Recurring concern
Failure to implement protective measures for people at risk of self-harm
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Request correctionFirst reported 5 May 2013•Latest report 27 May 2026
What this concern includes
Includes failures to identify, arrange, implement or maintain protective measures specifically intended to reduce a person's risk of self-harm, including additional safeguards during increased risk and protective factors addressing access to means or other identified risks.
Not included
- Excludes generic self-harm or suicide-risk assessment, documentation, communication or escalation failures where no failure to implement a protective measure is identified.
- Excludes clinical treatment, observation, admission or discharge deficiencies unless they directly concern implementation of a protective measure for self-harm risk.
- Excludes general safeguarding or care-planning deficiencies without an explicit self-harm protective-measure context.
- Excludes controls for preventing access to a particular hazard, substance or online content where that specific hazard supplies the more specific supported concern.
- Reports
- 8
- Individual concerns
- 9
- Date range
- 2013–2026
- Stated actions
- 4
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
Failure to maintain required supervision when staff attend to other patients
This report raised 7 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.1
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Action
Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Failure to ensure hospital staff know when high-risk patients leave the acute ward
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.1
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Action
Review and update policies and flowcharts guiding risk assessment and supervision of inpatients at high risk of self-harm.
Stated by Mid and South Essex NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
MSE is responsible for responding to the risk of high-risk self-harm patients leaving the acute ward without hospital staff knowing.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure of VRM case conferences to consider post-return check-ins with soldiers posing a risk of self-harm
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to put additional safety measures in place during increased risk to self
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to prioritise timely safer placements for patients at high risk of self-harm
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to put in place contact arrangements for patients discharged home at moderate to high risk of self-harm or suicide
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to put protective factors in place for individuals with self-harm intent and access to the means
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to prevent patients at risk of self-harm from being left alone
Confusion about confidentiality when providing safety supervision for patients at risk of self-harm
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 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
Publish a consensus statement promoting information sharing to help prevent suicide, within the relevant law.
Stated by Department of Health and Social Care -
Action
Publish supplementary guidance clarifying when confidential information may be disclosed in the public interest.
Stated by Department of Health and Social Care
Data last updated 7 September 2026