Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Lee Bonsall · 31 Jan 2014 · Jonathan Layton, Carmarthenshire & Pembrokeshire
“The ten month waiting times for psychotherapy effectively means that this is not a viable alternative to anti-depressant medication”
What was promised
Stated action 1 · response to Lee Bonsall (31 Jan 2014) · stated timescale: due course
“NICE will be reviewing its guidelines on depression (CG90) in due course”
judiciary.uk/…/2014-0044-Response-by-Department-of-Health.pdf
Stated action 2 · response to Lee Bonsall (31 Jan 2014) · stated 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.”
judiciary.uk/…/2014-0044-Response-by-Department-of-Health-1.pdf
Stated action 3 · response to Heather Carey (12 Feb 2019) · stated 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.”
judiciary.uk/…/2019-0046-Response-from-Tameside-Metropolitan-Bo…
6 further stated actions are listed on the full chain page.
What recurred
- 12 Feb 2019 · Heather Carey · Andrew Bridgman · Closely related · confidence 0.90 (high)
- 3 Mar 2020 · Shaun Turner · Alison Mutch · Closely related · confidence 0.90 (high)
- 9 Feb 2022 · Michelle Jennings · Alison Mutch · Closely related · confidence 0.90 (high)
- 10 Oct 2023 · Alex Dews · Abigail Combes · Closely related · confidence 0.80 (moderate)
- 30 Jan 2024 · Nicolas Gerasimidis · Andrew Cox · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · 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”
Later · 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.”
What happened next
No evidence found either way · stated action 1
“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.”
Overview | Depression in adults: treatment and management | Guidance | NICE · nice.org.uk/guidance/ng222
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“You are using an unsupported browser ×”
eCFR :: 45 CFR Part 1302 Subpart D -- Health and Mental Health Program Services · ecfr.gov/…/subpart-D
“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.”
Department of Behavioral Health · dbh.ohio.gov
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“This document can be downloaded from our website.”
Quality Standards for Psychological Therapies Services · rcpsych.ac.uk/…/appts-standards-3rd-edition.pdf?sfvrsn=64384490…
“Administration and Policy in Mental Health · 2024-05-11 · 52(1):210-222”
Using Progress Feedback to Enhance Treatment Outcomes: A Narrative Review · pmc.ncbi.nlm.nih.gov/articles/PMC11703940
No evidence found does not mean the action did not happen.