First reported 3 Dec 2013•Latest report 1 Jun 2026
Definition
What this concern includes
Includes deficiencies in the mental health risk-assessment process, including incomplete assessment, inadequate documentation or formulation, failure to gather relevant information, and reliance on insufficient indicators when assessing patients with mental health concerns.
Not included
Excludes failures in communication, handover, escalation, review, or safety planning unless the report explicitly presents them as a component failure of the mental health risk-assessment process.
Excludes risk assessments concerning unrelated hazards, settings, or beneficiary groups, such as antenatal growth risk, roadside trees, or general safeguarding.
Excludes generic workforce training or staffing deficiencies that are not specifically tied to inadequate mental health risk assessment.
Reports
118
Distinct published reports
Individual concerns
135
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
234
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.
NHS England20
Department of Health and Social Care19
Essex Partnership University NHS Foundation Trust8
North East London NHS Foundation Trust7
North London NHS Foundation Trust7
Birmingham and Solihull Mental Health NHS Foundation Trust6
Central and North West London NHS Foundation Trust6
East London NHS Foundation Trust5
Oxleas NHS Foundation Trust5
Hampshire and Isle of Wight Healthcare NHS Foundation Trust4
Midlands Partnership University NHS Foundation Trust4
NHS Birmingham and Solihull Integrated Care Board4
Care Quality Commission3
Greater Manchester Health and Social Care Partnership3
Greater Manchester Mental Health NHS Foundation Trust3
NHS trust88
Ministerial department23
Executive non-departmental public body20
Police force15
Integrated care board10
Healthcare site5
Local health board5
Prison or young offender institution5
Health-system partnership4
Type not available4
Executive agency3
Health and social care service regulator3
Private limited company3
Coronial office2
English county council2
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.
Suffolk
Concerns raised2
Failure to recognise elevated suicide risk from prolonged refusal to eat or drink
Failure to recognise prolonged refusal to eat or drink as action to end life
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
Hold a reflective multidisciplinary away day using food-and-drink case studies to strengthen holistic clinical risk assessment.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Action
Discuss food-and-drink risk assessment in clinical supervision and review it in future team meetings.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 April 2024.
Action
Use daily team huddles to prompt consideration of eating and drinking in holistic clinical risk assessments.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Action
Revise SBAR handover records to capture eating-and-drinking quantity, not only appetite, for clinical risk assessment.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Action
Develop and deliver bespoke training linking suicide prevention with malnourishment, with subject-matter expert support.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
Swansea and Neath Port Talbot
Concerns raised1
Unavailability of relevant medical records to s.12 doctors before MHA 83 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 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
Continue working with the Health Board through joint forums to secure appropriate WCCIS access for mental-health professionals requiring it.
Stated by Swansea CouncilStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
Action
Provide all SBUHB-employed Section 12 doctors with read access to WCCIS for Mental Health Act assessments.
Stated by Swansea Bay University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Some matters raised in the report fall outside the Council’s remit, so it will not respond to them.
Stated by Swansea CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
SBUHB and NHS Wales must primarily address concerns about Section 12 doctors’ records access and assessment recording.
Stated by Swansea CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Operational responses to the concerns are assigned to the health board and local authority, while Welsh Ministers set the policy and strategic framework.
Stated by Welsh GovernmentRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised2
Insufficient staff awareness of the importance of exploring suicide risk
Failure to ask patients whether they feel suicidal during psychiatric consultations
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Suffolk
Concerns raised1
Inadequate risk assessment in response to urgent referrals
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
Update the Clinical Risk Assessment and Management Policy through governance, publish it, and progress its implementation plan.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
Norfolk
Concerns raised1
Failure to conduct full and proper assessments and independently verify service users’ responses
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.4
Action
Develop and establish a core competency framework for CRHTT assessors.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
Action
Complete induction, competency assessment and supervised competency development for CRHTT assessing staff.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
Action
Recruit qualified, experienced CRHTT clinicians and provide a structured 12-week preceptorship, supervision and development portfolio.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
Action
Monitor the impact of CRHTT measures through monthly audits and report findings through Trust quality and safety governance.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The witness evidence does not reflect the investigation findings or recognise the need for full assessment of service users’ responses.
Stated by Norfolk and Suffolk NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner West London
Concerns raised1
Failure to adequately assess the risk of impulsive suicide
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.1
Action
Issue guidance reminding staff to consider consultant psychiatrist assessment for people with complex emotional needs and suicide risk.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responding to the Coroner’s specific concerns falls outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Trust is responsible for responding to the Coroner’s specific concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Inadequate suicidal risk assessment
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.6
Action
Roll out the SAFETool across all MHSOP wards with staff training on its use.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Embed SAFETool paperwork in the RIO electronic patient record and require staff to complete forms there.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Strengthen SAFETool training with family and carer involvement content and reflective case studies.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Incorporate SAFETool learning and reflection into staff supervision and monitor training and supervision compliance.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024.
Action
Update clinical risk guidance, safety-planning documentation, audits and healthcare-record forms in line with current evidence and guidelines.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024.
Action
Ratify the updated Clinical Risk and Safety Policy.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
SAFETool use is not clinically indicated for every patient admitted to the ward.
Stated by Nottinghamshire Healthcare NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Staffordshire and Stoke-on-Trent
Concerns raised1
Inadequate exploration of matters affecting suicide risk
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
Train staff in suicide awareness, risk formulation and collaborative safety planning across the organisation.
Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
Action
Include families and carers in collaborative safety planning.
Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
Manchester North
Concerns raised1
Failure to identify or recognise suicide risk during referral screening
This report raised 8 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.
Hampshire, Portsmouth and Southampton
Concerns raised1
Lack of structured arrival handover and risk-history enquiry for detained patients
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.
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
Work with Portsmouth Hospitals University NHS Trust and continue supporting developments addressing emergency-department handover and shared patient care arrangements.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 November 2023.
Action
Review the standardised handover, triage and risk-assessment approach to ensure self-harm and absconding risks are considered at handover.
Stated by Portsmouth Hospitals University NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 November 2023.
Action
Meet with Solent NHS Trust to review transfer-of-care priorities, including clinician-to-clinician discussion before Emergency Department transfer.
Stated by Portsmouth Hospitals University NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 November 2023.
Action
Agree an implementation timeline with Solent NHS Trust for its electronic handover system.
Stated by Portsmouth Hospitals University NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Solent NHS Trust is developing the electronic handover system, with implementation timing to be agreed jointly.
Stated by Portsmouth Hospitals University NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes deficiencies in the mental health risk-assessment process, including incomplete assessment, inadequate documentation or formulation, failure to gather relevant information, and reliance on insufficient indicators when assessing patients with mental health concerns.
