Physical health check delays mental health referrals
Norfolk and Suffolk NHS Foundation Trust received 5 coroners' reports about this hazard between 23 Jul 2014 and 9 Oct 2024.
They came from 4 different coroners in 2 coroner areas. A similar concern was raised again 4 times after the first warning.
A published response was found for 3 of the 4 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay in cases requiring urgent referral”
Original on judiciary.uk ↗ No published response from Norfolk and Suffolk NHS Foundation Trust was found for this report.
- 2 years 7 months later
“On 25 February 2016 Mr [name redacted] was referred by a Social Worker at Herring House, where he was residing, to the Community Mental Health Team and he was given an appointment for 21 March 2016, under 4 weeks from the date of the initial referral.”
Original on judiciary.uk ↗ Norfolk and Suffolk NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The service user will be given the phone number for the duty worker so if they experience change in their circumstance before attending their appointment they can speak to someone.”
Web search (Tavily): No evidence found either way
Norfolk and Suffolk NHS FT | Norwich ↗ - 5 years 6 months laterClosely relatedConfidence 0.90 · higha different coroner
“It is not clear from the evidence what is now in place to ensure that relevant and requested physical health checks are carried out”
Original on judiciary.uk ↗ Repeated from the earlier report:physicalhealth
Norfolk and Suffolk NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The ward has improved their processes which now ensures the nurse in charge is identified and roles allocated to the shift team members. To achieve this, the daily allocation form has been reviewed which clearly identifies the nurse in charge. In addition, the Matron oversees the off duty rota and delegates nurse- in-charge duties each shift. This is monitored by the Clinical Team Leader and Modern Matron. [name redacted] to this aspect the trust is formulating a seminar on shift co-ordination and”
Stated timescale: three months
- 1 year 7 months later
“The adequacy of NSFT's Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals.”
Original on judiciary.uk ↗ Norfolk and Suffolk NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust has recently been reviewing and updating their Clinical Risk Assessment and Management Policy. This Policy is currently progressing through Trust internal governance processes and is due to be published end of June 2024, with a Policy implementation plan to be progressed during July/August 2024.”
Stated timescale: end of June 2024
Web search (Tavily): No evidence found either way
[PDF] Clinical Risk Assessment and Management Policy ↗ - 6 months laterClosely relatedConfidence 0.90 · higha different coroner
“an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.”
Original on judiciary.uk ↗ Repeated from the earlier report:mentalhealth
Norfolk and Suffolk NHS Foundation Trust responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Norfolk and Suffolk NHS Foundation Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2014 → 2022Eliot Harris8 years 1 month after Graeme Kidd · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with ensuring timely physical health checks for patients with mental health needs. The earlier report notes delays due to mandatory checks before referral, while the later report points out uncertainty about current processes to carry out those checks.
Graeme Kidd · 23 Jul 2014
“GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay in cases requiring urgent referral”
Original on judiciary.uk ↗ Eliot Harris · 22 Aug 2022
“It is not clear from the evidence what is now in place to ensure that relevant and requested physical health checks are carried out”
Original on judiciary.uk ↗ 2014 → 2024Nigel Hammond10 years 3 months after Graeme Kidd · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a barrier that prevents mental health professionals from making immediate referrals to specialist services, causing dangerous delays. The earlier barrier involves GPs needing a physical health check before referral; the later barrier involves AMHPs being unable to refer directly to the Crisis Resolution and Home Treatment Team.
Graeme Kidd · 23 Jul 2014
“GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay”
Original on judiciary.uk ↗ Nigel Hammond · 9 Oct 2024
“an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.”
Original on judiciary.uk ↗ 2017 → 2024Nigel Hammond7 years 8 months after David Read · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight barriers in the referral pathway that delay or prevent timely access to the Crisis Resolution and Home Treatment Team. The earlier case shows excessive waiting times after referral; the later case shows a lack of authority to make direct referrals, causing a similar delay in crisis intervention.
David Read · 8 Feb 2017
“On 25 February 2016 Mr [name redacted] was referred by a Social Worker at Herring House, where he was residing, to the Community Mental Health Team and he was given an appointment for 21 March 2016, under 4 weeks from the date of the initial referral.”
Original on judiciary.uk ↗ Nigel Hammond · 9 Oct 2024
“However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The service user will be given the phone number for the duty worker so if they experience change in their circumstance before attending their appointment they can speak to someone.”
2024 → 2024Nigel Hammond6 months after Ellen Woolnough · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports concern problems with accessing the Crisis Rehabilitation/Home Treatment Team (CRHTT) – one focuses on the adequacy of the team's response to urgent referrals, the other on barriers preventing direct referral by approved mental health professionals.
Ellen Woolnough · 28 Mar 2024
“The adequacy of NSFT's Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals.”
Original on judiciary.uk ↗ Nigel Hammond · 9 Oct 2024
“However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.”
Original on judiciary.uk ↗
No published response from Norfolk and Suffolk NHS Foundation Trust was found for this report.
Stated action
“The service user will be given the phone number for the duty worker so if they experience change in their circumstance before attending their appointment they can speak to someone.”
What happened next: No evidence found either way
The trust's website and board documents describe crisis helpline services and staffing arrangements but do not mention providing duty worker phone numbers to service users for pre-appointment contact.
“Posts by our comms team. Please don't leave urgent messages or messages concerned with your care - for urgent help, call 111 and select Mental Health option.”
“the effectiveness of services. The service now had a 24-hour urgent mental health helpline (111 service) for professionals and the general public and people who used services to access crisis services.”
No evidence found does not mean the action did not happen.
Stated action · timescale: three months
“The ward has improved their processes which now ensures the nurse in charge is identified and roles allocated to the shift team members. To achieve this, the daily allocation form has been reviewed which clearly identifies the nurse in charge. In addition, the Matron oversees the off duty rota and delegates nurse- in-charge duties each shift. This is monitored by the Clinical Team Leader and Modern Matron. [name redacted] to this aspect the trust is formulating a seminar on shift co-ordination and”
Stated action · timescale: end of June 2024
“The Trust has recently been reviewing and updating their Clinical Risk Assessment and Management Policy. This Policy is currently progressing through Trust internal governance processes and is due to be published end of June 2024, with a Policy implementation plan to be progressed during July/August 2024.”
What happened next: No evidence found either way
The Trust's policy indicates it is reviewing and updating its Clinical Risk Assessment and Management Policy, with publication planned for the end of June 2024 and implementation in July/August 2024.
“Clinical Risk Assessment and Management Policy Services Applicable Trustwide x Mental Health and LD Community Health Services Version number : 5.0 Consultation Groups The Quality Committee membership and staff involved in complaint investigation and handling Approved by (Sponsor Group) The Quality Committee Ratified by: The Quality Committee Date ratified: 14th October 2020 Name of originator/aut”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Norfolk and Suffolk NHS Foundation Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2014 → 2022 | 0.61 | 0.26 | Closely related · 0.90 | different |
| 2014 → 2024 | 0.64 | 0.16 | Closely related · 0.90 | different |
| 2017 → 2024 | 0.69 | 0.07 | Closely related · 0.85 | different |
| 2024 → 2024 | 0.72 | 0.10 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Norfolk and Suffolk NHS Foundation Trust
- Restricted access to treatment for borderline personality disorder2 reports · 2019–2024
- Inconsistent medication quantity documentation and unrecorded stock2 reports · 2017–2022
- Staff unawareness of observation requirements2 reports · 2015–2022
- Lack of formal mental health act assessment2 reports · 2019–2019
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.