Recurring concern
Inadequate mental health risk assessment
- 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 118 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
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.
Linked response
- Coventry and Warwickshire Partnership NHS Trust
Stated actions 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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Coventry and Warwickshire Partnership NHS Trust
Conduct daily electronic environmental audits, address identified hazards, and escalate matters requiring Estates intervention.
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Coventry and Warwickshire Partnership NHS Trust
Implement a multidisciplinary, formulation-based safety and risk assessment framework that explicitly considers impulsivity and related risk factors.
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Coventry and Warwickshire Partnership NHS Trust
Provide training supporting formulation-based risk management, professional curiosity, multidisciplinary collaboration, and information triangulation.
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Coventry and Warwickshire Partnership NHS Trust
Monitor risk-assessment quality through ward management audits and additional Matron-led assurance audits using the AMaT system.
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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.
Linked response
- Hywel Dda University LHB
Stated actions 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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Hywel Dda University LHB
Use comprehensive assessment and referral-support tools to prompt multi-source information gathering, collateral enquiries and documentation of information sources.
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Hywel Dda University LHB
Continue delivering WARRN training across mental health services on multi-source assessment, professional curiosity, collaborative risk management and safety planning.
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Hywel Dda University LHB
Work with police colleagues to strengthen understanding and use of Pembrokeshire police handover processes so relevant information reaches assessing clinicians.
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Hywel Dda University LHB
Strengthen duty-practitioner expectations so urgent assessments include seeking necessary collateral information beyond analysing information presented.
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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Hywel Dda University LHB
Implemented, immediate and ongoing safety work collectively addresses the identified risk-assessment concerns.
-
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.
Linked response
- Warwickshire County Council
Stated actions 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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Warwickshire County Council
Deliver phased, mandatory Tier 2 practitioner training to identified Children and Families staff, with refreshers and ongoing training for new starters.
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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Warwickshire County Council
Tier 2 practitioner training will be phased over three years because financial considerations and workforce capacity constrain faster implementation.
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Warwickshire County Council
Mandatory completion of universal suicide-awareness training across the Council remains subject to further corporate agreement.
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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.
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.
Linked response
- Essex Police
Stated actions 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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Essex Police
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.
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Essex Police
Develop Mental Health Risk Management Briefings to bring relevant agencies together to manage risks involving people experiencing mental ill health.
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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.
Linked response
- NHS England
Stated actions 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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NHS England
Publish national best-practice guidance promoting proactive involvement of trusted others in safety assessment and management.
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NHS England
Launch nationally available e-learning training complementing the suicide-safety guidance for mental health practitioners.
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NHS England
Share draft personalised-care guidance with Integrated Care Boards on involving families, carers and support networks in care and safety planning.
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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NHS England
Published suicide safety guidance clarifies national expectations for proactively involving trusted others in safety planning.
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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.
Linked response
- South London and Maudsley NHS Foundation Trust
Stated actions 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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South London and Maudsley NHS Foundation Trust
Participate in the national Culture of Care Programme pilot on personalised approaches to suicide risk.
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South London and Maudsley NHS Foundation Trust
Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.
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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.
Linked response
- Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Stated actions 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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Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Roll out a redesigned mental-health risk assessment and management training programme incorporating perinatal risks.
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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.
Linked response
- Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Stated actions 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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Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Deliver bespoke risk-management training sessions to community mental health teams, including Andover.
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Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Develop a standardised organisation-wide mental-health risk-management training programme.
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Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Roll out the standardised risk-management training programme using a train-the-trainers approach followed by full staff delivery.
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Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Standardise community mental health risk-assessment compliance auditing through a revised Quality Assurance Tool.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026