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.
Inner West London
Concerns raised1
Inadequate recording of patients' mental health history by CATT
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.1
Action
Deploy enhanced documentation practices to support coordinated care.
Stated by West London NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 July 2023.
Inner North London
Concerns raised1
Lack of a formal mental health and suicide or self-harm risk assessment at PCR delivery
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
Develop a policy requiring supervised, documented risk assessments before issuing PCRs to recordable-offence suspects, including risk management and decisions on personal service.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 8 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Current pre-charge bail arrangements and guidance provide further opportunities to assess suicide risk, so additional assessment at postal charge requisition is not identified.
Stated by College of PolicingExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure to consult medical notes and records during leave risk assessment
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.
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
Remind Gardner Ward and City and Hackney inpatient staff to record clinical decisions, review RIO notes, and discuss leave-recording requirements at scheduled away days.
Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 June 2023.
South Wales Central
Concerns raised1
Failure to provide assessing practitioners with immediate and comprehensive access to relevant mental health records across localities
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.11
Action
Standardise management of required paper records.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 2 July 2026.
Action
Scope phasing out paper notes and maximise existing digital systems before implementing the single electronic record.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 2 July 2026.
Action
Review paper and electronic archives and systems and standardise approved inpatient and outpatient care-planning documentation.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.
Action
Map information transfer between community and inpatient teams and share admission and discharge flow diagrams across the Care Group.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.
Action
Develop and distribute user guides for accessing and using FACE and shared-drive records.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.
Action
Use secure email inboxes for information sharing between RGH and Bridgend mental health teams.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.
Action
Develop and distribute the Clinical Information Access and Recording Matrix and accompanying standard operating procedure across mental health clinical teams.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.
Action
Develop and endorse a business case for a unified electronic record system.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.
Action
Review the national Welsh Community Care Information System strategic programme with Digital Health and Care Wales and other health boards.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 2 July 2026.
Action
Plan the pre-implementation phase for transferring existing community mental health users to a Health Board Welsh Community Care Information System.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 2 July 2026.
Action
Review the unified-record business case using implementation lessons to determine required resources and approach.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 2 July 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Implementation of the integrated electronic record was delayed by infrastructure and resource issues, while national programme review affected implementation timescales.
Stated by Cwm Taf Morgannwg University Local Health BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East London
Concerns raised1
Failure to incorporate available clinical information into self-harm risk assessments
This report raised 14 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
Use live RiO records for handovers, daily run-throughs and MDT ward rounds.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
Action
Audit compliance with live-record use and risk-assessment processes.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised2
Absence of a rolling risk assessment facility in SystemOne
Absence of ongoing risk assessment documentation for patients with mental illness in SystemOne
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Add an accessible risk-assessment document to SystemOne for Trust staff.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 March 2023.
Action
Roll out the SystemOne risk-assessment process to clinical staff using a practice alert and Standard Operating Procedure.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 March 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The Trust is restricted in changing the national prison software, and national SystemOne changes may take time.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
SystmOne is working correctly and safely from a system perspective.
Stated by The Phoenix Partnership (Leeds) LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The system commissioner decides whether and how to use SystmOne templates, decision support, alerts, reminders and warnings.
Stated by The Phoenix Partnership (Leeds) LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Concerns about SystmOne record keeping are for Birmingham and Solihull Mental Health Foundation Trust to address locally.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NICE-aligned risk assessments, SystmOne templates and staff training provide sufficient arrangements for mental health assessment documentation.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised2
Lack of detailed risk assessment during transition between mental health teams
Lack of detailed risk assessment when weaning Clonazepam medication
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.
North London
Concerns raised1
Failure of assessment protocols to require consideration of dissociation and psychosis risks and effects
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.
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
Require assessment of dissociation and psychosis, including consideration of self-harm and suicidality risks.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 March 2023.
Essex
Concerns raised1
Failure of risk assessments to capture key risk information before ward observation levels are reduced
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.7
Action
Revise observation recording documentation and add observation-level decision and audit requirements to assurance audits.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Introduce an Engagement and Observation Plan recording observation commencement, review, changes and discontinuation against patient risk.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Implement an electronic clinical dashboard showing recent clinical entries, current risk assessments and observation levels at handover.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Review the Trustwide Engagement and Supportive Observation Procedure to require MDT decisions informed by comprehensive risk assessment and documented care-plan rationale.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Configure risk-assessment documentation in Paris and Mobius to carry forward risk history while capturing newly identified risks.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Continue observation assurance monitoring through Tendable and observation-engagement audits, with weekly review of findings by the Inpatient Clinical Support Group.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023.
Action
Continue the adult inpatient record-keeping clinical audit covering current risk assessments, risk-management plans, MDT input, observation care plans and crisis plans.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023.
Liverpool and the Wirral
Concerns raised1
Failure of ambulance triage to assess presenting mental-health and self-harm risks
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.
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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.
