Recurring concern
Unreliable objective criteria for safety risk assessment
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Request correctionFirst reported 3 Dec 2013•Latest report 7 Apr 2026
What this concern includes
Includes failures of generic safety risk-assessment criteria, tools or processes where objective criteria are absent, inconsistently applied, unclear, incomplete or insufficient to support consistent risk ratings across practitioners.
Not included
- Excludes risk assessments belonging to a separately named system, pathway or hazard when that named concern provides the more specific parent boundary.
- Excludes failures limited to recording, communicating or acting on a risk assessment when the assessment criteria themselves are adequate.
- Excludes generic training, staffing or supervision deficiencies unless they directly cause unreliable application or design of the risk-assessment criteria.
- Excludes clinical or operational decisions that do not identify an unsafe deficiency in the objectivity, consistency or clarity of risk-assessment criteria.
- Reports
- 26
- Individual concerns
- 26
- Date range
- 2013–2026
- Stated actions
- 35
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 directly ask about suicidal ideation when suicidal thoughts are indicated in referral information
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
Deliver phased, mandatory Tier 2 practitioner training to identified Children and Families staff, with refreshers and ongoing training for new starters.
Stated by Warwickshire County Council
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
Tier 2 practitioner training will be phased over three years because financial considerations and workforce capacity constrain faster implementation.
Stated by Warwickshire County Council
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Position
Mandatory completion of universal suicide-awareness training across the Council remains subject to further corporate agreement.
Stated by Warwickshire County Council
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Concerns raised1
Insufficient coverage of blood-thinner-related scenarios in care-plan risk assessments
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
Update the standard anticoagulant risk assessment to require emergency calls after falls or head blows and disclosure of anticoagulant use.
Stated by The Care Bureau Limited -
Action
Update the standard falls risk assessment to distinguish witnessed and unwitnessed falls and require anticoagulant checks and emergency notification.
Stated by The Care Bureau Limited -
Action
Review anticoagulant users’ Care Plans and Carer App notes to ensure anticoagulant risks are appropriately highlighted.
Stated by The Care Bureau Limited
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
Implemented measures are considered sufficient to address the concerns and reduce the likelihood of similar issues arising.
Stated by West Northamptonshire Council
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Concerns raised1
Incomplete risk assessments failing to include all ligatures
This report raised 30 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
Continue developing and refreshing personalised, descriptive risk assessments and safety plans, with daily prioritisation of significant risks.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Inaccurate categorisation of risk as medium after a patient absconds
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 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 mandatory refresher training on structured risk assessment, dynamic risk documentation and appropriate observation levels, with monthly compliance audits.
Stated by The Trust
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Concerns raised1
Failure to conduct timely risk assessments with complementary risk management plans
This report raised 24 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
Deliver revised risk-assessment training to new practitioners and introduce new training for experienced staff.
Stated by HM Prison and Probation Service -
Action
Deliver further risk-assessment training events for practitioners responsible for managing people in the community.
Stated by HM Prison and Probation Service -
Action
Develop, pilot and launch the Continuing Professional Development risk-learning product for experienced practitioners.
Stated by HM Prison and Probation Service
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Action
Develop and roll out the ARNS digital assessment and sentence-planning service with supporting staff learning.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to factor water rescue equipment availability into dynamic patrol risk assessments
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 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
Provide throw-line access for officers conducting pre-planned operations near bodies of water.
Stated by Metropolitan Police Service
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
Officers on pre-planned operations near water are already required to have access to throw lines under the Water Intervention Risk Assessment.
Stated by Metropolitan Police Service
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Concerns raised1
Failure of risk assessment to engage with the particular patient
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 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 of the falls risk assessment document to prompt consideration or documentation of attachments
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.2
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Action
Review the falls risk assessment and identify required improvements to capture equipment-related mobility risks.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Add a PICS falls-assessment dropdown for equipment such as drains and record the selected information in the Patient Handling Assessment Form.
Stated by University Hospitals Birmingham 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
Manual handling and falls assessments need not automatically feed into each other because staff are expected to consider them together with other records.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Concerns raised1
Lack of understanding that short periods away from mental health units do not preclude high-risk status when a patient fails to return
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 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
Develop and disseminate a seven-minute briefing on mental-health terminology, associated risk, Golden Hour principles, communications data, costs, and Aide Memoire use.
Stated by Greater Manchester Police -
Action
Circulate an interim memorandum to District Commanders for dissemination on mental-health terminology, risk, Golden Hour tasks, and mobile-phone data access.
Stated by Greater Manchester Police -
Action
Review whether further supervisor training on missing-person investigations, risk assessment, Golden Hour principles, communications data, and costs should be provided and determine its form.
Stated by Greater Manchester Police
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Action
Include Golden Hour guidance, cell-siting costs, family updates, and mental-health learning in operational briefings, then verify completion across districts.
Stated by Greater Manchester Police
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Concerns raised1
Inconsistent approaches to risk assessment
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 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.
Data last updated 7 September 2026