Recurring concern

Unreliable objective criteria for safety risk assessment

First to latest report 3 Dec 2013 — 7 Apr 2026

Reports that mention this concern
26
Times this concern has been raised
26
Stated actions linked to this concern
35

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.

What is 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 and published responses 26 reports

See individual reports that have raised this concern, and the actions taken in response

  1. County Durham and Darlington

    AI-generated summary

    Margaret Atkinson · 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

    Margaret Atkinson, who had a long history of mental health illness and was in prison healthcare, was found unresponsive in her cell on 24 January 2016 after staff observed clothing around her neck and delayed entering the cell; she died in hospital on 2 February 2016. The jury found that staff should have entered earlier, and the report identified difficulties in describing such situations and assessing risk when unusual behaviour had become accepted as normal.

    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 use appropriate language when describing situations for risk assessment

    Wider context from the report

    “(1) The case revealed issues and difficulties about how situations were described and the choice of appropriate language with the corresponding difficulties resulting therefrom in assessing risk. Furthermore, as there was unusual behaviour over an extended period of time there was an acceptance of such behaviour as being normal and would not be considered as illustrative of increased risk unless there was a significant departure from that already unusual (or bizarre behaviour as it was described in evidence). HMP Low Newton have issued interim guidance to endeavour to address the matter and G4S likewise. A copy of the G4S guidance is attached. This appears good, I believe it needs to be shared throughout the prisoner state generally and not just in the North East cluster of prisons where G4S provides healthcare. ”

    Source location

    Margaret Atkinson · 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

    Implement specific descriptive language for observed behaviours and discuss the requirement with prison mental health staff.

    Verbatim wording from the response

    “Within the prison Mental Health services we have addressed the use of the term ‘ligature’ and staff are now describing what they observe more specifically. The requirement to do this has been discussed with all staff via discussion at team meetings. The Trust will work with partners to agree the guidance document which has been drafted. Following the”

    Source location

    2017-0021-Response-by-Tees-Esk-and-Wear-Valley-NHS-Trust
    Page 1 · response
    Published 19 February 2017

    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

    Work with partners to agree the drafted guidance document through the agreed governance processes.

    Verbatim wording from the response

    “Within the prison Mental Health services we have addressed the use of the term ‘ligature’ and staff are now describing what they observe more specifically. The requirement to do this has been discussed with all staff via discussion at team meetings. The Trust will work with partners to agree the guidance document which has been drafted. Following the”

    Source location

    2017-0021-Response-by-Tees-Esk-and-Wear-Valley-NHS-Trust
    Page 1 · response
    Published 19 February 2017

    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

    Promote the approved guidance with partners across the North East prison cluster for which the Trust is responsible.

    Verbatim wording from the response

    “document being approved through agreed governance processes we will actively promote this as partners within the NE prison cluster for which we are responsible. The Regulation 28 notice was also served to G4S and HMP nationally who will respond to this accordingly.”

    Source location

    2017-0021-Response-by-Tees-Esk-and-Wear-Valley-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    Open published response

  2. Mid Kent and Medway

    AI-generated summary

    Natalie Gray · 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

    Natalie Gray died after leaving Priority House, where she was an informal patient, and jumping in front of a train at Barming railway station on 21 April 2015. The principal concerns included insufficient risk assessments, inadequate handovers and failures in procedures for informal patient leave, communication of risk, recording third-party information and reporting her absence to police.

    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 define whether risk assessments record present, chronic and historic risk

    Wider context from the report

    “(2) The risk assessment form has not yet been addressed and is under review, there remains an issue as to whether the risk is recorded as a present risk alone or includes chronic risk (particularly for those with personality disorders) as oppose to historic risk. Although risk is discussed at handovers and ward rounds there is no evidence that the risk rating is communicated or signed off by the doctor when the record is completed by a nurse/junior doctor ”

    Source location

    Natalie Gray · Prevention of Future Deaths report
    Page 3 · 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

    Transform clinical risk assessment and management, including new training and electronic risk-assessment documentation.

    Verbatim wording from the response

    “The strategy recognised that those with a diagnosed Personality Disorder are at a higher risk, and therefore require priority due to being in this high risk group. There is work underway in line with this to transform clinical risk assessment and management, both in practice and recording, with new training in place, and new risk assessment documentation about to come onto our electronic clinical record system for general”

    Source location

    2017-0003-Response-by-Kent-and-Medway-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    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

    Implement the newly reviewed Trust risk policy and risk summary form across the organisation.

    Verbatim wording from the response

    “In January 2017 the Trust launched a newly reviewed risk policy and risk summary form, this is currently being implemented Trust-wide.”

    Source location

    2017-0003-Response-by-Kent-and-Medway-NHS-Trust
    Page 3 · response
    Published 19 February 2017

    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

    Update the Clinical Risk Policy with transition-of-care guidance and risk assessment and reassessment points.

    Verbatim wording from the response

    “We have taken a number of steps to highlight how the points of transition of care are an area of risk for those with a diagnosis of Personality Disorder. Changes have been made to our Clinical Risk Policy to reflect this. There is a flow diagram in the policy providing guidance on when to assess and reassess clinical risk and it highlights transition periods.”

    Source location

    2017-0003-Response-by-Kent-and-Medway-NHS-Trust
    Page 3 · response
    Published 19 February 2017

    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

    Deliver updated mandatory training on chronic and fluctuating risk, critical risk periods and transitions in care.

    Verbatim wording from the response

    “I am aware that its development was informed by learning from Serious Incidents and near misses. Natalie’s was a case where the grading of risk was key as there was always a chronic risk which would fluctuate. Updated mandatory training focuses on the critically high risk period as well as other transitions in care. The updated training explains how the period is often referred to as the ‘Low Risk Paradox’ with risk assessed as low in one environment yet high or escalating in another.”

    Source location

    2017-0003-Response-by-Kent-and-Medway-NHS-Trust
    Page 3 · response
    Published 19 February 2017

    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 real case examples with clinicians to improve multidisciplinary understanding of risk and its variability.

    Verbatim wording from the response

    “We are using learning from real case examples with our clinicians to ensure that the multidisciplinary teams understand risk, its importance and variability in a more sophisticated sense.”

    Source location

    2017-0003-Response-by-Kent-and-Medway-NHS-Trust
    Page 3 · response
    Published 19 February 2017

    Open published response

  3. Manchester (North)

    AI-generated summary

    Derek Hawkins · 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

    Derek Hawkins, who had bipolar disorder and was admitted for reassessment and treatment after increased suicidal thoughts, disclosed on 22 November 2013 that he intended to hang himself. He left the ward unescorted on 24 November and was found hanging in a derelict building near the hospital grounds that evening. The concerns included failures in communication, unclear leave arrangements, inadequate risk assessment after his disclosure of suicidal intent, and a risk-assessment tool that relied on subjective practitioner assessments.

    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 objective risk-factor rating in the risk assessment tool

    Wider context from the report

    “(1) The Risk Assessment tool currently in use relies on an individual practitioner’s subjective assessment and description of risk factors. The tool does not provide a means of objectively rating risk factors and means that less experienced practitioners may fail to recognise or identify an increase in risk. ”

    Source location

    Derek Hawkins · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Swansea and Neath Port Talbot

    AI-generated summary

    Matthew Thomas Purser · 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

    Matthew Thomas Purser hanged himself in his cell at Swansea Prison on 13 June 2012, after being remanded there and placed on self-harm monitoring. The report identified concerns about inadequate ACCT training, insufficiently objective recording and review of trigger events and significant interactions, and unclear arrangements for obtaining community mental health records.

    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 provide sufficient ACCT trigger-event recording and assessment guidance for objective risk assessment

    Wider context from the report

    “2. The trigger event endorsed on the documentation requiring review of Mr. Purser under the ACCT was given as “loss of contact with partner/breakdown in relationship”. Mr. Purser’s apparent dependence on maintaining contact with his partner was correctly identified by the prison but the way in which the wording of the trigger was expressed left much to the subjective assessment of the officers about the state of his relationship with his partner. Because of the way in which the ACCT records were kept officers did not have enough information to make a realistic assessment and in their evidence some officers draw a distinction between Mr. Purser’s relationship going through a difficult time and it having broken down. If a trigger event is something which cannot be easily and objectively determined by an officer more detailed observations and recording will be required. If the only way in which a trigger can be expressed is in similar language to the trigger some indication needs to be given as to how the assessment is to be carried out and how clearly information must be shared by means of the records kept. ”

    Source location

    Matthew Thomas Purser · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Essex

    AI-generated summary

    Josephine Foday and Komba Kpakiwa · 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

    Josephine Foday and Komba Kpakiwa were found floating in the swimming pool at Down Hall Country House Hotel, and their deaths were confirmed shortly afterwards. The inquests concluded that the deaths were accidental and that the cause of death for both was consistent with drowning. Concerns included the pool’s dangerous profile, inadequate risk assessments and signage, lack of lifeguards and trained aquatic-rescue staff, and ineffective supervision arrangements, including unmonitored CCTV.

    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 consider non-swimmers and poor swimmers in risk assessments

    Wider context from the report

    “5) It did not appear that non swimmers or poor swimmers had been considered in the risk assessment process. ”

    Source location

    Josephine Foday and Komba Kpakiwa · 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

    The swimming pool is closed, so no one else will be exposed to a similar risk at that facility.

    Verbatim wording from the response

    “We understand that the swimming pool concerned is now closed and so no-one else will be put at similar risk in this facility.”

    Source location

    2014-0301-Response-by-IOSH
    Page 1 · response
    Published 23 May 2014

    Open published response

  6. Inner North London

    AI-generated summary

    Agostino COSTA · 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

    Agostino Costa died after an accidental fall in hospital on 12 May 2013, which hastened death from terminal disease. The principal concerns were staff confusion about falls-risk classification and management, inadequate training for a junior doctor, limited sharing of the hospital root cause analysis, and non-mandatory attendance at falls-prevention seminars.

    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 clarity among staff about falls risk classification

    Wider context from the report

    “1. There was confusion among the staff as to whether Mr Costa was classified as red (high risk) or green (low risk) in terms of falls. 2. There was confusion among the staff as to whether a patient walking with a frame presents a high risk of falls. 3. There was confusion among the staff as to whether a patient with myelofibrosis and blood transfusions presents a high risk of falls. This confusion was also present in the hospital root cause analysis conducted after Mr Costa’s death. ”

    Source location

    Agostino COSTA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026