Recurring concern
Failure to implement protective measures for people at risk of self-harm
- Reports that mention this concern
- 8
- Times this concern has been raised
- 9
- Stated actions linked to this concern
- 4
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.
What is 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.
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.
Reports and published responses 8 reports
See individual reports that have raised this concern, and the actions taken in response
-
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.
Linked response
- Mid and South Essex 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.1
-
Mid and South Essex NHS Foundation Trust
Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.
-
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.
Linked responses
- Essex Partnership University NHS Foundation Trust
- Mid and South Essex 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.1
-
Mid and South Essex NHS Foundation Trust
Review and update policies and flowcharts guiding risk assessment and supervision of inpatients at high risk of self-harm.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Essex Partnership University NHS Foundation Trust
MSE is responsible for responding to the risk of high-risk self-harm patients leaving the acute ward without hospital staff knowing.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- Department of Health and Social Care
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
-
Department of Health and Social Care
Publish a consensus statement promoting information sharing to help prevent suicide, within the relevant law.
-
Department of Health and Social Care
Publish supplementary guidance clarifying when confidential information may be disclosed in the public interest.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026