First reported 30 Apr 2014•Latest report 17 Mar 2026
Definition
What this concern includes
Includes failures of the mental-state assessment process, including delayed or missed assessment, failure to undertake an appropriate mental state examination, and materially inconsistent or inadequate assessment of mental state.
Not included
Excludes general mental health risk assessments unless the asserted deficiency specifically concerns assessment of the patient’s mental state.
Excludes failures of treatment, referral, admission, discharge or escalation where mental-state assessment is not itself the unsafe condition.
Excludes generic staffing, training, documentation or communication deficiencies unless they directly impair the mental-state assessment process.
Excludes assessments of physical condition or unrelated clinical states.
Reports
24
Distinct published reports
Individual concerns
25
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
36
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.
Department of Health and Social Care6
NHS England3
East London NHS Foundation Trust2
Essex Partnership University NHS Foundation Trust2
Greater Manchester Police2
HM Prison and Probation Service2
North London NHS Foundation Trust2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Black Country Healthcare NHS Foundation Trust1
BTCM Limited1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Cheshire and Wirral Partnership NHS Foundation Trust1
Cornwall Council1
Crown Prosecution Service1
NHS trust20
Ministerial department6
Police force6
Executive non-departmental public body3
Executive agency2
Healthcare site2
Integrated care board2
Company limited by guarantee1
English county council1
English metropolitan district council1
English unitary authority1
Health and care professional regulator1
Health and social care service regulator1
Mayoral policing body1
National policing body1
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.
South Yorkshire (Eastern)
Concerns raised1
Failure to undertake and document mental state examinations and risk assessments before granting ward 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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised1
Failure of the mental health team to undertake mental state examinations
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Milton Keynes
Concerns raised1
Delays in mental health team assessment in the Emergency Department
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Accept emergency-department referrals before medical clearance to enable earlier engagement, risk planning and support, with timely referral-response monitoring.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
Inner West London
Concerns raised1
Insufficient Mental Health in-reach team staffing for timely meaningful and quality mental health assessments
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 concerns
Each 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
Fill the vacant mental health in-reach team post.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Action
Recruit vacant mental health in-reach nursing posts following the successful recruitment campaign.
Stated by Oxleas NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 July 2025.
Action
Use bank or agency staff to fill vacant mental health service posts during recruitment.
Stated by Oxleas NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 July 2025.
Essex
Concerns raised1
Failure to review records and identify the need for urgent mental health assessment
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Require full biopsychosocial mental health assessments, with documented rationale for omissions.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 June 2025.
Action
Conduct monthly evidence-based assessment quality audits and provide feedback on findings.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 June 2025.
Action
Continue reviewing urgent-care learning, deadlines and impact through monthly quality and safety meetings.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 June 2025.
Essex
Concerns raised1
Differences of opinion in mental state assessments
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 concerns
Each 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
Action
Require Home Treatment Team staff to use an agreed home-visit documentation template covering mental state, physical health, safeguarding, risk assessment, and follow-up planning, with fortnightly audits.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 October 2024.
Action
Require Home Treatment Team mental-state examinations to record speech abnormalities and psychotic symptoms where mood-disorder concerns arise.
Stated by North East London NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 8 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The medical records indicate consistent staff opinions and do not support a difference of opinion about hypomanic symptoms.
Stated by North East London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
County Durham and Darlington
Concerns raised1
Failure to undertake medical and mental health assessments on SACU
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 concerns
Each 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
Action
Conduct a SACU pilot evaluating operational processes and health support to inform a safe, integrated workforce model.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 4 January 2023.
Action
Base a full-time nurse within the SACU to provide flexible healthcare input, including medical assessments.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 4 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing arrangements allow additional prison staff to assist with three-person unlocks, and resources are considered sufficient to respond effectively in future.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Failure to undertake mental health assessment and identify need for further or secondary mental health support
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Share suicide and self-harm documentation and assessment learning with all Frimley GP practices through bulletins, meetings, clinical leads and prescribing updates.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Deliver a recorded virtual training session on mental health assessment and documentation, then distribute the recording to all practices.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Send PHQ9 and GAD7 questionnaires before consultations and record their scores directly in EMIS Web.
Stated by Farnham Park Health Group and Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Create and circulate an Accurix template directing clinicians to GAD and PHQ9 resources for detecting anxiety and symptoms.
Stated by Farnham Park Health Group and Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 19 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
Existing clinical guidance, professional standards, revalidation and training arrangements are considered sufficient to support appropriate prescribing and diagnosis.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
The response disputes that secondary mental health referral was indicated, stating that the patient did not meet referral criteria and remained low risk.
Stated by Farnham Park Health Group and Recipient name withheldDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester City
Concerns raised1
Inadequate and incomplete risk assessments and mental state examinations
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to assess mental state, relapse and risk of harm
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of the mental-state assessment process, including delayed or missed assessment, failure to undertake an appropriate mental state examination, and materially inconsistent or inadequate assessment of mental state.
