National inquiries and reviews into serious mental health incidents, including the
#NottinghamInquiry ILT Review (2026) (link below) have formally identified recurring systemic themes including:
1/ failures of multi-agency coordination and fragmentation between services;
2/ inadequate proactive engagement with vulnerable individuals;
3/ an overreliance on “consent”, “choice” and disengagement frameworks when vulnerability is evident;
4/ failures to properly hear and respond to family/carer concerns; and
5/ missed opportunities to intervene before deterioration escalates, sometimes with devastating consequences for individuals, families and the wider public.
Many of those themes resonate. Next month I’ll sit before a Stage 3 Review Panel in Cornwall, challenging what I say were serious failures in the care, safeguarding and support provided to my child, many of which reflect the themes listed above. Having already been batted away twice by the local authority over the last 16 months, I suspect a third refusal may well follow.
But that, in itself, says something important about the system. It’s excruciatingly difficult for ordinary families, even those with knowledge of the law, to navigate processes that are complex, exhausting, drawn out and often deeply defensive. Too often, families are worn down, or broken beyond repair, long before accountability is reached, if it’s even reached at all.
nottingham.independent-inqui…