GIRFT MH ED Breach Analysis Tool

What are we asking you to do?

This is a time-limited, one-off data collection, with two planned collection periods:

June 2026
January 2027

Providers are asked to submit data on 10 consecutive patients who experienced an ED stay exceeding 12 hours where the primary reason for attendance was mental health-related

Please submit one completed form per patient. Each survey should take around 20 minutes to complete, depending on data availability.

Pilot Feedback – Important Considerations

We would like to thank colleagues at County Durham and Darlington NHS Foundation Trust and Tees, Esk and Wear Valleys NHS Foundation Trust for piloting this tool. Their insights have informed improvements to reduce burden and improve usability.

Data can be collected retrospectively or prospectively. Prospective collection is recommended where feasible, as some fields (e.g. timestamps) may not be routinely recorded.

During the data collection period, this may involve beginning to record the required information once an individual’s stay in the ED is approaching the 12-hour threshold. At this point, teams can capture key timestamps and information for the earlier stages of the pathway using clinical records, and continue recording in real time thereafter.

Completion of the submission may require collaboration between both the acute and mental health Trusts. For example, information relating to the early stages of the pathway (up to referral to the Mental Health Liaison Team) will typically be held within the acute trust records.

We recommend that each organisation identifies a nominated individual responsible for collating the required information, with joint responsibility for reviewing and submitting the final response.

Where data is unavailable, please select “Not recorded”. This tool is designed to support improvements in future documentation and EPR capture

To support completion:

• We recommend collecting data in advance using a spreadsheet template (PDF available in the Fact Bank - if you require an Excel format please contact suzannah.davies1@nhs.net)
• Use a nominated administrator to submit responses where possible
• Refer to the Fact Bank in the chronology section for definitions and guidance to ensure consistent interpretation

Providing Accurate Data

This is not a performance management or inspection tool - there is no “pass” or “fail”.

Providing accurate, honest data is essential to:

• Identify meaningful drivers of delay
• Support local, system, and national improvement
• Ensure the findings reflect real operational challenges

Information Governance

• Do not include patient identifiable information
• Follow local information governance processes
• Completion may require collaboration between acute and mental health provider teams

Supporting Comments

Where relevant, please use free-text responses to:

• Provide additional context
• Explain variation or local factors
• Highlight risks, constraints, or dependencies
• Share examples of good practice or gaps

Contents of the survey
(47 Questions) 

1. Respondent details 
2. Overview/ Context
3. Demographics/ History
4. Chronology
5. Reflections
6. Submission