Recurring concern
Inadequate mental health risk assessment
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Request correctionFirst reported 3 Dec 2013•Latest report 1 Jun 2026
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
- Individual concerns
- 135
- Date range
- 2013–2026
- Stated actions
- 234
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to ensure staff understand Section 17 Leave requirements and conduct required risk assessments
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to proactively assess a wider range of swallowable items for patients at persistent risk of impulsive ingestion
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Conduct daily electronic environmental audits, address identified hazards, and escalate matters requiring Estates intervention.
Stated by Coventry and Warwickshire Partnership NHS Trust -
Action
Implement a multidisciplinary, formulation-based safety and risk assessment framework that explicitly considers impulsivity and related risk factors.
Stated by Coventry and Warwickshire Partnership NHS Trust -
Action
Provide training supporting formulation-based risk management, professional curiosity, multidisciplinary collaboration, and information triangulation.
Stated by Coventry and Warwickshire Partnership NHS Trust
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Action
Monitor risk-assessment quality through ward management audits and additional Matron-led assurance audits using the AMaT system.
Stated by Coventry and Warwickshire Partnership NHS Trust
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Concerns raised1
Over-reliance on referrer-provided information in mental health risk assessments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Use comprehensive assessment and referral-support tools to prompt multi-source information gathering, collateral enquiries and documentation of information sources.
Stated by Hywel Dda University LHB -
Action
Continue delivering WARRN training across mental health services on multi-source assessment, professional curiosity, collaborative risk management and safety planning.
Stated by Hywel Dda University LHB -
Action
Work with police colleagues to strengthen understanding and use of Pembrokeshire police handover processes so relevant information reaches assessing clinicians.
Stated by Hywel Dda University LHB
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Action
Strengthen duty-practitioner expectations so urgent assessments include seeking necessary collateral information beyond analysing information presented.
Stated by Hywel Dda University LHB
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Implemented, immediate and ongoing safety work collectively addresses the identified risk-assessment concerns.
Stated by Hywel Dda University LHB
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Concerns raised1
Failure to directly ask about suicidal ideation when suicidal thoughts are indicated in referral information
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Deliver phased, mandatory Tier 2 practitioner training to identified Children and Families staff, with refreshers and ongoing training for new starters.
Stated by Warwickshire County Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Tier 2 practitioner training will be phased over three years because financial considerations and workforce capacity constrain faster implementation.
Stated by Warwickshire County Council
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Position
Mandatory completion of universal suicide-awareness training across the Council remains subject to further corporate agreement.
Stated by Warwickshire County Council
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Concerns raised1
Failure to undertake and document mental state examinations and risk assessments before granting ward leave
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to seek clarification of changed welfare circumstances
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 concernsEach 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
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Action
Train Contact Management staff in Right Care, Right Person, incident recording, National Decision Model, THRIVE, escalation and supervisory requirements through recruit and continuing-development programmes.
Stated by Essex Police -
Action
Develop Mental Health Risk Management Briefings to bring relevant agencies together to manage risks involving people experiencing mental ill health.
Stated by Essex Police
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Concerns raised1
Lack of clear guidance and protocols for clinicians to seek and include family or other relevant views in care and safety planning
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 concernsEach 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
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Action
Publish national best-practice guidance promoting proactive involvement of trusted others in safety assessment and management.
Stated by NHS England -
Action
Launch nationally available e-learning training complementing the suicide-safety guidance for mental health practitioners.
Stated by NHS England -
Action
Share draft personalised-care guidance with Integrated Care Boards on involving families, carers and support networks in care and safety planning.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Published suicide safety guidance clarifies national expectations for proactively involving trusted others in safety planning.
Stated by NHS England
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Concerns raised1
Failure to recognise and assess an identified suicide risk
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 concernsEach 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
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Action
Participate in the national Culture of Care Programme pilot on personalised approaches to suicide risk.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.
Stated by South London and Maudsley NHS Foundation Trust
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Concerns raised1
Linear approach to mental health risk assessment and formulation
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Roll out a redesigned mental-health risk assessment and management training programme incorporating perinatal risks.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust
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Concerns raised1
Failure to complete formal risk assessments in accordance with policy
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 concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Deliver bespoke risk-management training sessions to community mental health teams, including Andover.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Develop a standardised organisation-wide mental-health risk-management training programme.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Roll out the standardised risk-management training programme using a train-the-trainers approach followed by full staff delivery.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust
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Action
Standardise community mental health risk-assessment compliance auditing through a revised Quality Assurance Tool.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Data last updated 7 September 2026