First reported 12 Mar 2014•Latest report 14 Jan 2026
Definition
What this concern includes
Includes failures in patient-centred care delivery or patient-care decision-making where staff or services lose sight of the individual patient and fail to account for their needs, circumstances, preferences or relevant safety information.
Not included
Excludes failures belonging to a separately named clinical, safeguarding, statutory or operational system where that system provides the more specific supported boundary.
Excludes generic poor communication, documentation, staffing or governance deficiencies unless they directly result in non-patient-centred care or decisions.
Excludes dissatisfaction or disagreement with a clinical decision where the decision was individualised, adequately informed and appropriately involved the patient.
Excludes failures concerning family or carer involvement where patient-centred care is not the shared unsafe condition.
Reports
12
Distinct published reports
Individual concerns
12
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
16
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.
Department of Health and Social Care3
Kent and Medway Mental Health NHS Trust2
NHS England2
Tees, Esk and Wear Valleys NHS Foundation Trust2
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
HM Prison and Probation Service1
HM Prison Service1
Isle of Wight NHS Trust1
NHS Hampshire and Isle of Wight Integrated Care Board1
NHS Humber and North Yorkshire Integrated Care Board1
NHS Surrey and Sussex Integrated Care Board1
North Tees and Hartlepool NHS Foundation Trust1
Recipient name withheld1
Richmond Companions International (RCI)1
NHS trust9
Integrated care board3
Ministerial department3
Executive non-departmental public body2
Healthcare site2
Type not available2
Executive agency1
Sub-organisation1
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.
Kent and Medway
Concerns raised1
Failure to integrate significant indicators of elevated suicide risk into clinical decision-making
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.6
Action
Facilitate a phased training and support package with NHS Talking Therapies Collaborative to improve referral matching and risk communication.
Stated by Kent and Medway Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2026.
Action
Deliver a two-day CRAM training event for Urgent Mental Health Helpline staff to improve risk recognition, risk curiosity and co-produced care and risk management planning.
Stated by Kent and Medway Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2026.
Action
Introduce visual prompts at every call station and workstation directing staff to arrange Rapid Response assessment within four hours when risk is concerning.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Action
Update Urgent Mental Health Helpline training expectations for CRAM through the revised Standard Operating Procedure.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Action
Define high-risk patient categories and relevant risk-factor demographics in the revised Standard Operating Procedure.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Action
Require staff to review practicably accessible clinical records during triage, including CRAM risk event logs.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
An urgent referral was not indicated because reported deterioration lacked evidence of dynamic risk, risky behaviour, suicide planning or intent.
Stated by Vita Health Group LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Kent and Medway
Concerns raised1
Failure to provide patient-centred care
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.1
Action
Deliver dedicated CRAM training for Home Treatment and Rapid Response staff on risk questions, protective factors, masking symptoms, and collaboratively written care plans.
Stated by Kent and Medway Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2026.
Hampshire, Portsmouth and Southampton
Concerns raised1
Non-patient-centred decision making in trust services
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Suffolk
Concerns raised1
Failure to treat the views of experienced mental health professionals, patients and families as sufficient evidence in voluntary inpatient admission decisions
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to provide non-discriminatory care for confused elderly patients
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing alerts, one-to-one supervision, documented support and staff skills were considered sufficient to manage the confused patient's needs safely.
Stated by Whittington Health NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner West London
Concerns raised1
Risk-averse surgical decision-making denying care to complex patients
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Implement multidisciplinary referral teams with defined representation and records, and discuss significant complications at monthly mortality and morbidity meetings.
Stated by St George'S University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 May 2022.
Action
Embed EuroSCORE II risk assessment in practice and record risk predictions and material variances in patient consent and electronic records.
Stated by St George'S University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
There is no evidence that complex patients were denied care; transfers for ECMO or VAD support remain clinically appropriate irrespective of restrictions.
Stated by St George'S University Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
North Yorkshire and York including North Yorkshire Western District
Concerns raised1
Lack of person-centred autism-informed holistic care planning
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.4
Action
Provide autism training, supervision and consultation for clinical and non-clinical staff on risk, diagnosis, needs and holistic care planning.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Action
Require autism-informed care, treatment, safety summaries and safety plans within multidisciplinary team processes, including patient and advocate involvement where possible.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Action
Develop and embed an autism-informed care-planning process with evaluation and sustainability work for person-centred holistic plans.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Adopt nationally recommended collaborative care planning using holistic, individualised recovery plans based on the DIALOG model.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
TEWV is responsible for delivering core mental health care and making reasonable adjustments for patients with autism.
Stated by NHS Humber and North Yorkshire Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Sunderland
Concerns raised1
Failure to provide individualised person-centred care from the person’s perspective
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Deliver more person-centred, coordinated social care responsive to individual needs, promoting choice and maintaining independence.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Action
Apply a preventative, person-centred dementia-care model using assessment tools, tailored activities and proactive behavioural support plans.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
Action
Engage families and friends in care planning and incorporate life stories and ongoing assessment information into regularly reviewed care plans.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing person-centred models, life stories and tailored activities are considered sufficient to address individuals’ psychological, physical and social needs.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Brighton and Hove
Concerns raised1
Lack of patient-centred involvement in care plan updating
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West London
Concerns raised1
Decision-making without firsthand knowledge of the service and residents
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures in patient-centred care delivery or patient-care decision-making where staff or services lose sight of the individual patient and fail to account for their needs, circumstances, preferences or relevant safety information.
