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recurance

Lack of formal liaison between NHS and private mental health providers

Closely relatedConfidence 0.86 · high4 reports · 2014–2024No published response to an earlier report One-page brief (print or PDF)

Royal College of Psychiatrists received 4 coroners' reports about this hazard between 30 Apr 2014 and 15 Mar 2024.

They came from 4 different coroners in 4 coroner areas. A similar concern was raised again 3 times after the first warning.

A published response was found for 3 of the 3 earlier reports, stating 2 specific actions.

4
reports
4
different coroners
2014–2024
years
0.86
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Samiyo Farah↗

    30 Apr 2014 · Lisa Hashmi · Manchester (North)

    “Communication/contact between transferring establishments - there is no formal policy/protoco! in use/between the private sector and the NHS detailing steps that should be taken (and by whom) upon transfer of patients between sectors”
    Original on judiciary.uk ↗

    Royal College of Psychiatrists responded.Response (PDF) ↗

  2. 3 years 2 months later

    Raised again · 1st time

    Jonathan Zucker↗

    26 Jun 2017 · Andrew Walker · London (North)

    “That there was no requirement for ,or system for, a lead clinician from either the private or NHS treating teams to oversee and coordinate the care provided to Mr [name redacted] by the private and NHS mental health services.”
    Original on judiciary.uk ↗

    Royal College of Psychiatrists responded, stating 1 specific action.Response (PDF) ↗

    “The College is aware that CPA policy can be interpreted and applied differently across the country. Ideally a care co-ordinator will be able to negotiate patient discharges and their integration into the care of a new team. However, there are circumstances in which this is not straight-forward, e.g. if a section is ending or a person is being discharged from hospital.”

    Stated timescale: 2nd November 2017

  3. 5 years 10 months later

    Raised again · 2nd time

    Caroline Forte↗

    27 Apr 2023 · Penelope Schofield · West Sussex

    Closely relatedConfidence 0.86 · higha different coroner
    “Details of her consultations and treatments were not made readily available to those working in the NHS Trusts.”
    Original on judiciary.uk ↗

    Royal College of Psychiatrists responded, stating 1 specific action.Response (PDF) ↗

    “The Trust has also shared with us a helpful learning briefing on Section 17 leave from inpatient wards. This will be shared with the national Regulation 28 Working Group regional representatives for dissemination across the seven NHS regions, to raise awareness of the issue with their Trusts and to encourage best practice.”

    Stated timescale: 2025

  4. 11 months later

    Raised again · 3rd time

    Sarah Sutherland↗

    15 Mar 2024 · Karen Henderson · Surrey

    Closely relatedConfidence 0.90 · higha different coroner
    “However, there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other to ensure the best mental health care and safety of their clients.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:privatementalhealthcare

    Royal College of Psychiatrists responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗

  5. All reports to Royal College of Psychiatrists

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error