Excessive waiting time for psychotherapy
Department of Health and Social Care received 6 coroners' reports about this hazard between 31 Jan 2014 and 30 Jan 2024.
They came from 5 different coroners in 5 coroner areas. A similar concern was raised again 5 times after the first warning.
A published response was found for 5 of the 5 earlier reports, stating 9 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The ten month waiting times for psychotherapy effectively means that this is not a viable alternative to anti-depressant medication”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“NICE will be reviewing its guidelines on depression (CG90) in due course”
Stated timescale: due course
Web search (Tavily): No evidence found either way
Overview | Depression in adults: treatment and management | Guidance | NICE ↗“The Department and NHS England are committed to ending this imbalance. We believe that it is vital to develop and implement new access and waiting time standards to have true parity of esteem. We are committed to providing access to services and waiting times on a par with physical health.”
Stated timescale: April 2015
Web search (Tavily): No evidence found either way
eCFR :: 45 CFR Part 1302 Subpart D -- Health and Mental Health Program Services ↗- 5 years laterClosely relatedConfidence 0.90 · higha different coroner
“A target waiting list of 18 weeks is far too long but | was told that this was a funding issue.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 6 specific actions.Response (PDF) ↗Response (PDF) ↗
“the CCG is working with the Pennine Care NHS Foundation Trust to agree a Performance and Outcome Framework for 2019-20 to ensure activity, waiting times and outcomes are reported and monitored.”
Stated timescale: 2019-20
“The CCG is formally monitoring the impact of this investment through regular Safer Staffing Reports presented to the Pennine Care Quality Group. Reports from staff on the Tameside wards and the latest CQC report indicate that this is having a positive impact.”
4 more stated actions in the Promises tab.
- 1 year 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“he was worried about how long it would take him to be able to access appropriate mental health services and receive support.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- 1 year 11 months laterClosely relatedConfidence 0.90 · higha different coroner
“The inquest heard evidence that the backlogs for therapy were such that the waiting list at the time she was assessed as being appropriate for step 4 therapy had a two year wait time.”
Original on judiciary.uk ↗ Repeated from the earlier report:waitinglist
Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“we are committed to increasing investment in, and improving access to, mental health services. Under the NHS Long Term Plan1, by 2023/24 mental health services will receive £2.3billion more than in 2018/19, which will mean that 2 million more people will have access to mental health services, including an additional 370,000 adults with severe mental illnesses.”
Stated timescale: 2023/24
- 1 year 8 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“[the deceased] was not referred by school to NHS mental health services as a result of their experience that if [the deceased] was in receipt of any other support he would not be accepted onto the waiting list”
Original on judiciary.uk ↗ Repeated from the earlier report:mentalhealthservicessupportaccepted
Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 4 months later
Raised again · 5th time
Nicolas Gerasimidis↗
30 Jan 2024 · Andrew Cox · Cornwall and the Isles of Scilly
Closely relatedConfidence 0.85 · higha different coroner“Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;”
Original on judiciary.uk ↗ Repeated from the earlier report:Therapywaitinglistyear
Department of Health and Social Care responded.Response (PDF) ↗
- All reports to Department of Health and Social Care
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 → 2019Heather Carey5 years after Lee Bonsall · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight excessively long waiting times for psychotherapy/mental health treatment as a safety concern. The earlier report cites ten‑month waits in Wales; the later report notes an 18‑week target in Manchester deemed too long due to funding.
Lee Bonsall · 31 Jan 2014
“The ten month waiting times for psychotherapy effectively means that this is not a viable alternative to anti-depressant medication”
Original on judiciary.uk ↗ Heather Carey · 12 Feb 2019
“A target waiting list of 18 weeks is far too long but | was told that this was a funding issue.”
Original on judiciary.uk ↗ 2019 → 2020Shaun Turner1 year 1 month after Heather Carey · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight excessively long waiting times for mental health treatment as a safety concern. The earlier report cites an 18‑week target as too long, while the later report describes a person’s anxiety about delayed access to appropriate services.
Heather Carey · 12 Feb 2019
“A target waiting list of 18 weeks is far too long but | was told that this was a funding issue.”
Original on judiciary.uk ↗ Shaun Turner · 3 Mar 2020
“he was worried about how long it would take him to be able to access appropriate mental health services and receive support.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“the CCG is working with the Pennine Care NHS Foundation Trust to agree a Performance and Outcome Framework for 2019-20 to ensure activity, waiting times and outcomes are reported and monitored.”
2019 → 2022Michelle Jennings3 years after Heather Carey · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight excessively long waiting times for mental health therapy as a safety concern. The earlier report cites an 18‑week target due to funding, while the later report describes waits of 2‑3 years caused by therapist shortages.
Heather Carey · 12 Feb 2019
“A target waiting list of 18 weeks is far too long but | was told that this was a funding issue.”
Original on judiciary.uk ↗ Michelle Jennings · 9 Feb 2022
“The inquest heard evidence that the backlogs for therapy were such that the waiting list at the time she was assessed as being appropriate for step 4 therapy had a two year wait time.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The reviewing team are using this information alongside an exploration of alternative models of care to develop a new model of psychological therapy for people with complex mental health needs in Tameside and Glossop. This review will conclude by the 31 of July 2019.”
2020 → 2023Alex Dews3 years 7 months after Shaun Turner · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight barriers that prevent timely access to NHS mental health services due to systemic delays or eligibility rules.
Shaun Turner · 3 Mar 2020
“whilst they accepted that there had been attempted contact of him by mental health services he was worried about how long it would take him to be able to access appropriate mental health services and receive support.”
Original on judiciary.uk ↗ Alex Dews · 10 Oct 2023
“[the deceased] was not referred by school to NHS mental health services as a result of their experience that if [the deceased] was in receipt of any other support he would not be accepted onto the waiting list”
Original on judiciary.uk ↗ 2022 → 2024Nicolas Gerasimidis2 years after Michelle Jennings · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight excessively long waiting times for psychological therapy caused by staffing shortages.
Michelle Jennings · 9 Feb 2022
“The inquest heard evidence that the backlogs for therapy were such that the waiting list at the time she was assessed as being appropriate for step 4 therapy had a two year wait time.”
Original on judiciary.uk ↗ Nicolas Gerasimidis · 30 Jan 2024
“Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;”
Original on judiciary.uk ↗
Stated action · timescale: due course
“NICE will be reviewing its guidelines on depression (CG90) in due course”
What happened next: No evidence found either way
The Department of Health and Social Care has not indicated any plan to review the guideline.
“We reviewed this guideline and will not update the recommendations. See the [surveillance decision](https://www.nice.org.uk/guidance/ng222/resources/january-2026-exceptional-surveillance-of-depression-in-adults-treatment-and-management-nice-15604053806/chapter/surveillance-proposal?tab=evidence) for further details.”
No evidence found does not mean the action did not happen.
Stated action · timescale: April 2015
“The Department and NHS England are committed to ending this imbalance. We believe that it is vital to develop and implement new access and waiting time standards to have true parity of esteem. We are committed to providing access to services and waiting times on a par with physical health.”
What happened next: No evidence found either way
The Department of Health and Social Care did not specify a timeframe for implementing new access and waiting time standards in the provided sources.
“You are using an unsupported browser ×”
“We are taking an important step in reducing stigma and encouraging more Ohioans to seek the support they need to get well, be well, and stay well.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2019-20
“the CCG is working with the Pennine Care NHS Foundation Trust to agree a Performance and Outcome Framework for 2019-20 to ensure activity, waiting times and outcomes are reported and monitored.”
Stated action
“The CCG is formally monitoring the impact of this investment through regular Safer Staffing Reports presented to the Pennine Care Quality Group. Reports from staff on the Tameside wards and the latest CQC report indicate that this is having a positive impact.”
Stated action · timescale: 31 July 2019
“The reviewing team are using this information alongside an exploration of alternative models of care to develop a new model of psychological therapy for people with complex mental health needs in Tameside and Glossop. This review will conclude by the 31 of July 2019.”
What happened next: No evidence found either way
The promised review was expected to conclude by 31 July 2019, but no source confirms it was completed or published by that date.
“This document can be downloaded from our website.”
“Administration and Policy in Mental Health · 2024-05-11 · 52(1):210-222”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2021
“An additional £271,000 agreed in 2018/19 will be increased by an additional £673,000 per annum by 2021 to meet a range of pressures.”
Stated action
“the CCG is advised that due to actions taken internally the current waiting times for the service have improved, with a current waiting time for Cognitive Analytical Therapy of 13 weeks.”
Stated action
“have asked the Secondary Care Psychological Therapy Service to ensure that that when people are advised about the waiting times that they are supported to work with their care coordinator for stabilisation, containment and pre therapy work in preparation for therapy to ensure that they do not suffer the distress and despair that Ms [name redacted] family state that Ms [name redacted] experienced and evidenced by her tragic death”
No specific action could be extracted with a verified quote.
Stated action · timescale: 2023/24
“we are committed to increasing investment in, and improving access to, mental health services. Under the NHS Long Term Plan1, by 2023/24 mental health services will receive £2.3billion more than in 2018/19, which will mean that 2 million more people will have access to mental health services, including an additional 370,000 adults with severe mental illnesses.”
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.
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 Department of Health and Social Care 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 → 2019 | 0.79 | 0.15 | Closely related · 0.90 | different |
| 2019 → 2020 | 0.72 | 0.22 | Closely related · 0.90 | different |
| 2019 → 2022 | 0.79 | 0.15 | Closely related · 0.90 | different |
| 2020 → 2023 | 0.70 | 0.23 | Closely related · 0.80 | different |
| 2022 → 2024 | 0.73 | 0.24 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Department of Health and Social Care
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.