Lack of psychological therapy for emotional unstable personality disorder
Department of Health and Social Care received 3 coroners' reports about this hazard between 16 Nov 2017 and 4 Feb 2022.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“During the course of the evidence it became apparent that mental health in-patients still do not have access to therapy from a qualified Psychologist, despite the fact that this has been raised in previous Regulation 28 PFD Forms.”
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 ↗- 1 year 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“On the availability of beds in the acute mental health sector, we are aware that the number of mental health beds overall have reduced and this is in large part due to the growth of care in the community. It may also be of interest to note that mental health bed occupancy rates have remained stable at between 87.1 per cent and 90.8 per cent (from Quarter 1, 2010-11 to Quarter 3, 2018-19), and that latest data for Quarter 3, 2018-19 shows a bed occupancy of 88.5 per cent. However, it remains the”
Stated timescale: 2020/21
Web search (Tavily): No evidence found either way
Acute Hospital Inpatient Bed Capacity Expansion Plan ↗ - 3 years laterClosely relatedConfidence 0.90 · higha different coroner
“The Court heard that patients continue to experience lengthy waits if referred for psychological therapies, both locally and nationally. In the Tameside area, the current average wait was thought to be around one year from referral.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 1 specific action.Response (PDF) ↗
“We are investing more than £400 million over the 4 years up to 2024/25 to eradicate dormitory accommodation from mental health facilities to improve From [name redacted] of State Department of”
Stated timescale: 2024/25
- 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.
2017 → 2019Stephen Kennedy1 year 3 months after John Haines · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that patients under home treatment teams lack access to qualified psychologist services. The later report adds waiting‑list issues but concerns the same core barrier to psychological therapy.
John Haines · 16 Nov 2017
“During the course of the evidence it became apparent that mental health in-patients still do not have access to therapy from a qualified Psychologist, despite the fact that this has been raised in previous Regulation 28 PFD Forms.”
Original on judiciary.uk ↗ Stephen Kennedy · 7 Feb 2019
“The inquest heard that whilst he was under the care of the home treatment team there was no access to psychology services.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“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.”
2019 → 2022Joy Burgess3 years after Stephen Kennedy · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that patients face significant delays in accessing psychological therapy services. The earlier case describes long waiting lists preventing treatment, while the later case notes ongoing lengthy waits for psychological therapies.
Stephen Kennedy · 7 Feb 2019
“There were periods when he was under the care of the community mental health team but at this time he remained on a long waiting list for psychological services.”
Original on judiciary.uk ↗ Joy Burgess · 4 Feb 2022
“The Court heard that patients continue to experience lengthy waits if referred for psychological therapies, both locally and nationally. In the Tameside area, the current average wait was thought to be around one year from referral.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“From September 2019, subject to recruitment, we anticipate to be in a position whereby every individual Home Treatment Team has a 0.5WTE Clinical Psychologist within their team”
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.
Stated action · timescale: 2020/21
“On the availability of beds in the acute mental health sector, we are aware that the number of mental health beds overall have reduced and this is in large part due to the growth of care in the community. It may also be of interest to note that mental health bed occupancy rates have remained stable at between 87.1 per cent and 90.8 per cent (from Quarter 1, 2010-11 to Quarter 3, 2018-19), and that latest data for Quarter 3, 2018-19 shows a bed occupancy of 88.5 per cent. However, it remains the”
What happened next: No evidence found either way
The Department of Health and Social Care outlined plans for expanding acute mental health bed capacity through the Acute Hospital Inpatient Bed Capacity Expansion Plan 2024–2031, referencing stable occupancy rates and long-term demand pressures. No specific commitment to deliver additional beds by 2020/21 was found in the provided sources.
“Since 2020 an additional 1,218 additional new acut”
No evidence found does not mean the action did not happen.
Stated action · timescale: 2024/25
“We are investing more than £400 million over the 4 years up to 2024/25 to eradicate dormitory accommodation from mental health facilities to improve From [name redacted] of State Department of”
- 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 |
|---|---|---|---|---|
| 2017 → 2019 | 0.68 | 0.21 | Closely related · 0.90 | different |
| 2019 → 2022 | 0.60 | 0.15 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.