Recurring concern
Unreliable documentation of safety risk assessments
Pin
Get email alerts
Request correctionFirst reported 14 Jul 2014•Latest report 12 Jan 2026
What this concern includes
Includes failures to document formal, informal or clinically judged safety risk assessments, risk discussions, risk formulations, assessor identities and material assessment details in the records used for ongoing care, custody, safeguarding or safety review. Includes the anchor assertion, post-triage risk assessments, mental-health risk-assessment details and comparable police or prison risk-assessment records.
Not included
- Excludes failures to perform or clinically formulate a risk assessment where documentation is not itself deficient.
- Excludes generic clinical, care or administrative record-keeping failures that do not specifically concern documentation of a safety risk assessment.
- Excludes failure to communicate or act on a risk assessment after it has been accurately documented, unless the documentation process is also deficient.
- Excludes hazard-specific or named risk systems, such as mental-health, falls, suicide, prisoner or safeguarding risk-assessment systems, when the assertion is confined to a distinct system with a more specific supported parent.
- Reports
- 27
- Individual concerns
- 27
- Date range
- 2014–2026
- Stated actions
- 47
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.
-
Concerns raised1
Failure to document post-triage risk assessments in Rio notes
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 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
-
Action
Document the full rationale for Access referral decisions in RIO using collateral information from the Access Trigger Tool and audit the process monthly.
Stated by Avon and Wiltshire Mental Health Partnership NHS Trust
-
Concerns raised1
Substandard nursing-record documentation of risk assessments before weekend leave
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.3
-
Action
Implement and roll out the Informal patient leave agreement documenting doctor-approved leave, conditions, contingency plans, and signatures.
Stated by East London NHS Foundation Trust -
Action
Implement and roll out the inpatient leave checklist requiring risk assessment, family discussions, contingency plans, return feedback, and RIO documentation.
Stated by East London NHS Foundation Trust -
Action
Conduct quarterly audits of leave forms and corresponding RIO entries from July 2016 through January 2017.
Stated by East London NHS Foundation Trust
-
Concerns raised1
Failure to document discharge risk-factor assessments in clinical records
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.
-
Concerns raised1
Failure to record risk assessments on RIO
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.
-
Concerns raised1
Failure to complete and document patient risk assessments
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.
-
Concerns raised1
Failure to record rationales for changes to risk assessments
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
No further action is needed regarding the general system for assessing and managing risk.
Stated by Hampshire County Council
-
Concerns raised1
Lack of record keeping of risk assessments and assessor identities
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.3
-
Action
Implement electronic Rio recording of inpatient risk assessments, including automatic recording of assessment times and responsible staff.
Stated by Devon Partnership NHS Trust -
Action
Update inpatient risk assessments weekly and document daily risk discussions in electronic patient records.
Stated by Devon Partnership NHS Trust -
Action
Provide feedback on risk assessments and risk-management plans, and review random monthly samples to demonstrate staff competency.
Stated by Devon Partnership NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing policies, standards and guidance address the concerns; new standards are not required, though further assurance actions will be implemented.
Stated by Devon Partnership NHS Trust
Data last updated 7 September 2026