Failure to reliably locate people at immediate risk of suicide or self-harm
First to latest report 17 Oct 2014 — 8 Aug 2025
Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
7
What this concern includes
Includes failures of dedicated arrangements to establish the whereabouts of, contact, locate or obtain protective assistance for people at immediate risk of suicide or self-harm, including crisis-text-service and mental-health-service processes, police-location agreements, escalation routes and cross-service coordination where these directly affect prompt location and protection.
What is not included
Excludes generic missing-person, patient-contact or welfare-check failures where immediate suicide or self-harm risk is not a material part of the asserted concern.
Excludes general mental-health service access, treatment, follow-up or crisis-response deficiencies where locating the person is not the unsafe condition.
Excludes ordinary delays in emergency-service attendance after the person has been located, unless the delay is part of a deficient location-and-protection arrangement.
Excludes failures to provide protective measures or treatment after the person has been located when the location process itself operated reliably.
Excludes the existing broader concern concerning failure to locate patients requiring assessment when the assertion lacks the specific immediate suicide or self-harm-risk qualifier.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Betsi Cadwaladr University LHB1
Black Country Healthcare NHS Foundation Trust1
Department of Health and Social Care1
NHS England1
NHS Greater Manchester Integrated Care Board1
Wrexham County Borough Council1
Executive non-departmental public body1
Integrated care board1
Local health board1
Ministerial department1
NHS trust1
Welsh county borough council1
Reports and published responses 3 reports
See individual reports that have raised this concern, and the actions taken in response
Manchester North
Concerns raised1
Unavailability of arrangements for locating people at immediate risk across all charity crisis text services
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care
NHS England
NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
NHS Greater Manchester Integrated Care Board
Implement a phased, locally delivered crisis-text service integrated with the Greater Manchester 111 mental-health crisis line.
NHS Greater Manchester Integrated Care Board
Review the interface between the crisis-text service and Greater Manchester Police during service scoping and mobilisation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
NHS England
The non-NHS charity’s service delivery and clinical governance arrangements fall outside the respondent’s ability to comment on.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS Greater Manchester Integrated Care Board
NHSE and its provider should address the crisis text service's interface with Greater Manchester Police through their commissioning arrangements.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
Independent charitable organisations providing crisis text services are outside Government and NHS control.
Outside remitThe respondent said that this matter was outside its role or authority.
North Wales (East and Central)
Concerns raised1
Failure to make every possible effort to contact people under mental health care after credible indications of an immediate risk of harm
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Betsi Cadwaladr University LHB
Wrexham County Borough Council Social Services department
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department
Develop a social work checklist guiding risk assessment, escalation, communication, recording and crisis planning for mental health and duty cases.
Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department
Disseminate the checklist and safety-huddle procedures to Community Mental Health Team social work staff.
Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department
Develop Local Authority mental health, escalation, risk-management, pathway, and reporting and recording policies and procedures, including crisis planning.
Black Country
Concerns raised1
Deficiencies in systems for promptly contacting and locating patients at immediate risk of self harm
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Black Country Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Black Country Healthcare NHS Foundation Trust
Generate a start-of-shift list of patients referred to A&E and follow up attendance, taking further action where required.
Black Country Healthcare NHS Foundation Trust
Develop and apply a protocol requiring timely cold calls and police safe-and-well checks when immediate-risk service users cannot be contacted or located.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.