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 North London
Concerns raised1
Failure to explore potential triggers for disclosed suicidal thoughts
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.
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, approve and implement a revised first-night mental-health risk assessment with staff training, SystmOne integration and advisory clinical-judgement guidance.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2016.
Birmingham and Solihull
Concerns raised1
Failure to undertake a formal suicide and overdose risk 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.
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
Issue a formal practice alert reinforcing suicide-risk, medicines-management and safe-medication-administration requirements, with staff acknowledgement.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 July 2016.
Action
Establish a Clinical Risk Management Group addressing risk-management training, suicide prevention and crisis-care-plan implementation.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 July 2016.
Action
Review the Medicines Code and supporting staff guidance to address medication-administration and risk-assessment issues, and report through internal governance.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 July 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust is responsible for addressing concerns about medication access, risk assessment and staff recognition of available drugs.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Eastern)
Concerns raised1
Failure of the IAPT risk assessment tool to record less threatening levels of risk and deterioration over time
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 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 existing IAPT risk-assessment system is considered sufficient, so the service decided not to adopt the alternative Columbia scale.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Central Hampshire
Concerns raised1
Failure to carry out proper risk assessments before discharge
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 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
Communicate through RCA learning events that risk assessments must occur before discharge.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 January 2016.
Inner West London
Concerns raised1
Failure to complete or appropriately document mental health team risk assessments
This report raised 4 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.
Cumbria
Concerns raised1
Failure of psychiatric assessments to recognise mental disorder and suicide risk
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.
West Sussex
Concerns raised1
Lack of staff awareness of relevant mental health policies
This report raised 4 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
Load a shortcut to SASH policies onto Psychiatric Liaison staff computers.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 May 2015.
Action
Make the SASH translation-services policy mandatory reading for staff working at East Surrey Hospital.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 May 2015.
Inner North London
Concerns raised2
Failure to ask patients about thoughts of suicide
Failure to ask patients about thoughts of harming another person
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 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
Pilot the mental health assessment proforma and make it available to mental health colleagues.
Stated by Whittington Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The triage assessment was recorded electronically, including the patient’s arrival, assessment, police attendance and high risk of self-harm.
Stated by Whittington Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Wiltshire and Swindon
Concerns raised1
Failure to record information obtained from mental health patients, including perceived risk and assessment urgency
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 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.4
Action
Implement the College of Emergency Medicine mental health risk assessment tool for ED suicide and self-harm risk assessment and urgency documentation.
Stated by Salisbury NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 February 2015.
Action
Implement a mental health referral proforma to record risk, assessment timeframe, accepting practitioner and agreed actions for out-of-hours referrals.
Stated by Salisbury NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2015.
Action
Incorporate the mental health referral proforma into the upgraded ED electronic system for electronic transfer and storage by the end of 2015.
Stated by Salisbury NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2015.
Action
Conduct a joint root cause analysis with Salisbury District Hospital and the Armed Forces, including review of relevant policies and procedures.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Further advice on the specific concerns cannot be provided because Public Health England is not in a position to advise further.
Stated by Public Health EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Department of Health, Ministry of Defence and NHS England will address the specific concerns through their ongoing discussions.
Stated by Public Health EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The mental health providers named in the report are expected to comment on the particular case and address concerns locally.
Stated by Public Health EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local mental health providers are expected to address the specific case and concerns from their local perspective.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
Failure to undertake risk assessments specific to suicidal ideation
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.
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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.
