Recurring concern

Unreliable recording of suicide-risk information

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First reported 9 May 2014•Latest report 12 Jan 2026

Definition

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

Distinct published reports

Individual concerns
19

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
26

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.

HM Prison and Probation Service3
NHS England3
Care UK2
Essex Partnership University NHS Foundation Trust2
Greater Manchester Mental Health NHS Foundation Trust2
Pentonville Prison2
Tees, Esk and Wear Valleys NHS Foundation Trust2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Central and North West London NHS Foundation Trust1
HCRG Care Services Ltd1
Herefordshire and Worcestershire Health and Care NHS Trust1
Lancashire & South Cumbria NHS Foundation Trust1
London Ambulance Service NHS Trust1
Mid and South Essex NHS Foundation Trust1
Midlands Partnership University NHS Foundation Trust1

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.

  1. Surrey

    AI-generated summary

    Stephen Ian William Tidey · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stephen Ian William Tidey was found deceased on 22 December 2016, having been found hanging from a tree outside the cabin where he was residing, with self-inflicted wounds to both wrists. The report raised concerns that a high-risk MASH referral, made after he lost his job, was not followed up and that there were no safeguards to ensure referrals were acted upon, including outside normal office hours.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record the basis for reduced risk-of-self-harm assessments

    Wider context from the report

    “He was assessed by a member of the Criminal Liaison and Diversion Service (CLDS) on the same day and was initially assessed by them as being at risk of self-harm. The member of the CLDS subsequently telephoned the Home Treatment Team to discuss referring him to the service. Mr Tidey was then re-assessed by the same member of the CLDS who stated he appeared calmer and was no immediate risk to himself. No notes were recorded on the Police or Mental Health Service computer system to record how this assessment of reduced risk of self-harm had been reached. ”

    Source location

    Stephen Ian William Tidey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Triage SCARF referrals by checking factual content, risks, vulnerabilities, warnings, previous referrals and escalation needs, with risk ratings adjusted and justified where necessary.

    Verbatim wording from the response

    “Police Officers submit a risk assessment form called a Single Combined Assessment of Risk Form (SCARF) to the Police MASH where it is triaged.”

    Source location

    2018-0140-Response-by-Surrey-Police
    Page 1 · response
    Published 1 July 2018

    Open published response

  2. Swansea and Neath Port Talbot

    AI-generated summary

    Christopher John Llewellyn Roberts · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christopher John Llewellyn Roberts was pronounced dead at his home on 19 October 2015 after an overdose involving prescribed opiate medication. He was receiving treatment for mental illness, and his medication use was described as chaotic. The report raised concerns that a care plan review was not recorded, including whether a recent overdose attempt had been considered, and that nomad trays may be unsuitable for some patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to document consideration of recent suicide attempts during care plan review

    Wider context from the report

    “1. The care plan review was not recorded which would not allow another person reviewing the file to ascertain that a care plan review had taken place and what the outcome of that review was. It was also the case that a lack of documentation would not demonstrate whether CMHT had considered the matter of the attempt on his own life by the deceased in the weeks leading up to that review, when considering whether to amend or retain the care plan in place at the time. ”

    Source location

    Christopher John Llewellyn Roberts · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. County Durham and Darlington

    AI-generated summary

    Thomas Whitfield · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thomas Whitfield was a voluntary patient at Farnham Ward, Lanchester Road Hospital, and was found hanging in his room on the morning of 28 July 2016, shortly after being re-assessed by his Consultant Psychiatrist. The concerns included whether information from his sister about perceived suicide risk was communicated and recorded, and the absence of monitoring or recording of telephone calls that might have clarified what was said.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record family concerns about suicide risk in the Paris notes

    Wider context from the report

    “The deceased’s sister made a statement advising that she had spoken to hospital staff alerting them to the risk that she perceived her brother had of suicide. Her statement states that staff had acknowledged this and were aware of this, were monitoring him and they had been able to listen to his telephone conversations which took place near to their desk. Evidence was given that it would be expected that such calls would be recorded in the Paris notes and acted upon including speaking to the patient. A Consultant Psychiatrist gave evidence that if he had been aware of such family concerns it would have affected his risk assessments. There is only one telephone call recorded in the Paris notes which does not make any reference to any such concerns. Many calls now are recorded for monitoring and training purposes and had such calls being so monitored and or recorded then at least it would be possible to prove one way or the other whether such calls had taken place and what their content was. There is no such monitoring or recording of calls at the present time. There is CCTV in the hospital, which can be viewed after an event to clarify what did/not happen. ”

    Source location

    Thomas Whitfield · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Inner North London

    AI-generated summary

    John WILLIAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to accurately record self-harm or suicide assessments

    Wider context from the report

    “1. The first reception nurse who saw Mr Williams when he entered HMP Pentonville gave evidence that he had no thoughts of self harm or suicide, but she recorded that he had. It appears she may benefit from additional training and/or supervision. ”

    Source location

    John WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester City

    AI-generated summary

    Nicholas Patrick SULLIVAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Nicholas Patrick SULLIVAN, who had a chronic mental illness and was experiencing suicidal ideation and auditory hallucinations, attended an emergency department but was not triaged or referred for a timely mental health assessment. He left after waiting, later reiterated that he was suicidal, ran into a road and was struck by a car, dying from his injuries on 30 November 2014. The principal concerns included failures to record mental health risks at reception, trigger urgent triage and safeguarding, activate escalation procedures, and ensure appropriate coordination and staffing.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a reception checklist for identifying and recording mental health and self-harm or suicidal ideation information

    Wider context from the report

    “5.1 Whilst recognising that Emergency Departments can by busy, reception staff did not work to a short bullet point pro-forma checklist which identifies issues of mental disorder/conditions and check and record important background issues, such as self-harming behaviour or suicidal ideation. This information is vital to record and should trigger urgent triage/mental health assessment. ”

    Source location

    Nicholas Patrick SULLIVAN · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. County Durham and Darlington

    AI-generated summary

    Michael Peter McMonigle · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michael Peter McMonigle was admitted as an informal patient to Farnham Ward at Lanchester Road Hospital and was assessed as being at significant risk of self-harm. On 11 August 2015 he left the hospital during accompanied leave, was later found suspended by a ligature, and was declared dead on 12 August. The principal concerns included failures to update and communicate risk information and leave arrangements, inadequate handover and policy implementation, and delays and omissions in responding to his absence.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to update risk assessments, case notes and intervention plans with self-harm, suicide and escorted-leave information

    Wider context from the report

    “(1) The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant Psychiatrist in particular. (2) The failure to follow the policy in terms of conducting an assessment prior to the handover. (3) The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives. See paragraphs 6.7 and 6.8, the policy of Leave from Hospital and Leave of Absence under Section 17 Mental Health Act 1973, policy no CLIN00025. (4) The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm or suicide and details of conditions for escorted leave following the formulation meeting on 10th August 2015. Instead, it fell to staff to verbally convey this information to colleagues who had not attended at the formulation meeting and to members of the family. (5) Failure to respond to Michael’s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively at 21:00hrs when it was conceded that the alarm could have been raised given that was the normal time for return from leave. (6) The response to Michael’s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage. (6) The following responses were undertaken after 19.20 and 21.00 when in conclusion of the jury the alarm could have been raised: enquiry with friends or relatives from 22:30hrs at earliest, an attempt to telephone Michael from 22:40 hrs at earliest, contact with relatives from 22:30 hrs at the earliest (Michael’s mother said 23.15), Police at 23:45hrs at the earliest, other hospital staff at 00:15hr on 12th August at the earliest, the medical staff at 12:20hrs at the earliest. Staff knowledge of the Leave policy and Missing Patients Procedure was inadequate. ”

    Source location

    Michael Peter McMonigle · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Inner North London

    AI-generated summary

    Samuel Rodney Darren BLAIR · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record assessment of mood and suicidal thoughts during prison triage

    Wider context from the report

    “1. Although the assistant psychologist who triaged Mr Blair in prison on 2 July 2015 asked him about his alcohol dependency, she did not ask him about drug use, nor did she record asking him about his mood or any suicidal thoughts. ”

    Source location

    Samuel Rodney Darren BLAIR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Concerns 2, 3 and 4 relate to BEH-MHT services rather than the services addressed by this response.

    Verbatim wording from the response

    “Response: We refer you to the response provided by BEH-MHT as these concerns are relating to their services rather than the services of Care UK.”

    Source location

    2016-0196-Response-by-Care-Uk
    Page 1 · response
    Published 19 May 2016

    Open published response

  8. Worcestershire

    AI-generated summary

    Stephen Martin ADAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stephen Martin ADAMS was being cared for by the Home Treatment Team of Worcestershire Health and Care NHS Trust when he died by suicide by hanging at his home. The inquest identified that the suicide-risk assessment section of a Mental Health Liaison Team risk assessment document had not been completed, and that risk assessment was instead inferred from the worker’s actions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record suicide risk assessment in risk assessment documents

    Wider context from the report

    “(1) It emerged during the inquest that the Risk Assessment document completed by the Mental Health Liaison Team worker was not complete in as much as the box indicating the assessment of suicide risk had not been completed. The witness indicated that many workers do not complete this box and the assessment of risk is to be extrapolated from the actions taken by the worker. No where on the document is the assessment of risk to be found. ”

    Source location

    Stephen Martin ADAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Inner South London

    AI-generated summary

    Gary Richards · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to properly assess and record self-harm and suicide risk

    Wider context from the report

    “(1) Psychiatric staff did not properly assess his risk of self harm, nor communicate his vulnerability to others. At discharge on 10/05 his risk of self harm was not fully measured. On being seen on 14/06 his risk assessment was not recorded and the risk plan not sent to the GP. The consultant explained that the risk was not mitigatable as no mental illness was found. Evidence was heard that his forensic history indicated that he belonged to a group of patients with 80 times the risk of suicide compared with the general population, yet he was considered at low risk. The value of performing a proper risk assessment to demonstrate the risks and vulnerabilities of the patient to other agencies, such as housing and social services, does not seem to have been considered, although it was reluctantly conceded by the consultant to be of value especially as homelessness presented as the primary problem. ”

    Source location

    Gary Richards · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remind staff to record risk assessments in the correct electronic patient-record section.

    Verbatim wording from the response

    “The Trust’s policy on risk assessment is clear in its documentation and staff have been reminded to ensure that when risk is assessed, that this is documented in the correct fashion in the relevant section of the electronic patient record to ensure that this is easily accessible by all clinical staff.”

    Source location

    2014-0212-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 9 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Risk was assessed during admission but recorded in the wrong electronic-record location, rather than not being assessed.

    Verbatim wording from the response

    “It is correct that there is no formal documentation of risk in the correct location on the PJS (our electronic patient record system) either at the point of his presentation under Section 136 or whilst on the Triage Ward. This was noted in the Trust’s investigators in their report. However, there is clear evidence in the clinical records that risk was assessed and is documented in the detailed entries made by the ward medical staff during his admission. It was acknowledged that there was a risk of suicide but this was not linked to mental illness but rather the difficult circumstances he found himself in, in particular, his homelessness.”

    Source location

    2014-0212-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 9 May 2014

    Open published response
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Data last updated 7 September 2026