledge of local specialist services as well as the local offer information; Assessment of the impact of the above …
Tower Hamlets GP Care Group
Tower Hamlets GP Care …
Stevenage — recommendation 7.2b
have information about services available to victims, which is brought together in a leaflet
Stevenage Community Safety Partnership
Norfolk — recommendation 8
Learning from this Review should be disseminated and generate a review of service delivery to those with the coexisting issues of domestic abuse, mental ill-health, and/or substance misuse, and be informed by service users themselves. The aims of this review should include: • coordinating service provision to improve access and …
Norfolk County Community Safety Partnership | …
NHS Norfolk and Waveney …
Isle of Wight — recommendation 6.12
That the commissioners and providers of Isle of Wight drugs and alcohol treatment services examine the feasibility of ensuring that multiple offers of service are made in varied ways based on the hypothesis that some clients may respond to different types of approach thereby increasing the likelihood of engagement.
Isle of Wight drugs and alcohol …
Northampton — recommendation 1
The Trust should re-launch the multi-agency Adults At Risk (ARM) process in order to support those individuals for whom access to services is a challenge.
Northampton General Hospital
NORTHAMPTON GENERAL HOSPITAL NHS …
Leicester — recommendation 2
The Community Safety Partnership with partners across Leicester, Leicestershire and Rutland should promote and develop safe access points, where victims of abuse can access advice and support.
Community Safety Partnership | Leicester, Leicestershire …
NHS Leicester, Leicestershire and …
Central Bedfordshire — recommendation 1.10.20
Review Mental Health/Counselling Pathway.
West Street Surgery
Endless Street Surgery
Croydon — recommendation GP1-R4
This case to be discussed with the local Mental Health Commissioner to review local services and establish whether any support is available in adulthood to those on the autistic spectrum or whether existing services have experience in/feel they are able to adapt sufficiently to meet the needs of this group …
GP 1
Milton Keynes — recommendation 13
To ensure that all victims of domestic abuse are offered access to the Domestic Abuse Case Worker and given contact details of women's organisations (including culturally specific organisations).
Dacorum Borough Council
Dacorum Borough Council
Welwyn Hatfield — recommendation b
To consider additional ways of supporting victims/survivors including young parents who are experiencing substance use and domestic abuse to ensure they can access support.
Hertfordshire Children’s Services
CQC enforcement actions(4)
Conditions Imposed: Tavistock and Portman NHS Foundation Trust
The Care Quality Commission (CQC) imposed conditions on the registration of Tavistock and Portman NHS Foundation Trust following an announced, focused inspection in October and November. Inspectors found significant concerns within the Gender Identity Development Services (GIDS), including over 4,600 …
Jan 2021
Warning Notice: West London NHS Trust
CQC told West London NHS Trust to make improvements to its community-based mental health services following an inspection in May. The inspection found significant staffing issues and delays to people accessing treatment, which put some people at risk of harm. …
Jul 2022
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Greater Manchester Mental Health NHS Foundation Trust. This action followed a focused inspection in April of community-based mental health services for adults of working age. Inspectors found that patients and …
Jun 2022
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an inspection of their community-based mental health services for people of working age in October. Inspectors found safety concerns still needed addressing …
Mar 2023