Recurring concern
Failure to reliably locate people at immediate risk of suicide or self-harm
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Request correctionFirst reported 17 Oct 2014•Latest report 8 Aug 2025
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.
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.
- Reports
- 3
- Individual concerns
- 3
- Date range
- 2014–2025
- Stated actions
- 7
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports 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.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Implement a phased, locally delivered crisis-text service integrated with the Greater Manchester 111 mental-health crisis line.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Review the interface between the crisis-text service and Greater Manchester Police during service scoping and mobilisation.
Stated by NHS Greater Manchester Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The non-NHS charity’s service delivery and clinical governance arrangements fall outside the respondent’s ability to comment on.
Stated by NHS England
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Position
NHSE and its provider should address the crisis text service's interface with Greater Manchester Police through their commissioning arrangements.
Stated by NHS Greater Manchester Integrated Care Board -
Position
Independent charitable organisations providing crisis text services are outside Government and NHS control.
Stated by Department of Health and Social Care
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Develop a social work checklist guiding risk assessment, escalation, communication, recording and crisis planning for mental health and duty cases.
Stated by Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department -
Action
Disseminate the checklist and safety-huddle procedures to Community Mental Health Team social work staff.
Stated by Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department -
Action
Develop Local Authority mental health, escalation, risk-management, pathway, and reporting and recording policies and procedures, including crisis planning.
Stated by Betsi Cadwaladr University LHB and Wrexham County Borough Council Social Services department
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Generate a start-of-shift list of patients referred to A&E and follow up attendance, taking further action where required.
Stated by Black Country Healthcare NHS Foundation Trust -
Action
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.
Stated by Black Country Healthcare NHS Foundation Trust
Data last updated 7 September 2026