Unclear psychiatric referrals
Ambiguous or poorly defined referral processes for psychiatric units, leading to delays or inappropriate patient placement.
Source spread
Where this theme appears
This theme appears across 13 independent accountability sources, so the source mix matters as much as the headline total.
22 PFD reports
1 committee rec
1 HSSIB rec
2 PPO recs
2 IMB recs
1 Article 2 learning point
19 DHR recs
6 PHSO decisions
1 LGO/SPSO decision
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(22)
Sarah Shepherd
Concerns: The Trust's Psychiatric Intensive Care Services policy lacked a clear inpatient referral process and required no written response in patient notes. Resuscitation training for nursing staff was unclear and misinterpreted guidelines, compounded by misleading aide-mémoires on equipment.
Overdue
Kirabo Kiwanuka
Concerns: The coroner noted a lack of agreement among senior professionals on diagnosing and managing NMS, and uncertainty about the optimal care model for acutely manic patients with physical illness. There were also concerns about limited family involvement in best interest decisions for sectioned patients.
Overdue
Andrew Horgan
Concerns: The coroner identified knowledge gaps among doctors and medical staff regarding referral procedures for mental health assessments and engaging Mental Health Partnership personnel, noting a need for improved training on effective communication pathways.
Response (Great Western Hospital NHS Foundation Trust): • The Avon and Wiltshire Mental Health Partnership (AWP) documentation record was updated to clarify the purpose of telephone calls from Great Western Hospital (GWH) staff regarding mental health referrals. … (AI summary)
Responded
Stuart Long
Concerns: The coroner noted confusion among professionals regarding the appropriate management of anti-social behaviour by individuals who are intoxicated or mentally unwell, suggesting a place of safety could have prevented Mr Long's death.
Overdue
Andrew Frost
Concerns: The coroner noted a lack of shared understanding between general practitioners and the Islington Crisis Team regarding the team's capacity and whether it functions as an emergency service, recommending specific training for GPs on crisis team limitations.
Response (Killick Street Health Centre): • Killick Street Health Centre met with the Crisis Team on 19 March to discuss service provision. • The Health Centre decided to meet with the Crisis Team on a … (AI summary)
Responded
Richard Jones
Concerns: The coroner raises concerns about the inconsistent recording of information from patients presenting with mental health issues, specifically regarding the perceived level of risk and urgency for assessment. There were also conflicting accounts about the division of responsibilities and the urgency of care between different mental health services.
Response (Ministry of Defence): • The Ministry of Defence stated it is updating its medical policy document (JSP 950, leaflet 2-7-2) to include new guidance on transfer principles and clarification of primary responsibility for … (AI summary)
Response (Avon and Wiltshire NHS Trust): • The Critical Incident Review Group considered the report. • The Trust stated it would conduct a joint root cause analysis investigation with Salisbury District Hospital and the Armed Forces. … (AI summary)
Response (Department of Health2): • Discussions are underway between the Department of Health, Ministry of Defence, and NHS England regarding the transfer of medical notes between services. • These discussions are intended to address … (AI summary)
Response (Salisbury NHS Trust): • The Trust implemented a new mental health risk assessment tool and amended its Standard Operating Procedure in collaboration with Avon & Wiltshire Mental Health Partnership (AWP). • A 'Mental … (AI summary)
Response (UK Health Security Agency): • The UK Health Security Agency (PHE) outlined its existing role in supporting public health parity for mental health, including the National Mental Health Dementia and Neurology Intelligence Network. • … (AI summary)
Responded
Christopher Higgins
Concerns: The coroner noted gaps in staff observation protocols, insufficient procedures for mental health patient transfers involving police, and a lack of environmental risk assessment for an outdoor area. There was also no formal agreement between services for managing detained patients in A&E.
Response (Norfolk and Suffolk NHS Trust): • The Trust reviewed and updated its observation policy and communicates updates to staff. • The Trust reviewed and modified the disabled access ramp railing and commenced work to enclose … (AI summary)
Response (James Paget University Hospitals NHS Trust): • The Trust, in collaboration with Norfolk and Suffolk Mental Health Trust, developed a process and flow-diagram for patients under mental health services requiring acute care. • This new process … (AI summary)
Response (Queen Elizabeth Hospital NHS Trust): • The Trust collaborated with Norfolk and Suffolk NHS Foundation Trust to develop a referral pathway for mental health inpatients requiring Emergency Department care. • A written pathway and flow … (AI summary)
Responded
Clarice Hilton
Concerns: The coroner identified a lack of policy or guidance for psychiatric unit staff on actions to take when a patient refuses physical health observations, leading to uncertainty regarding MEWS calculation and when to seek medical assessment.
Response (5 Borough Partnership NHS Trust): • The Trust completed a full review of its Modified Early Warning Scores (MEWS) operational guidance. • The MEWS guidance was changed to include instructions for staff on assessing patients … (AI summary)
Responded
Dean Saunders
Concerns: The coroner identified lacunas in the admissions protocol for transferring mentally disordered individuals from police custody and a lack of clarity in hospital transfer processes. Concerns were also raised regarding ACCT process training, family involvement, and the resilience of psychiatric cover at Chelmsford prison.
Response (NHS England): • Care UK circulated a document to staff providing contact details for medical staff authorised to sign Mental Health Assessment documents. • A new provider will deliver healthcare at HMP … (AI summary)
Response (Essex Partnership NHS Trust): • The Trust submitted its admissions protocol for regional review and referred the issue of best practice for the forensic pathway for regional discussion. • The Trust engaged with NHS … (AI summary)
Response (Care UK): • Care UK revamped its national Mental Health Pathway and adapted it to incorporate best practice. • The new Mental Health Pathway was formally signed off on 28 March 2017. … (AI summary)
Overdue
Daisy French
Concerns: The coroner identifies gaps in communication and transition between CAMHS and adult mental health services for 16-18 year olds. This includes issues with out-of-hours provision, placement in adult crisis houses, and returning them to unsupervised supported living.
Response (Sheffield Health and Social Care): • The Trusts are strengthening and revising the Transitions Protocol for 16 and 17 year olds, with formal adoption planned by 31 March 2018. • A Section 136 bed for … (AI summary)
Response (Department of Health): • The NHS in Sheffield has provided staff training on transitions, opened a Section 136 suite, and employed a Mental Health Liaison Consultant. • An information sharing agreement is to … (AI summary)
Responded
Colette Dunn
Concerns: A full Mental Health Act assessment was not performed before discharge, despite police concerns about suicidal intent. The coroner also noted a lack of clear inter-agency discharge protocols and insufficient facilities for mental health crisis management in Milton Keynes.
Overdue
Khalid Yousef
Concerns: The coroner raises concerns about the absence of commissioned psychiatrists in Liaison and Diversion (L&D) services, limiting practitioners' ability to identify serious mental illness. This is compounded by police misunderstanding L&D's role and reduced availability of Forensic Medical Examiners.
Response (NHS England): • NHS England confirmed that national service specifications for Police Custody Healthcare Services and Liaison and Diversion services are designed to clarify responsibilities for individuals in mental health crisis. • … (AI summary)
Response (NHS England): • NHS England stated that psychiatric provision is not considered necessary within L&D multi-disciplinary teams, as Police Custody Healthcare Services are responsible for mental health crisis response. • NHS England … (AI summary)
Response (West Midlands Police): • West Midlands Police stated it would direct its head of custody to engage national Liaison and Diversion leads regarding the lack of commissioned psychiatrists. • West Midlands Police committed … (AI summary)
Response (West Midlands Police): • West Midlands Police stated its head of custody has been directed to engage national Liaison and Diversion (L&D) leads to raise awareness of the concern regarding the lack of … (AI summary)
Response (Birmingham and Solihull Mental Health): • The Trust has placed the matter of inter-agency clarity on the agenda for the next Joint Strategic Operational Group meeting. • The team manager will work with the Communications … (AI summary)
Response (response form Birmingham and Solihul Mental Health Trust): • The Trust placed the matter of inter-agency clarity on responsibilities onto the agenda for the next Joint Strategic Operational Group meeting. • The team manager will work with the … (AI summary)
Response (NHS England): • NHS England's national Health & Justice team officials will continue to work collaboratively with the National Police Chiefs Council to ensure Police Custody Healthcare Service and Liaison and Diversion … (AI summary)
Response (Home Office): • The Home Secretary asked her office to investigate the circumstances surrounding previous unreceived correspondence. • Home Office officials are working with the National Police Chiefs' Council (NPCC), NHS England, … (AI summary)
Responded
Roy Draper
Concerns: The coroner noted a lack of a clear system and protocol for initiating the unblinding process in clinical trials, particularly when a patient is treated in another hospital. There is also no formal referral system for reporting adverse events, which impacts transparency between hospitals.
Response (Medicines and Healthcare Products Regulatory Agency): • The MHRA stated that its Good Clinical Practice Guide and HRA guidance outline protocols for contact details, out-of-hours arrangements, and emergency unblinding in clinical trials. • The MHRA described … (AI summary)
Responded
Andrew Shambrook
Concerns: The health board lacks a documented and robust policy for decision-making, criteria, and future treatment pathways for patients referred to the Home Treatment Team.
Response (Betsi Cadwaladr University Health Board): • An addendum to the Home Treatment Team Operational Policy has been provided and will be shared across the Mental Health and Learning Disability Division. • The existing Home Treatment … (AI summary)
Responded
Girmaye Guyo
Concerns: The coroner identified a risk that the Nearest Relative Power could lead to patient discharge despite them meeting detention criteria, due to a lack of thorough procedure or legal test for clinicians to apply.
Response (Department of Health and Social Care): • The Government stated it would not amend the Nearest Relative powers of discharge. • It noted that section 25 of the Mental Health Act provides powers for Responsible Clinicians … (AI summary)
Overdue
Rachel Garrett
Concerns: The coroner notes that Mental Health Liaison teams in acute hospital A&E departments cannot use Section 5 holding powers due to their employment by a separate Mental Health Trust, creating a risk of patients absconding before an acute hospital doctor can intervene.
Response (NHS England): • NHS Sussex Integrated Care Board (ICB) is undertaking a pathway review at place and system level. • Sussex Partnership Foundation Trust (SPFT) is in the planning stages of a … (AI summary)
Response (NHS Sussex Integrated Care Board): • The Integrated Care Board (ICB) commissioned an independent review of Mental Health crisis pathways in June 2023. • The ICB will contact other Integrated Care Boards to explore how … (AI summary)
Responded
Donna Donnellan
Concerns: The coroner identified a lack of understanding between Acute and Mental Health Trust clinicians regarding the specific role of the Mental Health Liaison Team for eating disorder patients. There was also a lack of clarity on referral pathways to specialist eating disorder services.
Response (Northern Care Alliance NHS Foundation Trust): • The Trust finalised and ratified a policy, 'Management of Medical Emergencies in Adult Patients with Eating Disorders,' which is now in use. • The policy clarifies the roles and … (AI summary)
Response (Pennine Care NHS Foundation Trust): • Pennine Care NHS Foundation Trust and Northern Care Alliance NHS Foundation Trust reviewed policies and procedures to clarify referral processes. • The Trusts agreed to jointly review the policy … (AI summary)
Responded
Aaron Deeley
Concerns: The coroner identified gaps in mental health care for patients held under Section 5(2) MHA on acute wards, noting no allocated Responsible Clinician and lack of mental health liaison team attendance for risk assessment. Concerns also included acute staff's lack of specialist training, confusion over 1:1 observation policy, and no joint protocol between Trusts for these vulnerable patients.
Response (NHS England): • NHS England's National Adult Mental Health Team reviewed the report and concerns. • NHS England confirmed that its Regulation 28 Working Group discusses all PFD reports to share learnings … (AI summary)
Response (Essex Partnership University NHS Foundation Trust): • The Trust updated its Mental Health Liaison Service Operational Policy to include support and advice for acute providers on risk management for patients requiring Mental Health Act assessment. • … (AI summary)
Response (Mid and South Essex NHS): • The Trust updated its policies for the admission and treatment of patients with mental health disorders in acute settings, incorporating new guidance and a flowchart for Section 5(2) pathways. … (AI summary)
Responded
Caroline Staite
Concerns: Concerns were raised regarding the robustness of procedures for clients being considered by Mind, and the lack of transparent processes for patients returning from Mind to the Neighbourhood Mental Health Team.
Response (Herefordshire Worcestershire NHS): • A Standard Operating Procedure (SOP) for the Community Mental Health Link Worker Service has been co-produced with Herefordshire MIND and implemented in draft form. • MIND Link workers have … (AI summary)
Responded
Hayley Beavington
Concerns: The coroner identified concerns regarding a crisis house's refusal to admit Ms Beavington despite high suicide risk, and the consultant psychiatrist not providing guidance on how to challenge this decision effectively.
Response (North London NHS Foundation Trust): • The Trust has introduced a structured escalation process for declined crisis house referrals, requiring senior clinical review. • A 24/7 Crisis Hub Health Professional Line now provides immediate access … (AI summary)
Responded
Man Ng
Concerns: The coroner raised concerns about the complex processes and lack of streamlining in the treatment of subarachnoid haemorrhages, particularly regarding the unclear overall responsibility between neurosurgical teams and interventional radiologists, which may place patients at risk.
Response (Royal College of Physicians): • The Royal College of Physicians continues to campaign on delays in emergency care. • The Royal College of Physicians offered to discuss the matter further with the Royal College … (AI summary)
Response (Royal College of Surgeons): • The College will work with the Society of British Neurological Surgeons (SBNS) and the British Neurovascular Group (BNVG) to develop a position statement setting out recommendations for the management … (AI summary)
Response (The Royal College of Radiologists): • The Royal College of Radiologists (RCR) sought input from its specialty interest groups, including the British Society of Interventional Radiology, to inform its response. • The RCR stated it … (AI summary)
Responded
Warren Green
Concerns: The coroner noted that patients at high risk of self-harm could leave the acute ward without proper risk assessment or staff knowledge. There was also a lack of clarity in the Mental Health Liaison Service's criteria for escalating patients to a Consultant Psychiatrist, limiting oversight.
Response (Mid and South Essex NHS Foundation Trust): • The Trust reviewed and updated policies and flowcharts for managing high-risk self-harm patients in inpatient settings. • Staff guidance on Section 5(2) Mental Health Act has been incorporated into … (AI summary)
Response (Essex Partnership University NHS Foundation Trust): • The Trust described its 'Core 24' model, which includes rapid mental health assessment and integrated liaison, as the framework applied. • The Trust confirmed that consultant and senior medical … (AI summary)
Responded
HSSIB safety recommendations(1)
PPO death in custody recommendations(2)
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff at Pentonville understand that referrals to secure mental health units should only be made through the prison’s mental health Inreach team.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who appear acutely, psychiatrically unwell are considered for transfer to a psychiatric hospital, and these discussions are recorded in the medical record.
IMB individual recommendations(2)
Wakefield (2022)
We ask the minister to explain how the government intends to address longstanding and yet unresolved problems with the assessment and transfer of prisoners who present with serious mental health and personality disorders from HMP Wakefield to hospital (section 47, Mental Health Act 1983).
Ministry of Justice
In Progress
Belmarsh (2023)
Would the Minister consider the impact of prison on those with serious mental illness and review systems for assessment and more appropriate placements?
Ministry of Justice
Health investigations(89)
*Mental health homicide investigation legacy report into the care and … — Rec L6
The trust should monitor and review the newly-developed personality disorder initiatives to ensure that all staff, medical and otherwise, are aware of what personality disorder services are available, how to refer, and the waiting time for referral. This should include knowledge of the referral process and criteria for referring service …
south_east
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 23
Trusts should disseminate across the services the criteria established by each branch of the service for acceptance into, and exclusion from that service.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 22
Trusts should ensure that all mental health professionals and staff across the various services are clear about who can make referrals to any other branches of the services, including psychiatrists, psychology, forensic, CMHT services, CRT, AOT and what the mechanism for referral is.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 17
Trusts needs to be clear where the remit for working with people with personality disorders falls. It needs to be recognised that personality disorders can be as serious as illnesses such as schizophrenia in terms of their negative impact on the individual and the society around them. Appropriate, ideally specialist, …
north_east_yorkshire
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 3
If the patient is assessed by a GPas being at risk, either by virtue of their past history or their present conduct and mental state, he/she must be referred for formal assessment by specialist mental health services under the direction of a psychiatrist. If the GPconsiders the risk to be …
london
Independent investigation: Ian LawsonSimon Richardson, Sunderland — Rec 9
The inquiry panel recommends that clearly defined processes for the referral of urgent cases to mental health services should be developed with the participation of primary care and secondary acute health services. Health services in Sunderland should determine and agree appropriate standards of information required for the referral of urgent …
north_east_yorkshire
Independent investigation: Ian LawsonSimon Richardson, Sunderland — Rec 8
The inquiry panel recommends that mental health services put in place protocols which allow the direct referral of cases from non medical mental health professionals to senior medical staff. Furthermore, there should be a more direct route of referral available, for appropriate cases, from primary care to the community mental …
north_east_yorkshire
Independent investigation: Steven Hoskin, St. Austell (2006) — Rec R3
Cornwall Partnership NHS Trust should ensure that referrals to mental health services by external agencies, or internally within mental health services, are governed by clear protocols identifying the timescales to be applied, the next-stage actions and the communication of the outcome(s).
south_west
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 1
West Hertfordshire Hospitals NHS Trust and the future commissioning body responsible should ensure that any patient with epilepsy who has a psychotic episode, irrespective of apparent cause, should be referred to a psychiatrist with neuro-psychiatry experience, for psychiatric assessment.
east_of_england
Independent investigation: Peter Hartley, Keighley (2001) — Rec 6.2.2
Review the CMHT operational policy to include: ■ Criteria of access ■ Recording of referral meetings /clinical discussions ■ Include standard letter format with reason for referral, purpose of initial assessment in the operational policy ■ Criteria for taking onto CMHT case load to be established ■ Eligibility for CPA …
north_east_yorkshire
Independent investigation: Pauline StephenHanane Parry, Aintree Merseyside (2003) — Rec 5
A liaison psychiatric referral policy or care pathway for use by A&E medical staff should be developed4.
north_west
Independent investigation: Melanie Welch (Ms B), Redhill, Surrey (2001) — Rec 7.2
The panel recommends a further dialogue between Surrey Oaklands NHS Trust and the Primary Care Trusts in relation to the provision of mental health services, including: Clarifying the roles and responsibilities of frontline staff; referral processes and access; what the Trust is able to offer (for example, anger management); and …
south_east
Independent investigation: Mary Griffiths, Bury St (2009) — Rec 13.55.5
Where a referral is received by the CMHT from a GP for an assessment by a Consultant Psychiatrist, the referral should be brought to the attention of the Consultant Psychiatrist and agreement reached regarding who should assess the patient. If the Consultant Psychiatrist agrees that it is appropriate for other …
east_of_england
Independent investigation: Mark Kent, Hayes (2007) — Rec 5
Where a referral is received by the CMHT from a GP for an assessment by a Consultant Psychiatrist, the referral should be brought to the attention of the Consultant Psychiatrist and agreement reached regarding who should assess the patient. If the Consultant Psychiatrist agrees that it is appropriate for other …
london
Independent investigation: Lesley Wright, Tooting (2006) — Rec R9
The PCT and the trust should clarify the systems for GPs requesting action under the MHA. The trust should ensure that all CMHT staff who act as the first point of contact are clear about expectations and responsibility for follow through action after requests are made for assessment under the …
london
Independent investigation: Keziah Flux Edmonds, East Cowes, IoW (2016) — Rec 12
The IAPT referral information requires further amendments in order to clarify the criteria of referrals, including any prohibitive risk histories.
south_east
Independent investigation: Julie McKinley, Finsbury Park (2009) — Rec 2
Care Pathway between START and HTT – It is recommended that a protocol be developed to clarify the care pathway between START and the HTT. This protocol should make it clear what action is to be taken by whom when a person is referred on to the HTT. Secondly the …
london
Independent investigation: John Redhead, Potters Bar (2007) — Rec 13
The Trust should put processes in place to ensure that inter team and service referrals are acknowledged on receipt, and that any referrals not acknowledged are followed up by the referrer.
east_of_england
Independent investigation: John Redhead, Potters Bar (2007) — Rec 12
The Trust should ensure that clinicians and managers are aware of the appropriate pathway and referral routes for inter team referrals, and develop interface agreements between services which will then clarify the movement of service users between teams.
east_of_england
Independent investigation: John Redhead, Potters Bar (2007) — Rec 11
The Trust should ensure that communication and referral pathways between CATT’s, CMHT’s and inpatient services are clear and auditable and are understood by all relevant clinical staff.
east_of_england
Joint Domestic Homicide Review and independent mental health homicide investigation … — Rec 6
The Trust must demonstrate that referrals for Psychiatric Intensive Care Unit (PICU and/or out-of-area treatment include clinical assessment and recommendations.
north_west
Independent investigation: Janet Keegan, Enfield & Harringay (1997) — Rec 8
The Social Services Department should clarify its eligibility criteria for long term mental health cases. If the term ·severe and enduring' mental health problems, or a similar term, is used, its definition must be clearly understood. In particular, whether individuals with anti-social personality disorder are eligible needs to be clarified.
london
Independent investigation: Eric Daggers, Croydon (2005) — Rec 13
It needs to be made clear how differences in opinion should be resolved when patients are referred to medium secure services. (DB)
london
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 17
Where referrals are made they should be followed up in a timely fashion. Save in exceptional circumstances, reports or responses from the person or service referred to should be made available to the patient (in a way which the patient is able to understand) and if appropriate their family member …
north_east_yorkshire
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 16
When a patient is referred to another discipline or to supportive resources within or external to the trust, it is good practice to supply a basic clinical context to the referral, and to specify its purpose.
north_east_yorkshire
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 15
Referrals to other disciplines of clinician for assessment or advice should be made in the name of the responsible consultant and if possible countersigned by them, or another senior clinician. This should ensure that the opinions of other disciplines are properly requested, that they come back to the consultant responsible …
north_east_yorkshire
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 3
GPs making referrals to secondary mental health services should review, with their patients, whether the referral has been acted upon by those services, and taken up by the patient. This is particularly important where avoidance may be part of the patient’s condition. When GPs are notified by secondary mental health …
north_east_yorkshire
Independent investigation: Chloe Fahey, Manchester (2003) — Rec H.3
It is recommended that artificial distinctions between “referral” and “non-referral” are reviewed across all social services.
north_west
Independent investigation: Chloe Fahey, Manchester (2003) — Rec F.1
It is recommended that protocols are put in place to: i. Clarify when medical personnel must be contacted or medical reviews requested by social workers for CMHT patients for whom they are key worker/care co-ordinator. ii. Emphasise the rights of nearest relatives to request Mental Health Act (MHA) assessments iii. …
north_west
Independent investigation: Chloe Fahey, Manchester (2003) — Rec C.1
It is recommended that when a referral is received by CMHT from a medical practitioner, a report should be made to them within 28 days of the initial contact with the patient. The report should outline the CMHT assessment plan, any actions required by the GP/medical practitioner and indicate arrangements …
north_west
Independent investigation: Jason Dean, Eston, Middlesbrough (2018) — Rec 7
The Trust should seek assurance on how it supports individuals with complex presentations, developing and providing guidance for staff on key referral and care planning pathways. This should include consideration of any additional assessments, any referral to specialist services and specialists (forensic, dual diagnosis) and consideration of increased psychiatric review …
north_east_yorkshire
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: Anthony Kitely, Cardiff (2009) — Rec 3.9
The protocols in place should be reviewed to ensure appropriate referrals are made to the in-reach team. We note this may be strengthened by the in-reach team now being located at HMP Parc.
wales
Independent investigation into the care and treatment of Mr T … — Rec R3
The trust should issue a practice guidance note reminding all staff that a referral for a psychiatric assessment should always be made if requested. If a referral is not to be made a recorded rationale for why must be placed on the patient’s notes.
Mr T and Mr U . At the time of the homicide (2012) Mr T and Mr U were ex-mental health service-users from Berkshire Healthcare NHS Foundation Trust
south_east
Independent investigation into the care and treatment of Mr R: … — Rec 9.3
When service users have an extensive forensic history and present a significant risk to others, consideration should be given to referring for a forensic psychiatric opinion.
Mr R . At the time of the homicide (January 2013) Mr R was receiving care and treatment from Oxford Health NHS Foundation Trust
south_east
*Independent investigation into the care and treatment of Mr N: … — Rec 1
To ensure the efficacy of the EIP team and the appropriateness of care delivery to patients, the Trust should routinely audit case files to ensure that the EIP team is focused on those patients with psychosis, or at risk of psychosis. Those patients with a presentation suggestive of personality disorder …
South West Yorkshire Partnership NHS Foundation Trust
north_east_yorkshire
An independent external quality assurance review (published November 2019) can … — Rec 6
TEWV must take action Trust-wide to ensure that any referral made to an external or internal service indicates clearly the level of urgency.
north_east_yorkshire
An independent external quality assurance review (published November 2019) can … — Rec 6
TEWV must take action Trust-wide to ensure that any referral made to an external or internal service indicates clearly the level of urgency.
north_east_yorkshire
An independent external quality assurance review into the care and … — Rec 3R ecommendation 3
When working with a person who is suspected of having committed an offence but who also has mental health problems, all operational staff should know how to access mental health assessments and should have clear routes for referral and escalation of requests for urgent psychiatric evaluation, including during out of …
south_east
Independent investigation into the care and treatment of Ms A: … — Rec 4
Tees, Esk and Wear Valleys NHS Foundation Trust, local primary care services and their commissioner (CCGs) should agree a referral form to be used when primary care referring a patient to Tees, Esk and Wear Valleys NHS Foundation Trust’s community and inpatient mental health services.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of Mr T — Rec 8
The role of the Crisis Team in assessing informal referrals should be clarified in policy given the principles in the concordat and the gatekeeping requirements. The aim should be to ensure a seamless and responsive assessment process for clients in acute crisis and clarity as to responsibilities where different service …
Mr T who committed a homicide in May 2014. Mr T was in receipt of services from Camden and Islington NHS Foundation Trust
london
Accepted
*Independent investigation into the care and treatment of Mr A: … — Rec 1
West Hertfordshire Hospitals NHS Trust and the future commissioning body responsible should ensure that any patient with epilepsy who has a psychotic episode, irrespective of apparent cause, should be referred to a psychiatrist with neuro-psychiatry experience, for psychiatric assessment.
Hertfordshire Partnership NHS Foundation Trust
east_of_england
An independent investigation into the care and treatment of Harry … — Rec 11
We recommend that LTHT take steps to ensure that appropriate referral criteria are developed to advise pharmacy staff when they should seek advice from a pharmacist working in specialist mental health services, and a psychiatrist, in the cases of patients with severe and enduring mental illness such as schizophrenia.
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of a … — Rec 4
The Trust must provide clarity about protocols and responsibilities with respect to responding to increased need for interventions, zoning, and the process for considering and effecting inpatient admissions from the community.
east_of_england
An independent external quality assurance review of the independent investigation … — Rec 2
The Trust must ensure that clarity is provided to the Early Intervention Team about the process for seeking a 2nd opinion and/or formal consultation with another clinician or team (in particular the forensic team) when a patient has not responded to treatment for a prolonged period of time and where …
north_west
An independent external quality assurance review of the independent investigation … — Rec 1
The Trust must ensure that clarity is provided to early intervention team staff about what approach to take when there is diagnostic uncertainty (either within a single team or between teams involved in a patients’ care and treatment).
north_west
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (i)
The Trust should ensure that the case of every new patient referred to the Out-patient Clinic is initially screened by a multi-disciplinary team and that a decision is then taken as to whether the patient is a suitable candidate for mental health or social care and, if so, by whom …
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 30
There needs to be clarification as to the point at which the consultant assumes clinical responsibility for a patient referred to the CMHT.
london
Independent investigation: David Huitson, Newcastle (2001) — Rec 9
The arrangements for securing the input of clinical psychology from the forensic service should be made clear and explicit to the referrer from general adult services.
north_east_yorkshire
Independent investigation: Angela Titley, Private Psych hospital, Redhill, Surrey (2004) — Rec R2
We recommend to the Department of Health and to SHAs that consideration should be given to the creation of a National Directory of organisations (both within the NHS and in the independent sector) which provide services to the mentally ill, with details of those organisations’ admission criteria.
south_east
PHSO casework decisions(6)
P-001294 — North West Boroughs Healthcare NHS Foundation Trust
Miss Y complained the Trust incorrectly referred her to outreach services instead of a psychiatrist and that the assessment staff member was unsympathetic.
NHS in England
Feb 2022
P-003321 — Kent and Medway NHS and Social Care Partnership …
Mx E complained Kent and Medway NHS and Social Care Partnership Trust did not appropriately assess them as an autistic person, denied access to secondary mental health services, and a nurse behaved inappropriately.
NHS in England
Feb 2025
P-003967 — Surrey and Borders Partnership NHS Foundation Trust
Mrs E complained the Trust misdiagnosed her son's psychotic crisis as autistic behavior and failed to conduct a senior psychiatric consultant assessment. She stated this led to mental health deterioration.
NHS in England
Sep 2025
P-004260 — Oxford Health NHS Foundation Trust
Dr J complained a mental health nurse from Oxford Health NHS Foundation Trust gave incorrect advice to police, resulting in her unnecessary removal from home under the Mental Capacity Act.
NHS in England
Nov 2025
P-004265 — Cornwall Partnership NHS Foundation Trust
Dr J complained Cornwall Partnership NHS Foundation Trust's CAMHS assessment failed to measure her son's needs, use full evidence, and inappropriately labelled him with a mild learning disability.
NHS in England
Nov 2025
P-004668 — Kingston and Richmond NHS Foundation Trust
Mr A complained the Trust dismissed his symptoms, pressured him into a psychiatric diagnosis and medication, ignored evidence, and linked his issues to past drug use unprofessionally.
NHS in England
Jan 2026
Domestic Homicide Reviews(19)
Cornwall — recommendation 8f
It has been recommended that guidance is to be produced for staff relating to situations where a proposal to refer to the CMHT is refused by the patient.
NHS Kernow | Cornwall Foundation Partnership …
NHS Kernow
Cornwall — recommendation 8b
It is further recommended that a) cases are referred on for specialist psychological therapy in secondary care, and b) that specific risk questions are asked. (See Action Point below)
NHS Kernow | Cornwall Foundation Partnership …
NHS Kernow
Barnet — recommendation 2
There should be an agreed process between the Ministry of Justice and Mental Health Services as to how Psychiatric/Psychological reports are commissioned by the Courts with Terms of Reference and timings agreed within which the report will be produced.
Ministry of Justice | Her Majesty's …
Ministry of Justice
Epping Forest — recommendation 12.1
Psychiatric Liaison Service and Access and Assessment Brief Intervention Team must be made aware that service users are taken on by Early Intervention in Psychosis Team for up to three years and can be referred back at any point during that time.
NELFT
North East London NHS …
Barnsley — recommendation 2
The CCG should ensure that staff working in primary care services understand the current referral criteria for the mental health Single Point of Access Service [SPA] provided by South West Yorkshire Partnership Foundation Trust
Barnsley Clinical Commissioning Group
Banes Clinical Commissioning Group
Salford — recommendation 4b
Salford Community Safety Partnership should ensure that information regarding referral pathways is widely disseminated and understood.
Salford Community Safety Partnership
West Berkshire — recommendation 3
It is recommended that policy and practice within CPE is reviewed in relation to ensuring that GPs’ specific requests for a psychiatrist’s opinion are routinely referred to a CPE psychiatrist for consideration, particularly where there is evidence of failure to respond to treatment. Measure of success: An audit will show …
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Barnet — recommendation 3
It is recommended that the Magistrates Bench and Justices Clerks are provided with information and/or training clarifying the difference between a mental health assessment and a psychiatric report, thus assisting them with determining which type of mental health report will provide the most appropriate and timely assessment to inform sentencing …
Ministry of Justice | Her Majesty's …
Ministry of Justice
Epping Forest — recommendation 12.7 (4)
A further recommendation is made for NELFT to communicate to all teams the correct referral pathways to the local drug and alcohol service.
NELFT
North East London NHS …
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
Sandwell — recommendation 6/
Sandwell Metropolitan Borough Council Adult Social Care and Birmingham City Council Adult Social Care should ensure and provide assurances that pathways and online guidance to section 13(4) MHA ‘nearest relative’ assessments requests are clear and accurate, properly publicised and understood by call handlers receiving requests for such support as well …
Sandwell Metropolitan Borough Council Adult Social …
Sandwell — recommendation 4/
That the Black Country Healthcare NHS Foundation Trust (BCHFT) should review existing pathways into the Trust’s mental health support and update them where necessary, and promote those pathways with the Black Country & West Birmingham Clinical Commissioning Groups and all Hospital Trusts referring into BCHFT: • The pathways should facilitate …
Black Country Healthcare NHS Foundation Trust …
Black Country Healthcare NHS …
Gwynedd — recommendation 7
General Practice to understand the mechanisms used by CMHT to assess GP referrals to them in the knowledge of the protocol and key sections.
General Practice
Wandsworth — recommendation SG1
There is an identified need to review the way the mental health risk scoring matrix is used, in conjunction with the psychiatry liaison service and it would be advisable to devise and implement a policy that states referrals from the ED or GPs to specialist teams cannot be refused and …
St George’s Healthcare NHS Trust | …
St George's University Hospitals …
Cornwall — recommendation 21.13.1
For GPs to be informed at the time an urgent referral assessment to CMHT is either declined or passed to another agency. For all patients to be receptive to confidential information sharing of concerns.
GP Practice and Cornwall Integrated Care …
West Berkshire — recommendation 2
We recommend that updated information and advice be provided to GPs in the recognition and treatment of mental health needs. Furthermore we recommend that BHT put in place processes for regular updating of GPs about how and in what circumstances to refer to their services.
GPs | Berkshire Healthcare NHS Foundation …
Government Procurement Service
Norfolk — recommendation 35
That the University reviews the existing information provided on its website to ensure that there is a single, easily traced, and navigated pathway to make contact with concerns about a student 24 hours a day and that there is clarity about what anyone raising concerns can expect in terms of …
University of Manchester
The University of Manchester
Preston — recommendation 8
The CMHT should be given clearer guidance about rating referral information and working to agreed timescales to action a referral to assessment completion.
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …
Preston — recommendation 5
The CMHT should be given clearer guidance about rating referral information and working to agreed timescales to action a referral to assessment completion.
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …