Recurring concern

Inadequate mental health risk assessment

First to latest report 3 Dec 2013 — 1 Jun 2026

Reports that mention this concern
118
Times this concern has been raised
135
Stated actions linked to this concern
234

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.

What is 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 and published responses 118 reports

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

  1. Avon

    AI-generated summary

    Maria STANCLIFFE-COOK · 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

    Maria STANCLIFFE-COOK was found dead on 1 August 2019 after intentionally taking her own life using helium, causing asphyxiation. The principal concern was that her suicide risk was downgraded from high to medium by members of the mental health team who had not previously dealt with her, followed by a brief telephone contact that did not include an assessment or plan to manage her risk.

    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 check risk assessments before downgrading a well-known patient’s suicide risk

    Wider context from the report

    “The trust have themselves admitted the failures reflected in an independent report they commissioned after the death, that report said “we would not expect a patients level of risk to be downgraded from high ... to medium immediately following a suicide attempt”; In addition I heard evidence in relation to the assessment on the 26th July 2019 when the risk was downgraded from high to medium. I listened very carefully to the steps that the Trust has taken to make changes following this death and I am pleased that a number of changes have taken place. I raised my concern about the downgrading of risk from high to medium in this case by two members of the team that had no previous dealings with Maria. Maria was well known to the trust and her own care coordinator said “We were concerned about the ongoing risk of completed suicide given she continued to be in possession of a helium bottle, the risk was not considered to have changed since my first meeting with her when the risk to self was recorded as high”. That was a reference to a multidisciplinary meeting which took place a matter of weeks before her death. I was told that risk is dynamic and that professionals assess risk at the time and that it can go up and down. I was also told that there are lots of assessments by staff that do not know patients. That said there is a concern that there is a risk of future death - is it right that the risk of a patient, who is well known to the trust, with a care coordinator who knew her well, is downgraded without any check put in place. ”

    Source location

    Maria STANCLIFFE-COOK · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Complete a full multi-professional review of autonomous working and safe patient care.

    Verbatim wording from the response

    “At the conclusion of the inquest held on 5 July 2021 you shared your concerns with regard to the downgrading of risk status by practitioners who had ‘no previous dealings with Maria’. We acknowledge your concerns alongside the recommendations made within the Niche report. Please be assured, we have completed a full multi-professional review to consider how we can ensure that our staff can continue to work in an autonomous manner whilst maintaining the safe care of patients as indicated within your Regulation 28 report. The implementation of learning from this is our absolute priority.”

    Source location

    2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
    Page 1 · response
    Published 9 July 2021

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    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 and implement the action plan supporting consistent application of systems, policies, procedures and guidelines.

    Verbatim wording from the response

    “We have updated and continue to work with the action plan shared during the inquest. We will continue to support staff, patients and carers to ensure that all systems, policy, procedures and guidelines are consistently and robustly implemented in practice.”

    Source location

    2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
    Page 1 · response
    Published 9 July 2021

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    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 the new care-plan and risk-supervision tool during monthly management supervision to audit records and address identified concerns.

    Verbatim wording from the response

    “A new care plan and risk supervision tool has been introduced as a means to support staff to audit their patient records through management supervision each month. The tool is more comprehensive than the Trust sample audit and is specific to risk assessment, management, crisis and contingency, formulation of care and how individual practitioners are meeting the standards as indicated within the tool.”

    Source location

    2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
    Page 2 · response
    Published 9 July 2021

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    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

    Develop a face-to-face training package on risk assessment and management, including suicidality, self-injury and complex behaviours.

    Verbatim wording from the response

    “A ‘task and finish group’ has also been formed to specifically develop a new face-to-face training package to address risk assessment and management including suicidality, self-injurious and complex behaviours. Again, this is a co-produced delivery group and to the training is expected to commence in the next couple of months.”

    Source location

    2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
    Page 2 · response
    Published 9 July 2021

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    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 the procured 4Mental Health training package, including co-produced safety plans, to an initial 60 staff members.

    Verbatim wording from the response

    “Earlier this year, the Trust procured the services of ‘4Mental Health’ to provide AWP staff with a training package to be delivered in September and October 2021. The training package is 3.5 days and will initially be delivered to 60 members of staff. This is anticipated to promote consistency and benchmark standards of competency, linking the research of Dr ████████. It specifically includes the co-production of Safety Plans. This training was identified to provide support to address the quality of risk assessments and care plans. These are areas of practice which have been recognised as thematic learning from investigations.”

    Source location

    2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
    Page 3 · response
    Published 9 July 2021

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    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

    Develop autism, risk-assessment and suicide-prevention guidance for the Clinical Toolkit and RiO Clinical Support.

    Verbatim wording from the response

    “Suicide prevention remains a key area of development and concern. We are particularly focussing on developing guidance for staff regarding autism, risk assessment and suicide prevention. These will form part of a Clinical Toolkit and RiO Clinical Support. Our Library Services have started sending out literature on suicide prevention so that staff are up to date with the latest research and thinking on suicide prevention.”

    Source location

    2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
    Page 3 · response
    Published 9 July 2021

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    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

    Hold a suicide-prevention workshop featuring specialist autism guidance on supporting people experiencing complex or suicide risk.

    Verbatim wording from the response

    “There is a quarterly Suicide Prevention Workshop held for Bristol services that hosts guest speakers, reviews identified literature and explores challenges in practice through break-out groups. The next workshop is in November 2021 and is hosting the Specialist Autism Team who are providing a presentation for staff on how to support individuals experiencing complex and/or suicide risk.”

    Source location

    2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
    Page 3 · response
    Published 9 July 2021

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    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

    Share learning from the circumstances of the death more widely with colleagues.

    Verbatim wording from the response

    “Please be assured that learning from the circumstances of this tragic death will also be shared more widely with colleagues.”

    Source location

    2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
    Page 4 · response
    Published 9 July 2021

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    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

    A policy change is not considered necessary because existing quality-improvement work addresses risk-assessment practice.

    Verbatim wording from the response

    “We will achieve this through; audit, governance and assurance across all levels of the Trust. We do not believe that a change of policy would support the quality improvement work that has commenced and is already being introduced into practice. Instead, the Trust is continuing to support the delivery of these commitments with the actions detailed below, to improve the understanding and application of risk assessment and ensure that practitioners are able to demonstrate a clear and informed decision making process whenever risk is assessed.”

    Source location

    2021-0235-Response-from-Avon-and-Wiltshire-Mental-Health-Partnership-NHS-Trust_Published
    Page 2 · response
    Published 9 July 2021

    Open published response

  2. Derby and Derbyshire

    AI-generated summary

    Hazel Ann Binks · 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

    Hazel Binks died on 14 January 2021 after placing a fastened plastic bag over her head, following earlier preparations to asphyxiate herself and leaving a farewell note. The principal concerns were that information about her suicidal thoughts was not passed from the GP practice administration to the GP, that the GP did not undertake a meaningful mental health or risk assessment, and that the practice’s internal review did not identify these issues.

    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 undertake meaningful mental health or risk assessments

    Wider context from the report

    “(2) Dr ████████ did not undertake any meaningful mental health or risk assessment during the consultation with Hazel. ”

    Source location

    Hazel Ann Binks · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Martin Gibbons · 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

    Martin Gibbons attempted to take his own life on 19 March 2020 and was taken to hospital, where he was assessed as needing admission to a psychiatric ward. While waiting for a bed, he left the hospital unobserved and was found dead on 24 March 2020; the inquest concluded suicide. Concerns included differing assessments of risk between acute and mental health trusts, the absence of shared risk assessments and care plans, and delays in obtaining a mental health bed.

    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 a shared definition of high-risk mental health patients between acute and mental health trusts

    Wider context from the report

    “1. During the course of the inquest evidence was heard that the acute and mental health trusts involved had assessed the level of risk he presented differently in part due to there being no shared definition of risk or the factors that triggered a patient being treated as high risk. The inquest heard that across the NHS there is in relation to mental health no shared definition between acute and mental health trusts of what constitutes a high risk patient. The two trusts involved in this inquest had since Mr Gibbon’s death identified that as an issue and work was underway between them to develop and implement a shared definition locally in the absence of any shared national definition. ”

    Source location

    Martin Gibbons · Prevention of Future Deaths report
    Page 3 · concerns

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    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 a triage assessment tool guiding emergency-department nurses toward appropriate pathways based on patient risk and presentation.

    Verbatim wording from the response

    “• The LMHT has now completed a joint piece of work with their ED colleagues at TGICFT. A triage assessment tool has been implemented which guides the triage nurse to consider the most appropriate pathway for the patient based on their risk/presentation at that time.”

    Source location

    2021-0166-Response-from-GMCA_Published.pdf
    Page 2 · response
    Published 24 May 2021

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a joint risk-assessment tool that stratifies risk and determines the level of emergency-department observation required.

    Verbatim wording from the response

    “• A joint risk assessment tool has now been implemented. This is initially completed by the triage nurse and guides them into rating the patient’s risk at that time in terms of high (red), medium (amber) and low (green). This then informs the level of observation required for the patient whilst in the ED.”

    Source location

    2021-0166-Response-from-GMCA_Published.pdf
    Page 2 · response
    Published 24 May 2021

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    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Embed a standard operating procedure across both organisations reflecting shared-care principles.

    Verbatim wording from the response

    “As an outcome of the investigation both trusts recognised the need to develop shared care principles and an agreed risk stratification/triage tool, including actions required should a person present to the emergency department (ED) who is considered a high risk to themselves. This document also needed to specify who is responsible for caring for the patient at given times when in the ED and include”

    Source location

    2021-0166-Response-from-GMCA_Published.pdf
    Page 1 · response
    Published 24 May 2021

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    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

    Risk assessments should be personalised rather than based on shared definitions or standardised tools, which are poor predictors of suicide or specific behaviour.

    Verbatim wording from the response

    “With regard to a shared definition of risk, evidence from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH)¹, as well as National Institute for Health and”

    Source location

    2021-0166-Response-from-Department-of-Health-Social-Care_Published.pdf
    Page 1 · response
    Published 24 May 2021

    Open published response

  4. Birmingham and Solihull

    AI-generated summary

    Azra Parveen HUSSAIN · 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

    Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.

    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 update risk screens after significant changes in presentation

    Wider context from the report

    “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs. ”

    Source location

    Azra Parveen HUSSAIN · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Monitor the trust’s ligature-risk and care-planning improvements through monthly leadership meetings and weekly progress reports.

    Verbatim wording from the response

    “Conditions were placed on the trust’s registration certificate by CQC following the inspection on 23 November 2020 which identified concerns in relation to ligature risks, risk assessment and care planning. The Trust has complied with our conditions and have been submitting monthly updates on their progress to replace doors and improve care planning. Inspectors have been meeting monthly with the trust leadership team to discuss the progress and improvements made to date. As a result of the meetings CQC has asked for weekly reports on the ward improvements programmes to understand ongoing mitigation whilst the replacement of en-suite doors is incomplete.”

    Source location

    2021-0082-Response-from-CQC-Redacted
    Page 4 · response
    Published 30 March 2021

    Open published response

  5. Inner West London

    AI-generated summary

    Valeria Munoz Biggs · 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

    Valeria Munoz Biggs died on 20 September 2019 after jumping in front of a train at Holland Park Underground Station while suffering agitated depression, possibly on the bipolar spectrum. The report identified concerns including underestimation of her suicide risk, inadequate engagement with and support for her family, missed planned visits, delayed psychiatric assessment, insufficient consideration of hospital admission, and treatment not in line with guidance.

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    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 assess suicide risk during the current treatment episode

    Wider context from the report

    “2. That the Trust staff need training in relation to assessment of suicide risk, how to engage with families and carers, not to use inappropriate personal comment to try and bolster the patient, how to provide support to families and carers, that risk needs to be assessed during the present treatment episode in order to mitigate suicidality at that particular point in time and in record keeping and updating. ”

    Source location

    Valeria Munoz Biggs · Prevention of Future Deaths report
    Page 3 · concerns

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    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 staff training in suicide risk assessment

    Wider context from the report

    “2. That the Trust staff need training in relation to assessment of suicide risk, how to engage with families and carers, not to use inappropriate personal comment to try and bolster the patient, how to provide support to families and carers, that risk needs to be assessed during the present treatment episode in order to mitigate suicidality at that particular point in time and in record keeping and updating. ”

    Source location

    Valeria Munoz Biggs · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. West Sussex

    AI-generated summary

    Christopher Swain · 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

    Christopher Swain, who was detained under Section 3 of the Mental Health Act 1983, was found unresponsive in his room at Langley Green Hospital on 22 September 2019 with a ligature around his neck and was confirmed deceased by paramedics. Concerns included inconsistent staff practices when conducting observations, uncertainty about when he was last seen alive, the absence of a formal mental health review, care plan and adequate risk assessment, inadequate record-keeping, no recorded therapeutic engagement, and failure to provide staff to accompany a sectioned patient to another hospital.

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    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 carry out adequate mental-health risk assessments

    Wider context from the report

    “a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not entering a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinced that it is clear as to what is required by staff. b) Following the evidence the Jury concluded:- (a) that during Christopher’s time at Langley Green Hospital no formal review, care plan or adequate risk assessment was carried out in respect of his mental health. (b) that the nursing and clinical records were not kept in accordance with the trust health and record policy. (c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher's short stay. Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case. c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hospital for treatment for a physical condition. Requesting family member to undertake this role puts the patient and/or the family at risk ”

    Source location

    Christopher Swain · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Review inpatient care plans, risk assessments and clinical documentation, and maintain compliance through audits and competency plans.

    Verbatim wording from the response

    “The absence of clinical documentation for Christopher during his admission to Langley Green Hospital was not completed to an expected standard in accordance with Trust Policy. The Trust therefore completed a review of professional conduct of all the staff involved in Christopher’s care through HR processes and made referrals to relevant Regulatory bodies. The Langley Green Hospital Leadership team and Trust took immediate action to prevent reoccurrence of any non-compliance with Trust Policy including an immediate review of all care plans, risk assessments and clinical documentation. This has been maintained through audit and competency plans. Feedback was given to the whole team by the Trust Deputy Chief Nurse due to the seriousness and the immediate requirement to reflect and improve.”

    Source location

    2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
    Page 3 · response
    Published 6 January 2021

    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 staff safety days with training on clinical risk assessment, professional responsibility, accountability and clinical curiosity.

    Verbatim wording from the response

    “Staff were supported with safety days which commenced in December 2019 with specific training on Clinical Risk Assessment which focusses on professional responsibility, accountability, and clinical curiosity.”

    Source location

    2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
    Page 4 · response
    Published 6 January 2021

    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

    Conduct daily risk-assessment, huddle and clinical-notes audits with Ward Manager oversight from senior leadership.

    Verbatim wording from the response

    “There have, since Christopher's death, been daily risk assessment audit, daily huddles as well as notes audits by Ward Managers with oversight by the senior leadership team. These audits demonstrate as of December 2020 there is 100% adherence to the training in quality record keeping.”

    Source location

    2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
    Page 3 · response
    Published 6 January 2021

    Open published response

  7. Inner South London

    AI-generated summary

    CLAIRE LILLEY · 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

    Claire Lilley was detained under the Mental Health Act and admitted to Avery Ward following a significant overdose. While on Section 17 overnight leave at home, she hung herself on 12 February and did not survive. The report identified diffuse risk information, no central risk formulation, and insufficient management cover to review risk as substantive concerns.

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    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 a centralised, formulated risk record

    Wider context from the report

    “(1) Individuals who are the subject of detainment under the Mental Health Act are risk assessed at numerous times. For those that are on Section 17 home leave, they are additionally assessed prior to leaving the ward on each occasion. In addition, risks are also reviewed on the regular multi-disciplinary ward rounds. (2) However, such assessments are not centralised in any one place – there is no central formulation. Reviews by any clinician would have to cover 3 or 4 different entries by way of example: the risk assessment page, the MDT notes, the psychology entries (although they, per se, do not enter risks assessments). (3) The Court’s expert confirmed that such a centralisation/ formulation (supported by the Route Cause Analysis report), would assist in reviewing an individual’s risk and allowing ward staff to see the wider input in one place. (4) Training has been implemented by the Trust to assist staff in formulating risk, a process that was in place at the time of Claire’s death. However, there is no central repository/formulation of the outcomes of those assessments. Different teams continue to use different tools; there is no stand-alone document. (5) Consideration should therefore be given to the creation of a centralised, formulated, risk document to be entered upon by all clinicians irrespective of their own speciality. ”

    Source location

    CLAIRE LILLEY · 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

    Introduce the Risk Assessment document as the central risk record and add a mandatory formulation summary that flows to the MDT template and inpatient care plan.

    Verbatim wording from the response

    “The Risk Assessment document will now be the centralised document for all professionals to document all risks immediately. To support, a new mandatory section will be added to the Risk Assessment document in RiO. This section will be a formulation summary. This summary will then automatically pull through to show on the MDT template and the inpatient care plan.”

    Source location

    2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
    Page 2 · response
    Published 8 January 2021

    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

    Reinforce that every professional must record identified risks immediately in the Risk Assessment document.

    Verbatim wording from the response

    “1. Reinforce that all professionals are responsible for taking ownership for updating the Risk Assessment document. This will address an over reliance by multi-professional teams (nurses, psychologists, occupational therapists etc) on Consultants to update the Risk Assessment document. This means that in addition to escalating risks to the Consultant that all professionals must document risks at the time they are identified. It means that all professionals will be constantly thinking about risks and updating the Risk Assessment document when things happen. This will give a much better and clearer picture of risk events rather than that which might be achieved a formulation alone.”

    Source location

    2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
    Page 2 · response
    Published 8 January 2021

    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

    Require each MDT meeting to decide risk, allocate responsibility for updating records, and update the Risk Assessment and associated care-plan management after identified risks.

    Verbatim wording from the response

    “4. A decision will be made about the risk at every MDT meeting. The MDT meeting will record as an action, who present at the MDT is going to update the risk assessment for a service user and then ensure that it is done. The allocated clinician will update the RiO Risk Assessment and associate management plan in the care plan for every risk identified after the MDT so it captures what was discussed and agreed.”

    Source location

    2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
    Page 3 · response
    Published 8 January 2021

    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

    Remove the Responsible Clinician’s policy responsibility and assign post-MDT risk-record updates to a professional allocated during the meeting.

    Verbatim wording from the response

    “5. To facilitate this we will remove from the current Risk Management Policy that it is the Responsible Clinician responsibility to ensure that a clinical risk assessment and clinical risk management plan is made before the decision is taken to discharge a person or grant leave. Currently the expectation is that the primary nurse does this but it is not working effectively when the primary nurse is not in the ward round. By making it the responsibility of a professional allocated at the time of the MDT meeting, the expectation that this happens immediately after the MDT meeting will ensure that the Risk Assessment document and associate management plan in the Care Plan is updated contemporaneously.”

    Source location

    2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
    Page 3 · response
    Published 8 January 2021

    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

    Require all clinicians to update the Risk Assessment whenever risk changes between MDT meetings.

    Verbatim wording from the response

    “6. If anything changes in the period between MDTs, as stated, all clinicians will be expected to exercise their individual responsibility to personally update the Risk Assessment.”

    Source location

    2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
    Page 3 · response
    Published 8 January 2021

    Open published response

    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 MDT template must remain separate from the Risk Assessment document because weekly meetings cannot realistically update and summarise risk.

    Verbatim wording from the response

    “2. Reinforce the use of the Multidisciplinary Team (MDT) template where all involved professionals are required to input their feedback ahead of an MDT meeting to include their actions about documented risks that they have identified and added to the Risk Assessment document. However this needs to remain separate to the Risk Assessment document as it is not realistic for the weekly MDT meeting to update, summarise and state what might improve or worsen the risk. Currently the MDT template is not being used as effectively as it could be in a meaningful way, evidenced by internal transfers and this is being addressed with teams to reduce the variation.”

    Source location

    2020-0297-Response-from-Oxleas-NHS-Foundation-Trust-Published
    Page 2 · response
    Published 8 January 2021

    Open published response

  8. East London

    AI-generated summary

    Trinder Kaur Birdi · 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

    Trinder Kaur Birdi had a history of depression and personality disorder and was assessed as at high risk of suicide after reporting two paracetamol overdoses. Following assessment by a psychiatric nurse, the risk was reduced to low and a non-urgent Community Mental Health Team referral was made; she was later admitted with acute liver failure and died from the likely effect of self-administered drug toxicity. The principal concern was that her suicide risk was downgraded without consultation with the general practitioner, a documented second opinion, or assessment by a psychiatric doctor, and that safeguards were absent in these circumstances.

    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 safeguard downgrading of suicide risk by staff unfamiliar with the patient

    Wider context from the report

    “The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional. It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance, such as a discussion with the referring general practitioner, second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor. ”

    Source location

    Trinder Kaur Birdi · 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

    Introduce referral to the on-call psychiatrist when presenting risk significantly differs from another clinician’s same-day assessment.

    Verbatim wording from the response

    “1. A requirement will be introduced for a referral to the on-call psychiatrist to be completed where the presenting risk is significantly different to that of another clinician (including GP) who has reviewed the patient on the same day.”

    Source location

    2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
    Page 3 · response
    Published 29 December 2020

    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

    Amend the Psychiatric Liaison Service assessment template to prompt documentation of concerns, protective factors and the risk management plan.

    Verbatim wording from the response

    “2. The assessment template used within the Psychiatric Liaison Service will be amended to prompt the documentation of the consideration given to concerns raised by friends/family/healthcare staff, protective factors and risk management plan.”

    Source location

    2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
    Page 3 · response
    Published 29 December 2020

    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

    Review Clinical Risk Advanced training to include differing clinical opinion scenarios and guidance on addressing them.

    Verbatim wording from the response

    “5. A review of the Clinical Risk Advanced level training to include case scenarios that indicate a difference in clinical opinion, and to reiterate guidance how to address these scenarios.”

    Source location

    2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
    Page 3 · response
    Published 29 December 2020

    Open published response

  9. North East Kent

    AI-generated summary

    PAUL HILLS · 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

    Paul Hills was found deceased at home in his garage on 24 April 2020 after suspending himself from a rafter. He had a history of post-traumatic stress disorder, reported episodes and dry runs of self-harm, and was receiving treatment. Concerns included inadequate risk assessment and care-plan updates, failure to document or share escalating risk information, insufficient planning for remote treatment during the COVID-19 pandemic, and limitations affecting local treatment and communication.

    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 update risk assessments when risk scores or behaviour change

    Wider context from the report

    “2. Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour. ”

    Source location

    PAUL HILLS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 risk assessment for virtual mental health appointments during service changes

    Wider context from the report

    “1. No risk assessment was completed on the issue of moving mental health appointments to virtual during the COVID-19 pandemic and how patients could be kept safe in the event of deterioration in his mental health. There was no plan in place for patients that required urgent assessment/review due to deterioration in their mental health. ”

    Source location

    PAUL HILLS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 document disclosures relevant to mental health risk

    Wider context from the report

    “4. His risk assessment was not up-to-date and his disclosures during April were not documented. ”

    Source location

    PAUL HILLS · 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

    Improve clinical record keeping to ensure care plans, risk assessments and clinical reasoning are documented clearly and electronically.

    Verbatim wording from the response

    “Sgt Hills’ risk was assessed by treating clinicians in Department of Community Mental Health, London, and as a result he was offered a face-to-face appointment. Following discussion with Sgt Hills, who was concerned about attendance in person, a telephone appointment was agreed as an alternative. We agree that the factors his clinicians considered in proceeding with telephone consultations should have been documented more clearly. Steps have now been taken to ensure better record keeping. This is covered in more detail below, in the response to your matters of concern 2 and 4.”

    Source location

    2020-0247-Response-from-MP-MOD-Redacted.pdf
    Page 2 · response
    Published 29 December 2020

    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

    Strengthen senior-clinician oversight of record-keeping quality and regularly review clinicians whose performance falls below the required standard.

    Verbatim wording from the response

    “More broadly, steps have been taken to ensure that Senior clinicians focus on the quality of record keeping and, should the performance of any treating clinician fall below the expected standard, that person’s performance will be reviewed regularly until the required quality is achieved. To support this, Defence Primary Healthcare is currently updating its guidance on the delivery of mental healthcare to ensure clinicians, Departments of Community Mental Health and Regions have the support they require and can be held to account for their adherence to clinical policy.”

    Source location

    2020-0247-Response-from-MP-MOD-Redacted.pdf
    Page 3 · response
    Published 29 December 2020

    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

    Introduce enhanced risk-management training for all Department of Community Mental Health clinical staff, including tools for recognising, assessing and managing mental-health risks.

    Verbatim wording from the response

    “On the issue of risk management, Defence Primary Healthcare is introducing enhanced risk management training for all Department of Community Mental Health clinical staff. This will be delivered by a recognised national provider and will be completed for all mental health clinicians by the end of March 2021. The training will provide best-practice tools to recognise, assess and manage risks for mental health and related matters.”

    Source location

    2020-0247-Response-from-MP-MOD-Redacted.pdf
    Page 4 · response
    Published 29 December 2020

    Open published response

    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 care plan was updated and risk levels were reviewed, contrary to the concern that neither had been updated as risk escalated.

    Verbatim wording from the response

    “Sgt Hills’ care plan was updated on a number of occasions and his risk levels were being reviewed. However, the records of this case were not to the standard expected. Sgt Hills’ initial care plan, dated October 2019, formed the basis for treatment. Within a Department of Community Mental Health, subsequent updating of the care plan is part of the overall treatment record, which clinicians document on a review/assessment template. On this template, there is a section for recording any updates to the care plan, or to confirm the extant care plan, as well as assessment of risks, clinical reasonings and any prescribed medication.”

    Source location

    2020-0247-Response-from-MP-MOD-Redacted.pdf
    Page 3 · response
    Published 29 December 2020

    Open published response

  10. Lincolnshire

    AI-generated summary

    Toby Peter Edward Nieland · 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

    Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

    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

    Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures

    Wider context from the report

    “5. Inadequate evaluation of the deceased's previous history; his purported non-concordance (repeated assertions of not wanting treatment/support that ought to have been interpreted as an increase in his risk); progression of his complex vulnerabilities; his personal circumstances (reaction to accommodation and relationships); events suggestive of on-going misuse of drugs - all gave rise to a missed opportunities to appreciate a series of acceptable relapse signatures; ”

    Source location

    Toby Peter Edward Nieland · Prevention of Future Deaths report
    Page 4 · 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

    Use a prompt system at every NSP visit to assess presentation, health, housing, harm reduction, substance use and treatment referrals.

    Verbatim wording from the response

    “• Our staff now use a ‘prompt system’ at each visit. These include discussions around the persons initial presentation, mental and physical health, housing needs, harm reduction, more in depth substance use and clarifying and discussing referrals into structured treatment should it be required and consented to.”

    Source location

    2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
    Page 2 · response
    Published 26 October 2020

    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 an enhanced NSP questionnaire to identify complex health issues and mental-health concerns, informing risk assessment and decisions.

    Verbatim wording from the response

    “• We have introduced better identification of those with complex health issues. We have implemented an enhanced standard questionnaire for our NSP service users. It incorporates questions to ascertain concerns individuals may have on their own mental health and current engagement with mental health (or any other relevant) services. The aim is to enable the key-worker to make better informed decisions of any immediate concerns / risks surrounding an individual’s mental health, based on presentation and information disclosed.”

    Source location

    2020-0164-Response-from-We-Are-With-You-charity_Redacted.pdf
    Page 2 · response
    Published 26 October 2020

    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

    Roll out revised suicide-prevention training covering history, accommodation, relationships and substance and alcohol misuse risk factors.

    Verbatim wording from the response

    “Learning from the tragic death of Mr Nieland, the Trust has taken steps to enhance the training offered to staff about assessing risk of suicide to reinforce the complex interplay of factors mentioned above including previous history, accommodation and employment needs, substance and alcohol misuse patterns and relationships. This revised suicide prevention training will be rolled out to all staff commensurate with their role and clinical responsibility, within the next 6-12 months.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 5 · response
    Published 26 October 2020

    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

    Review training and competencies to cover dual-diagnosis presentations, risk assessment and information sharing.

    Verbatim wording from the response

    “The Trust is committed to a review of the training provided to staff to ensure they are appropriately equipped with the knowledge and ability to care for patients with dual diagnosis. The Learning and Development Lead is working with Divisional staff to develop the appropriate training package, over the next 6-12 months.”

    Source location

    2020-0164-Response-from-Lincolnshire-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 7 · response
    Published 26 October 2020

    Open published response

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