Lack of access to qualified psychologist during home treatment team care
Department of Health and Social Care received 2 coroners' reports about this hazard between 16 Dec 2014 and 16 Nov 2017.
They came from 1 coroner. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“staff were unable to make any such referral for inpatients due to lack of i) availability of suitably qualified practitioners and ii) resources.”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- 2 years 11 months laterIdentical hazardConfidence 0.95 · high
“patients cannot access a qualified Psychologist whilst under the care of the Home Treatment Team (HTT') etc.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“The CCG commissioned a new Primary Care Mental Health Pathway during 2016/17, which mobilised in May 2017. The model has been developed to respond to the local population needs, preparing service users to access therapy in order to optimise recovery performance. The service is subject to robust a performance dependent payment framework which provides assurance of performance delivery.”
Stated timescale: May 2017
Web search (Tavily): No evidence found either way
Benefits of Mental Health Treatment in Primary Care - NeuroFlow ↗ - 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 → 2017John Haines2 years 11 months after Janette Insley · same coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight that patients cannot access a qualified psychologist while receiving inpatient or home treatment team care due to service gaps.
Janette Insley · 16 Dec 2014
“staff were unable to make any such referral for inpatients due to lack of i) availability of suitably qualified practitioners and ii) resources.”
Original on judiciary.uk ↗ John Haines · 16 Nov 2017
“patients cannot access a qualified Psychologist whilst under the care of the Home Treatment Team (HTT') etc.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
Stated action · timescale: May 2017
“The CCG commissioned a new Primary Care Mental Health Pathway during 2016/17, which mobilised in May 2017. The model has been developed to respond to the local population needs, preparing service users to access therapy in order to optimise recovery performance. The service is subject to robust a performance dependent payment framework which provides assurance of performance delivery.”
What happened next: No evidence found either way
The organisation did not state that the pathway was commissioned or operational by May 2017.
“Benefits of Mental Health Treatment in Primary Care”
“Evolving Models of Behavioral Health Integration in Primary Care”
No evidence found does not mean the action did not happen.
- 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 → 2017 | 0.78 | 0.12 | Identical · 0.95 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.