First reported 2 Dec 2013•Latest report 21 Oct 2025
Definition
What this concern includes
Includes failures to obtain, record, retrieve, flag or provide previous self-harm, suicide-attempt or suicide-risk information when it is needed for referral, admission, custody or other safety assessments.
Not included
Excludes generic clinical-history or record-access failures where self-harm or suicide-risk information is not the material concern.
Excludes failures to assess or manage current suicide or self-harm risk after relevant historical information was reliably made available.
Excludes failures involving current suicidal intent or self-harm protective measures where no deficiency in accessing or providing historical risk information is identified.
Excludes generic family-information, inter-agency communication or documentation deficiencies unless they directly impair availability of previous self-harm or suicide-risk information.
Reports
9
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
18
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.
Central and North West London NHS Foundation Trust3
NHS England3
Winchester Prison2
Department of Health and Social Care1
GeoAmey PECS Limited1
Gloucestershire Constabulary1
Hampshire and Isle of Wight Constabulary1
HCRG Care Group1
HM Prison Service1
Imperial College Healthcare NHS Trust1
Manchester Prison1
Ministry of Justice1
Portland Road Practice1
Sussex Partnership NHS Foundation Trust1
The Langford Centre1
NHS trust4
Executive non-departmental public body3
Prison or young offender institution3
Healthcare site2
Ministerial department2
Police force2
Multi-service care provider1
Private limited company1
Sub-organisation1
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.
Essex
Concerns raised1
Inability to navigate System One records to find previous incidents of self-harm in prison
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 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.5
Action
Deliver structured SystmOne training through induction, refresher training, and equivalent training for long-term agency staff.
Stated by HCRG Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 October 2025.
Action
Require agency staff to confirm in writing that they understand how to navigate SystmOne clinical records and record confirmations.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Reinforce through clinical governance that practitioners consider risk-related history, including information beyond the default summary record view.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Expand monthly clinical-note audits to check access to relevant historic information during risk assessments and report findings through governance and quality monitoring.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Embed SystmOne training into governance and supervision processes to support consistent and safe use of the platform.
Stated by HCRG Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 October 2025.
East Sussex
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 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
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 CentreStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.
Action
Amend initial medical and risk assessments to capture patients’ previous suicide attempts and self-harm histories.
Stated by The Langford CentreStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.
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 CentreStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.
Action
Publish guidance on information sharing and holistic assessment during admission, including key actions within 72 hours.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Referring Trusts or bodies are responsible for completing previous suicide-method information in the initial referral form.
Stated by The Langford CentreRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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 EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South London
Concerns raised1
Lack of a national risk-flagging system for previous self-harm attendances
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.
Inner West London
Concerns raised1
Lack of enquiry into previous self-harm and associated injury
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 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.
Central Hampshire
Concerns raised1
Failure to identify documented suicide and deliberate self-harm 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 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.7
Action
Require reception-screening staff to complete modified training and confirm competence through induction sign-off and supervision.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2020.
Action
Provide reception-screening nurses with a guide explaining how to register patients and access previous medical records.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2020.
Action
Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2020.
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 TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2020.
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 TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2020.
Action
Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2020.
Action
Audit mental-health risk assessments and resulting care plans quarterly and during the annual medical-records audit.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Clinicians are not reliant solely on patients’ disclosed answers or presentation when assessing suicide and self-harm risk.
Stated by Central and North West London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Brighton and Hove
Concerns raised1
Failure to obtain sufficient details of a reported suicide attempt
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Central Hampshire
Concerns raised1
Failure to provide PER staff with relevant previous self-harm and suicide risk information
This report raised 12 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
Use the next custody newsletter to reinforce PER completion, inspection, warning-page, envelope, risk-marker and external-information responsibilities.
Stated by Hampshire and Isle of Wight ConstabularyStated plannedThe respondent said that this action was planned when they made their response on 18 July 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Detention officers completing PERs had access to Hampshire Constabulary systems and the Police National Computer, but not other forces’ internal systems.
Stated by Hampshire and Isle of Wight ConstabularyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Obtaining information from every external agency on every occasion is impracticable, so officers cannot routinely obtain all external data.
Stated by Hampshire and Isle of Wight ConstabularyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Officers must rely on each police force or agency to place relevant information on the national Police National Computer.
Stated by Hampshire and Isle of Wight ConstabularyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Oxfordshire
Concerns raised1
Failure to make high-risk information available to responding officers
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 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
Complete a thorough review of the information-sharing concern, consulting senior colleagues across relevant departments.
Stated by Thames Valley PoliceStated completedThe respondent said that this action was complete when they made their response on 28 July 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Gloucestershire Police addressed the concern about using the Police National Database in its own response.
Stated by Thames Valley PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester City
Concerns raised1
Failure to attach existing Risk of Self-Harm / Suicide documents to ACCT documents
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 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 to obtain, record, retrieve, flag or provide previous self-harm, suicide-attempt or suicide-risk information when it is needed for referral, admission, custody or other safety assessments.
