Recurring concern

Failure to reliably complete My Safety Plans

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First reported 12 Aug 2024•Latest report 1 Sep 2025

Definition

What this concern includes

Includes failures of the named My Safety Plan process, including failure to initiate it on admission, complete it before discharge, populate it with relevant risks and safety actions, or maintain it when a patient’s circumstances or risks require review.

Not included

Excludes generic care plans, risk assessments or discharge checklists where My Safety Plan is not the identified safety-planning control.
Excludes failures to implement actions from a completed My Safety Plan when the plan itself was reliably created and maintained.
Excludes unrelated organisational action plans, incident action plans and service-improvement plans.
Excludes generic staff training or documentation deficiencies unless they directly impair completion or maintenance of a My Safety Plan.

Reports: 3
Individual concerns: 3
Date range: 2024–2025
Stated actions: 4

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

East London NHS Foundation Trust1

NHS Greater Manchester Integrated Care Board1

Pennine Care NHS Foundation Trust1

Priory Group1

Surrey and Borders Partnership 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 Sep2025
Inner North London
Concerns raised1
1. Failure to complete comprehensive patient risk assessments and associated safety documentation
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Provide monthly Dialog+, My Safety Plan and risk-assessment training for staff.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Require completion and review of Dialog+ and My Safety Plan documentation within 72 hours of admission, including weekly case-note audits.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Use daily unit huddles to report new admissions and monitor completion of initial assessments and care planning.
  Stated by East London NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  No further action is considered necessary because considerable work has addressed the identified concerns.
  Stated by East London NHS Foundation TrustNo action considered necessary
AI-generated summary

Name not published · 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

████████ was detained under the Mental Health Act and admitted to psychiatric wards at the Tower Hamlets Centre for Mental Health before being found unresponsive in a patient room on 7 June 2022; her death was verified later that day. The jury identified several contributing factors, including a non-functioning door-locking system and shortcomings in patient observations. Further concerns included risk assessment, staff understanding and attitudes towards risk, auditing, and clinical oversight.

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 complete comprehensive patient risk assessments and associated safety documentation
Wider context from the report
“5) Risk assessment of patients The Trust accepted that there were issues in the risk assessment of ████████ in that: what documentation there was stated there were risks but did not fully assess the risks; there was no ‘My Safety Plan’ in place; and ‘Dialog+’ had not completed. At the time, staff said that they had been trained regarding risk assessment and its importance. However, when giving evidence at the inquest, numerous members of staff were vague in their understanding of risk assessment. For example, a senior member of staff said that it was possible to complete the ‘My Safety Plan’ documentation even if a patient did not want to engage with the process, whereas other members of staff were insistent that if a patient doesn’t engage then the document should not be completed. ”
Source location
Name not published · Prevention of Future Deaths report
Page 4 · 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
Provide monthly Dialog+, My Safety Plan and risk-assessment training for staff.

Verbatim wording from the response
“There is a rolling programme of monthly Dialog+, my safety plan and risk assessment training for staff, with each member of staff completing this as a one-off.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 2 December 2025
Open published response
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
Require completion and review of Dialog+ and My Safety Plan documentation within 72 hours of admission, including weekly case-note audits.

Verbatim wording from the response
“In terms of the Trust’s expectations regarding whether staff should commence the My Safety Plan and Dialog+ documents in the absence of patient engagement, staff are expected to complete the Dialog+ and My Safety Plan within 72 hours of admission; where patients are not able to engage in this process staff will revisit and obtain their input. Staff are also encouraged to obtain collateral information from family, friends and carers. There are weekly case note audits to look at the quality of dialog+ including patients’ views, which provides opportunities for clarity of processes and expectations related to this documentation to be reinforced.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 2 December 2025
Open published response
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
Use daily unit huddles to report new admissions and monitor completion of initial assessments and care planning.

Verbatim wording from the response
“The daily unit huddle meeting in the Tower Hamlets Center for Mental Health requires ward managers to feedback on each new admission and the completion of their initial assessments and care planning. This is monitored until it is reported that all tasks have been completed. There is a record kept of this.”

Source location
Response from East London NHS Foundation Trust
Page 4 · response
Published 2 December 2025
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
No further action is considered necessary because considerable work has addressed the identified concerns.

Verbatim wording from the response
“I have addressed these in turn below. Please note that in respect of Concerns 2, 4, 5, 6, 7 and 8 the Trust entirely acknowledges the reasons for your concerns and has considered them extremely”

Source location
Response from East London NHS Foundation Trust
Page 1 · response
Published 2 December 2025
Open published response
14 Oct2024
Surrey
Concerns raised1
1. Failure of My Safety Plans to clearly convey suicide risk
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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Formal risk documentation and information-sharing procedures are considered sufficient; My Safety Plan is not intended to record or share clinical suicide risk.
  Stated by Surrey and Borders Partnership NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Locket Ure 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

Locket Williams, aged 15, died from injuries after leaving home and jumping to the road below on the night of 27 September 2021; their death was recognised at 00:01 on 28 September 2021. The report identified concerns about insufficient child psychiatric inpatient capacity, the recording and communication of suicide risk, and CAMHS engagement with multi-agency safeguarding meetings. The inquest found that the death was more than minimally contributed to by delays in assessment, underestimation of suicide risk, and delayed therapeutic treatment.

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 of My Safety Plans to clearly convey suicide risk
Wider context from the report
“Concern 3 I also heard that a child at risk of suicide may now be provided with a document, called “My Safety Plan”, one purpose of which is to help the child to communicate with others (including for example family members, teachers, and social workers) about their condition and risk. I was told that, if a child does not want to refer in the document to the risk of suicide, other terms such as “distress” may be used. To the extent that part of the purpose of the My Safety Plan is to enable the child to communicate their risk of suicide and thereby receive help to stay safe, I am concerned that by substituting the word “distress” for “suicide”, some plans may not refer to suicide and may not therefore ensure that the nature of the risk is clearly conveyed to those from whom the child may seek support, and to the responsible adults in their life. ”
Source location
Locket Ure Williams · Prevention of Future Deaths report
Page 4 · 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
Formal risk documentation and information-sharing procedures are considered sufficient; My Safety Plan is not intended to record or share clinical suicide risk.

Verbatim wording from the response
“My Safety Plan is not a tool for assessing or recording risk of suicide. The document is not written in clinical terms, and it is not intended to be a means of sharing information about risk between organisations. Instead, formal documentation of clinical risk (including clear and correct clinical terminology around suicide) is recorded in the Risk Formulation and Care Plan documents which, along with My Safety Plan, form an interlinked suite of documents which are held within a person’s Electronic Patient Record.”

Source location
Response from Surrey and Borders Partnership NHS
Page 2 · response
Published 14 October 2024
Open published response
12 Aug2024
Manchester North
Concerns raised1
1. Failure to commence and complete a safety plan during admission and before discharge
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Remind staff to complete required My Safety Plans and monitor compliance through daily dashboard reviews and audits.
  Stated by Priory GroupStated completed
Respondent positions 1
1. Position
  The NHS sending provider is responsible for overseeing individual care, including engagement in communication, discharge and care planning for out-of-area patients.
  Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibility
AI-generated summary

Mr David Thompson · 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

Mr David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.

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 commence and complete a safety plan during admission and before discharge
Wider context from the report
“1. The Incident Review of his admission to the Priory Dorking indicated that there was no My Safety Plan commenced on admission or complete prior to his discharge. ”
Source location
Mr David Thompson · 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
Remind staff to complete required My Safety Plans and monitor compliance through daily dashboard reviews and audits.

Verbatim wording from the response
“Issue a reminder to all staff the requirement to complete a My Safety Plan, and to outline the circumstances when a My Safety Plan is required.”

Source location
Response from Priory Group
Page 6 · response
Published 12 August 2024
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
The NHS sending provider is responsible for overseeing individual care, including engagement in communication, discharge and care planning for out-of-area patients.

Verbatim wording from the response
“GM ICB expect the NHS “sending” provider to oversee the individual care relating to any patient who is admitted as an Out of Area placement in line with National Host commissioner guidance. This includes attendance at ward rounds, face to face visits where appropriate and full engagement in discharge and care planning. The processes as described above have been implemented since December 2023 and have provided a much tighter grip and control and increased level of oversight of each individual patient.”

Source location
Response from Greater Manchester NHS
Page 2 · response
Published 12 August 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to complete comprehensive patient risk assessments and associated safety documentation

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of My Safety Plans to clearly convey suicide risk

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to commence and complete a safety plan during admission and before discharge

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 3

Respondent positions 1

Respondent positions 1

Actions described in response 1

Respondent positions 1