Recurring concern
Unreliable recording of suicide-risk information
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Request correctionFirst reported 9 May 2014•Latest report 12 Jan 2026
What this concern includes
Includes failures in clinical or mental-health processes to record, update or maintain suicide-risk information, suicidal ideation, suicide-risk enquiries or related risk formulations in the designated risk-screening or care record.
Not included
- Excludes generic clinical record-keeping deficiencies where suicide-risk information is not the material concern.
- Excludes failures to assess suicide risk, escalate concerns or provide treatment when the relevant suicide-risk information was recorded adequately.
- Excludes safeguarding, custody or police records unless the assertion specifically concerns recording suicide-risk information in a clinical or mental-health care process.
- Excludes failures to communicate or transfer already accurate suicide-risk records where the recording process itself was reliable.
- Reports
- 19
- Individual concerns
- 19
- Date range
- 2014–2026
- Stated actions
- 26
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 document self-harm and suicide risk in clinical records
This report raised 13 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.6
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Action
Review Prisoner Warning Notice alerts daily, record risk information in patient records, and alert relevant healthcare professionals, particularly mental health staff.
Stated by HCRG Care Group -
Action
Introduce targeted SystmOne training, require basic training for new staff, and provide refresher training for existing staff.
Stated by HCRG Care Group -
Action
Provide structured reception-nurse supervision, coaching, documentation audits, case-based feedback, and governance reporting to improve recording and escalation of mental-health risks.
Stated by HCRG Care Group
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Action
Review the need for an interim documentation and workflow support post before NOVA implementation.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Review existing EPR capability for consolidated personalised-care and safety-planning records and update standard operating procedures.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Monitor clinical-documentation timeliness and quality through supervision, monthly performance reporting, and targeted follow-up.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to accurately record contact and suicidal ideation in mental health records
This report raised 8 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
Deliver focused SystmOne training on recording suicidal ideation and review template completion fields with Mental Health Practitioners.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to highlight recent mental-health and self-harm risk information in medical records for clinical assessment
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
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Action
Ensure TAG referrals and healthcare applications are added to and visible in SystmOne.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Reinforce reviewing recent electronic patient-record activity before assessment or intervention through incident-meeting messages, governance dissemination, management reminders and supervision.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Document patient concerns in SystmOne so subsequent staff can identify raised concerns and plan care and treatment to mitigate risk.
Stated by Midlands Partnership University NHS Foundation Trust
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Concerns raised1
Failure to record critical suicide risk information completely and promptly
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
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Action
Review and revise Psychiatric Decisions Unit handover standards to require urgent information to be documented and communicated before transport, discharge and other significant decisions.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Failure to record recent suicide attempts in screening MDT notes
This report raised 8 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 obtain and record previous methods of self-harm and suicide at referral and admission
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.4
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Action
Amend the initial referral form to require referrers to record previous suicide methods and self-harm methods, with explanations for incomplete information.
Stated by The Langford Centre -
Action
Amend initial medical and risk assessments to capture patients’ previous suicide attempts and self-harm histories.
Stated by The Langford Centre -
Action
Roll out company-wide training for staff handling referrals, initial assessments, ward rounds, and multidisciplinary meetings on the amended processes and requested information.
Stated by The Langford Centre
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Action
Publish guidance on information sharing and holistic assessment during admission, including key actions within 72 hours.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Referring Trusts or bodies are responsible for completing previous suicide-method information in the initial referral form.
Stated by The Langford Centre
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Position
The Langford Centre, operated by an independent provider, is the appropriate organisation to respond to concerns about information collection and recording.
Stated by NHS England
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Concerns raised1
Failure to maintain adequate records of suicide-risk enquiries
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 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.4
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Action
Introduce a structured HBTT note format prompting documentation of visit purpose, presentation, and risk to self and others.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Train HBTT staff in contact requirements and documentation, supported by senior colleagues to embed the process.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Require senior staff to review selected clinical notes before supervision sessions.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Action
Conduct quarterly team audits of record keeping and compliance with procedures and clinical risk policy.
Stated by Greater Manchester Mental Health 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
Records indicate that HBTT staff explored risk and made care plans, although documentation did not always reflect discussions with the patient.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Failure to maintain accurate and usable summary and active-problem risk information
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
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Action
Distribute guidance and a standard process for reviewing, entering and linking diagnoses and problems in SystmOne.
Stated by Central and North West London NHS Foundation Trust -
Action
Review use of SystmOne’s problem section through the annual medical-records audit and assign improvement actions where required.
Stated by Central and North West London NHS Foundation Trust -
Action
Train all staff during induction to use SystmOne’s problem functionality and audit its use through quarterly care-quality meetings.
Stated by Central and North West London 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
The accuracy of SystmOne’s problem list depends on all providers updating records, not solely on CNWL.
Stated by Central and North West London NHS Foundation Trust
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Concerns raised1
Failure to record contemporaneous clinical notes, including presence or absence of suicidal ideation
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.
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 document and clearly formulate patient risks in the medical records
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
Prompt nursing teams to reassess patients’ risks and mental state immediately before leave and document the decision in clinical records.
Stated by Lancashire & South Cumbria NHS Foundation Trust -
Action
Include the actions’ impact in a clinical audit, then review findings and provide feedback through team clinical supervision.
Stated by Lancashire & South Cumbria NHS Foundation Trust
Data last updated 7 September 2026