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 South London
Concerns raised1
Failure to properly assess suicidal symptoms and risks before discharge
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.
Manchester North
Concerns raised1
Failure to provide Approved Mental Health Practitioners with full information about relevant mental-health contacts
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.3
Action
Consider the effectiveness of current information-sharing arrangements with partners and brief the Greater Manchester Health and Justice Board on the concerns raised.
Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 8 April 2020.
Action
Develop and implement a common, documented GMP-wide procedure with partners for responding to mental-health-related risk to life presented to blue-light services.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 8 April 2020.
Action
Jointly chair a pan-Greater Manchester task and finish group improving risk assessment, management, inter-agency communications and procedures for mental health crisis responses.
Stated by North West Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 April 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The relevant incidents were not coded as mental-health or safeguarding concerns, so there was no requirement to refer them to the CRT.
Stated by Greater Manchester PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South London
Concerns raised1
Failure to complete assessment sufficient to identify mental health diagnosis requiring treatment
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.2
Action
Strengthen community mental-health assessment oversight, including further face-to-face assessment where diagnoses differ and monthly quality audits.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
Action
Conduct reflective-practice sessions focused on assessment, risk documentation, record keeping and formulation, with impact monitoring.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
East London
Concerns raised1
Failure to elicit relevant information from first responders during assessment
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.
Inner North London
Concerns raised1
Failure to ask Crisis Line callers about current suicidal feelings
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
Provide crisis-line clinicians with training on risk-assessment competencies and required medical-record standards.
Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019.
Manchester City
Concerns raised1
Failure to obtain a broad assessment by an experienced psychiatrist
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.1
Action
Review all Choice assessments in a weekly multidisciplinary team meeting to support shared outcome decisions.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Systems and processes introduced since 2017 are considered sufficient to address the overall position and psychiatry concern.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised2
Failure to provide material arrest information for mental health assessments in custody
Failure to attempt timely assessment after a high-risk patient re-establishes contact
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.9
Action
Implement CONNECT access for Liaison and Diversion staff, including wider custody information and nursing read-write risk recording.
Stated by Black Country Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2019.
Action
Raise the report’s outcome and learning with police through quarterly Joint Operational Group meetings, stressing full handover before every assessment.
Stated by Black Country Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Develop a joint operating protocol with the Sandwell Liaison and Diversion Service for custody-based patient assessment.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Work with police forces to ensure liaison and diversion practitioners receive relevant arrest and presentation information.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Hold a national event to debrief information-sharing issues and share lessons with liaison and diversion practitioners, commissioners and police representatives.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Support development of the Connect police IT system and liaison and diversion functionality to improve custody information access.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2019.
Action
Provide information-sharing training to liaison and diversion teams and offer it to police healthcare providers.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 July 2019.
Action
Increase Home Treatment Team workforce capacity through additional managers, practitioners, medical staff, psychologists and administrative staff.
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 26 July 2019.
Action
Review the Home Treatment Team operating protocol to strengthen nurse-led triage, assessment screening and escalation to consultant psychiatrists.
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 26 July 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
Other concerns concerned NHS bodies and services not provided by the respondent, so the respondent did not comment on those outcomes.
Stated by Black Country Healthcare NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
The existing custody record and available information access adequately inform Liaison and Diversion assessments, so no future-death risk exists.
Stated by West Midlands PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
An adequate system records arrest circumstances and gives Liaison and Diversion practitioners access to relevant custody information.
Stated by West Midlands PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
No action is required because the existing system addresses the identified risk in this case.
Stated by West Midlands PoliceNo action considered necessaryThe respondent said that no further action was needed.
Position
Local NHS agencies are expected to address the report’s local concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Care and treatment concerns are largely for provider organisations to resolve.
Stated by NHS Birmingham and Solihull Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Bedfordshire and Luton
Concerns raised1
Poor appreciation of the likely risks of non-compliance with treatment linked to Community Mental Health Treatment Orders
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The local NHS is responsible for reviewing the case circumstances and taking necessary action to ensure services are safe and high quality.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Bedfordshire and Luton
Concerns raised1
Failure of staff to understand and apply risk assessment training
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.2
Action
Maintain additional risk-assessment training for staff following the Serious Incident Review.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2019.
Action
Deliver further Bedfordshire crisis-service training on risk assessment and suicide prevention.
Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2019.
Brighton and Hove
Concerns raised2
Failure to consider relevant substance use and suicide risk before prescribing Concerta
Failure to obtain sufficient details of a reported suicide attempt
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
Establish a senior medical decision-making group to review ADHD assessment, diagnosis, questionnaire use and prescribing practice.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 May 2019.
Action
Publish a Patient Safety Matters story covering the case and issues surrounding co-morbid substance misuse.
Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 May 2019.
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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.
