Recurring concern

Inadequate mental health risk assessment

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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

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.

  1. Bedfordshire and Luton

    AI-generated summary

    Mark Daniel VAGNONI · 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

    Mark Daniel Vagnoni, who had paranoid schizophrenia and was on remand at HM Prison Bedford, was found hanging in his cell on 11 July 2016 and died two days later. Concerns included the arrangements for risk assessment and observation after an ACCT was opened, the accessibility of information about previous ACCTs in NOMIS, and the lack of Wing Transfer documentation containing relevant risk information.

    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

    Inability to carry out risk assessments with mental health input during patrol state

    Wider context from the report

    “1. The ACCT was opened during patrol state. The first review was planned the following morning. Apart from 30 minute observations and the information on NOMIS (which was scant) there was no ability to carry out a risk assessment with mental health input. It seems to me that prisoners are especially vulnerable during this patrol state period and greater observations and/or other strategies should be undertaken until the first review can take place. ”

    Source location

    Mark Daniel VAGNONI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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-based ACCT observation levels already account for increased night-state risk when full review and mental-health input are unavailable.

    Verbatim wording from the response

    “Prison Service Instruction 64/2011 Safer Custody states that the level of ACCT observations needs to be set on the basis of a consideration of the level of risk, and with particular regard to any factors which may increase risk, and this would include an inability to undertake a full ACCT case review with mental health input during the night state. National policy also states that observation levels must be clearly documented on the front cover of the ACCT document, with observations made at unpredictable times.”

    Source location

    2017-0286-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 27 November 2017

    Open published response

  2. Black Country

    AI-generated summary

    Melvin James and Anne-Marie James · 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

    Melvin James experienced psychotic symptoms, was admitted to hospital, and was discharged without planned psychiatric follow-up. On 8 March 2017, he fatally stabbed his sister, Anne-Marie James, injured his mother, and sustained fatal stab wounds himself. The principal concerns were missed communication about his continuing delusions, inadequate information-sharing with family, and the absence of formal referral or aftercare following discharge.

    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 incorporate relevant information into discharge assessment

    Wider context from the report

    “1. Evidence emerged during the inquest that by the time of his discharge on Friday 10th February 2017 and as far as the Hospital were concerned, they recorded he showed no evidence of mental illness. However, the Clinician who dealt with the discharge confirmed that he wasn’t aware of the conversation he had with his brother on the way to Wolverhampton where Mr James was still talking about his delusions including creatures transforming. Significantly, during the inquest he accepted, had he known this he would have formed the view that he was still unwell. ”

    Source location

    Melvin James and Anne-Marie James · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    Jonathan Anthony MEANEY · 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

    Jonathan Anthony Meaney took an overdose on 13 March 2017 and was assessed at hospital, where inpatient treatment was recommended but no bed was found. He was discharged on 15 March after expressing a wish to leave and took his own life the following day; his medical cause of death was morphine and alcohol toxicity. Concerns included the prolonged wait for a bed, aspects of the pre-discharge mental health assessment, lack of consultation with another team member, and uncertainty about whether a proposed GP referral was made.

    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 reconcile and challenge contradictory suicide-risk information

    Wider context from the report

    “2. When the mental nurse assessed Mr Meaney before discharge on Wednesday, 15 March, he did not question Mr Meaney’s assertion that he had not intended to take an overdose two days before. This was despite the fact that Mr Meaney had told the assessing doctor that he had been trying to kill himself and he had written notes of intent. ”

    Source location

    Jonathan Anthony MEANEY · 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

    Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.

    Verbatim wording from the response

    “It follows that the Matters of Concern will need to be addressed substantively by CANDI, which we note has received your Prevention of Future Deaths Report. We understand that CANDI are undertaking a Serious Incident investigation and we are committed to working closely with CANDI, as necessary, to assist them in completing this investigation, developing and implementing an action plan to prevent similar incidents in future and to otherwise assist them in preparing their response to your Prevention of Future Deaths Report. Additionally, we have asked to be provided with copies of CANDI’s final Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately.”

    Source location

    2017-0244-Response
    Page 1 · response
    Published 1 October 2017

    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

    CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.

    Verbatim wording from the response

    “We have carefully considered the Matters of Concern, all of which relate to care that was delivered by the Camden & Islington NHS Foundation Trust’s Mental Health Liaison service, based within the Royal Free Hospital Emergency Department. The staff working within the Mental Health Liaison service are employed by the Camden & Islington NHS Foundation Trust (“CANDI”), not this Trust (the Royal Free London NHS Foundation Trust), and CANDI manage the Mental Health Liaison service. If a patient attending the Trust’s Emergency Department is considered to have a mental health problem (pertinent to the attendance) or requires a mental health assessment, they are referred to the Mental Health Liaison service, which will then assess the patient and take responsibility for referring onwards to either CANDI’s inpatient facilities or another mental health trust, as appropriate.”

    Source location

    2017-0244-Response
    Page 1 · response
    Published 1 October 2017

    Open published response

  4. Central Hampshire

    AI-generated summary

    Michael Folley · 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

    Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.

    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 complete SASH forms for risk information emerging outside current court detention

    Wider context from the report

    “I was also left with a concern that GEOAmey staff would only complete a SASH form if the current risk was identified during Mr Folley’s detention at Portsmouth magistrates’ court and not if anything came to the attention of the court detention officer to indicate there was a risk of self-harm or suicide within the last month before arrest. ”

    Source location

    Michael Folley · Prevention of Future Deaths report
    Page 5 · 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 the next custody newsletter to reinforce PER completion, inspection, warning-page, envelope, risk-marker and external-information responsibilities.

    Verbatim wording from the response

    “Force Custody publishes a quarterly newsletter to all custody officers and detention officers. The next publication is due in September 2019 and will reinforce the issues addressed in this Regulation 28 Notice.”

    Source location

    2019-0230-Response-by-Hampshire-Constabulary
    Page 2 · response
    Published 18 July 2019

    Open published response

  5. City of London

    AI-generated summary

    Charlotte Anne Agnew · 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

    Charlotte Anne Agnew became psychiatrically unwell and expressed suicidal ideation. After referrals to psychiatric services, her care was not effectively transferred, her suicide risk was not sufficiently assessed or managed, and no care plan was put in place; she died on 25 March 2016 after ingesting high levels of alcohol and medication and jumping in front of a London Underground train. The report identified an ongoing risk that similar failures in timely assessment, treatment, care transfer and suicide-risk management could recur.

    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 assessment of patients’ risk of suicide

    Wider context from the report

    “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were: (1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge. (2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide. (3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge. (4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness. (5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016. I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance. Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise). Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised. In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives. ”

    Source location

    Charlotte Anne Agnew · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Preston and West Lancashire

    AI-generated summary

    Stephen McDermott · 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

    Stephen McDermott was found deceased at home on 25 May 2015, having died sometime earlier as a result of the intentional application of a ligature; the inquest recorded the medical cause of death as hanging and concluded suicide. In the preceding months, he had presented repeatedly after overdoses and being recovered from train tracks, but was discharged without mental health follow-up. The principal concerns included fragmented and poorly used records, incomplete assessments and record keeping, insufficient consideration of overlapping mental health and substance misuse issues, missed opportunities for face-to-face assessment, limited information sharing between services, and an incomplete incident review.

    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 complete mental health and suicide risk assessments

    Wider context from the report

    “3) There was evidence of poor training with regards to incomplete assessments and poor record keeping. In respect of the telephone call from the GP to ████████ at the SPOA on 16 March 2015, there is no evidence in the records to evidence that ████████ asked any questions regarding Mr McDermott’s mental health, despite the fact that the GP was requesting referral into services for a mental health assessment. There is no evidence that ████████ followed the ‘Storm’ guidance (guidance that had not been disclosed at the inquest) to assess suicide risk factors or mental health issues. His evidence was that he would have asked the relevant questions but just did not document the responses, but I found on the balance of probabilities that the questions had not been asked; ”

    Source location

    Stephen McDermott · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Buckinghamshire

    AI-generated summary

    JACK OLIVER PORTLAND · 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

    Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

    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 obtain and update patients’ risk history and assessment

    Wider context from the report

    “(4) Whilst evidence from Whiteleaf indicated they were very used to receiving patients with little or no history and assessing them, the evidence in this case indicated that they had taken across the risk assessment from the Dene Hospital on transfer, that this had not been updated during Mr Portland’s time at Whiteleaf and that Whiteleaf did not appear to have taken any steps to identify and procure any earlier history in relation to Mr Portland’s time at HMP Woodhill. It was acknowledged in evidence that knowledge of risk of self-harm recorded in the HMP Woodhill ACCT documents would have been helpful. ”

    Source location

    JACK OLIVER PORTLAND · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Manchester South

    AI-generated summary

    Rachel Morgan · 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

    Rachel Morgan, who had post-natal depression with psychotic symptoms and was considered at high risk of suicide, was found with a ligature around her neck on 16 April 2016 and died from severe anoxic brain injury on 24 April 2016. The principal concerns were delays in reviewing her medication, failures to update risk assessments after information about her suicide risk was received, insufficient observation levels, and a lack of clarity about observation procedures.

    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

    Over-reliance on inpatient status as a protective factor in suicide risk assessment

    Wider context from the report

    “(5) As the Serious Incident Review highlighted, I am also concerned that staff at the Medlock Ward placed an over-reliance on the fact that Rachel was an inpatient as a protective factor. The evidence I have heard confirms the findings of the SIR that during her time on the Medlock Ward Rachel’s feelings of hopelessness and constant thoughts of self-harm did not reduce during her time and although her means for ending her own life were reduced, they were not entirely removed. There was evidence available to nursing staff that could indicated that Rachel was still thinking about ending her life whilst an inpatient and was considering the means that would allow her to do so. The jury have found that this was not adequately addressed by implementing enhanced observations. ”

    Source location

    Rachel Morgan · 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 conduct full self-harm and suicide risk assessments after concerning incidents

    Wider context from the report

    “(2) I am concerned that on 2 occasions matters came to the attention of the nursing staff that gave them cause for concern regarding Rachel’s risk of self-harm/ suicide and that neither of these incidents generated a full risk assessment to be conducted. Those incidents were the incident with the Nicorette Inhalator on the 14th April 2016 and the phone call from Rachel’s mother on the 15th April 2016. ”

    Source location

    Rachel Morgan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Mid Kent and Medway

    AI-generated summary

    Natalie Gray · 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

    Natalie Gray died after leaving Priority House, where she was an informal patient, and jumping in front of a train at Barming railway station on 21 April 2015. The principal concerns included insufficient risk assessments, inadequate handovers and failures in procedures for informal patient leave, communication of risk, recording third-party information and reporting her absence to police.

    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

    Ambiguous terminology in required mental health risk assessments

    Wider context from the report

    “(3) Kent Police and Kent & Medway NHS & Social Care Partnership Trust have agreed a Missing Person Procedure implemented 1st December 2015. There is a concern about the terminology for use in the risk assessment that the Mental Health Trust is required to complete which may lead to an inaccurate risk assessments. There appears to be no explanation as to whether the risk is that formally documented, or the risk at the time the patient left the facility which may be less clear. Additionally the use of the term 'significant' is highly subjective, is it intended to mean a likely risk of self harm or something more. It is not clear how the Trust should deal with those likely to place themselves in danger and therefore at medium risk of self harm, in terms of the timescales involved and whether 999 should be used or not. By way of example, Natalie's documented risk was inaccurately recorded as low, when it should have been medium and on leaving the facility medium to high, this could lead to an underestimation of the risk of self harm depending on how the form is interpreted by staff. ”

    Source location

    Natalie Gray · Prevention of Future Deaths report
    Page 3 · 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

    Transform clinical risk assessment and management, including new training and electronic risk-assessment documentation.

    Verbatim wording from the response

    “The strategy recognised that those with a diagnosed Personality Disorder are at a higher risk, and therefore require priority due to being in this high risk group. There is work underway in line with this to transform clinical risk assessment and management, both in practice and recording, with new training in place, and new risk assessment documentation about to come onto our electronic clinical record system for general”

    Source location

    2017-0003-Response-by-Kent-and-Medway-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    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 the newly reviewed Trust risk policy and risk summary form across the organisation.

    Verbatim wording from the response

    “In January 2017 the Trust launched a newly reviewed risk policy and risk summary form, this is currently being implemented Trust-wide.”

    Source location

    2017-0003-Response-by-Kent-and-Medway-NHS-Trust
    Page 3 · response
    Published 19 February 2017

    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

    Audit the quality of risk assessments as part of implementing the new Risk Summary.

    Verbatim wording from the response

    “We have changed our approach to testing practice in relation to risk assessment. As part of the programme for implementation of the new Risk Summary, auditing is focused on quality of the risk assessment rather than just the percentage of risk assessments completed.”

    Source location

    2017-0003-Response-by-Kent-and-Medway-NHS-Trust
    Page 3 · response
    Published 19 February 2017

    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

    Issue Trust-wide compliance bulletins and reminders specifying terminology for missing-person risk assessments.

    Verbatim wording from the response

    “• A compliance bulletin and reminders across the whole Trust, specifying terminology to be used.”

    Source location

    2017-0003-Response-by-Kent-and-Medway-NHS-Trust
    Page 4 · response
    Published 19 February 2017

    Open published response

  10. Greater Manchester (North)

    AI-generated summary

    Thomas Martin Gallagher · 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

    Thomas Martin Gallagher, aged 16, died by hanging after leaving home on 10 July 2015 and being found suspended from a tree in a nearby park the following morning. The report identified concerns about police handling of the missing-person call, including 14 unexplained delays, failure to allocate the incident or contact the family during the initial hour, inadequate staffing, and failures to follow relevant procedures.

    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 adequately recognise the significance of complex mental health issues in risk assessment

    Wider context from the report

    “It was clear from the initial ‘1-12’ and the additional information recorded by the call taker within FWIN 0405 that Tom was not only vulnerable by virtue of his age but also due to the fact that he had complex mental health issues, the significance of which was arguably understated as a result of point 1 above. It was accepted during the course of the evidence that the ‘1-12’ had been an initial assessment of risk only. ”

    Source location

    Thomas Martin Gallagher · 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

    Deliver vulnerability, mental-health and suicide-prevention training for Operational Communications Branch staff, including professional-curiosity, safeguarding and child mental-health content.

    Verbatim wording from the response

    “The Target Operating Model contains the guiding principles for GMP, expressly highlighting vulnerability as a priority. In line with this principal, and following ratification by the Organisational Learning Board, the Operational Communications Branch (OCB) has implemented a programme of staff training. The emphasis within this training is on developing professional curiosity to recognise, identify and respond to vulnerability and ensure effective steps are taken to safeguard the vulnerable through mitigation of risk.”

    Source location

    Thomas-Gallagher-Response
    Page 1 · response
    Published 11 August 2016

    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

    Develop a business case for posting two mental-health professionals to the Operational Communications Branch during key demand periods.

    Verbatim wording from the response

    “In addition to this, GMP is developing a business case to have two mental health professionals posted to the OCB during key demand times to professionalise the Police response to mental health calls by identifying high risk incidents and speaking directly with callers to seek more relevant information, ensuring a commensurate response is directed, better assisting the person in need.”

    Source location

    Thomas-Gallagher-Response
    Page 2 · response
    Published 11 August 2016

    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, launch, disseminate and apply the FWIN Escalation Policy with defined responsibilities, risk assessment, escalation, resourcing and delay-recording requirements.

    Verbatim wording from the response

    “The FWIN Escalation Policy has been reviewed by the OCB Senior Leadership Team (SLT) to include clearly defined roles and responsibilities for all OCB staff. The reviewed policy was prepared in June 2016 with a formal launch across Force in August 2016.”

    Source location

    Thomas-Gallagher-Response
    Page 2 · response
    Published 11 August 2016

    Open published response
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Data last updated 7 September 2026