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. Northamptonshire

    AI-generated summary

    Jane Marie Clark and Isobel Griffin · 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

    Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature risk.

    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 update risk assessments with emerging risks

    Wider context from the report

    “Re Jane Marie Clark 1. The very challenging events of the previous evening and that morning do not appear to have been handed over and the nurse in charge did not read the notes before granting leave. Her risk assessment then was ill informed. It was not discussed with anyone nor properly documented. 2. She did not place any boundaries on the leave for example providing a time by which Jane was to return. 3. Risk assessment documentation generally was poor and appeared perfunctory. Re Isobel Griffin 1. Mrs Griffin was admitted on 1 August and was not allocated a key worker until 8th August. The key worker did not read the notes so was not aware of the events of the 7th. 2. The risk assessment was not updated with the events of the 7th. 3. Mrs Griffin’s responsible clinician saw her on only one occasion on 14 August 2013 at which time he did not read the notes so he was unaware of events on the 7th when she handed in a belt and scissors and said she had 3-4 times tried to hang herself using a ligature. 4. A planned review of medication, diagnosis and treatment never took place despite a number of references in the notes to it from 6 August 2013. Mrs Griffin had been substantially unmedicated for most of the admission despite concerns expressed by her family. 5. On 11 August Mrs Griffin started to express thoughts to harm others. These thoughts distressed her. She did not intend to act on them but they were something new and a measure of her distress. These thoughts and their significance were not included in any risk assessment. 6. A risk assessment concluded on the 18th, the day after she had hanged herself on the ward, purports to be made with her agreement. It was evidence that risk assessment documentation is cut and pasted rather than reflecting the true circumstances. 7. The doors do not appear to be ligature proof and little was made available by way of evidence as to what measures would now be taken to minimise this risk. ”

    Source location

    Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. South Yorkshire (Western)

    AI-generated summary

    Alexander Matthew Holt · 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

    Alexander Matthew Holt had a history of serious self-harm attempts and died by an impulsive but deliberate act after taking an overdose that was not communicated to staff supervising his accommodation. The concerns included failure to provide intended treatment, failure of a referral process, lack of continuity and information-sharing, and insufficient consideration of risk, including that accommodation staff were unaware of his recent overdose.

    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 challenge minimised or concealed suicidal intent and account for parental fears

    Wider context from the report

    “(1) The prospect that Mr Holt was minimising or concealing the true extent of his suicidal intent should have been subject to a greater degree of challenge and his parent's fears in this regard should have carried more weight ”

    Source location

    Alexander Matthew Holt · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. County Durham and Darlington

    AI-generated summary

    Jeffrey Gash · 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

    Jeffrey Gash died after hanging himself on 30 September 2013, following contacts with his GP and the Crisis Team while reporting that he was feeling worse and hearing voices. The concerns included insufficient telephone assessment and exploration of his symptoms, failure to arrange or escalate to a face-to-face assessment, unclear policies and recording regarding home visits, and inadequate risk assessment and management.

    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 sufficiently enquire into mental state and risk when hearing voices are reported

    Wider context from the report

    “4. Given that there was an insufficiency of enquiry into the deceased’s state of mind and in particular, a failure to further explore the issue of him claiming to hear voices, on inadequate assessment of risk was undertaken and it was accepted by the Trust in evidence that there ought to have been a face to face consultation with the deceased and that had not agreed to it voluntarily, then there ought to have been a compulsory assessment. ”

    Source location

    Jeffrey Gash · Prevention of Future Deaths report
    Page 1 · 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

    Complete supervised observation, evaluation and competency development for telephone assessment practice.

    Verbatim wording from the response

    “As you have described, the individual nurse involved in the care of Mr Gash recognised in the inquest that she should have been more detailed in her questioning of him in relation to specific symptoms. This individual has, since the inquest, spent some time reflecting on this with her clinical supervisor. In addition, from September 2013 to January 2014 the individual nurse went through a period of informal capability management. During this time she did not undertake the shift co-ordinator role responsibilities and worked all shifts alongside a more senior and experienced member of the team. She observed best practice assessments and her assessment practice was observed and”

    Source location

    2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
    Page 1 · response
    Published 18 August 2014

    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

    Share recommendations with the crisis team and reinforce consultation with colleagues and medical staff for complex assessments.

    Verbatim wording from the response

    “Since Mr Gash's sad death, the individual nurse has critically reflected upon this at length with the team manager during her period of informal capability management described under point 1 above. I agree that more in-depth exploration of his reasons for not wishing to attend should have been undertaken. The Trust Did Not Attend policy does highlight that the nurse should have contacted the GP immediately to agree a management plan, in situations where high risks have potentially been identified. As noted above, the individual nurse has undergone a period of observed practice such that the Advanced Practitioner and Team Manager are now satisfied that she would now manage this situation differently, in that issues would be explored in more depth.”

    Source location

    2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
    Page 3 · response
    Published 18 August 2014

    Open published response

  4. Inner North London

    AI-generated summary

    Noleen Mary McPHARLANE · 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

    Noleen Mary McPHARLANE had longstanding contact with mental health services and a history of overdoses and self-inflicted wounds. She died after ingesting an excess of a drug purchased on the internet, although her intentions were unclear. Concerns included that her suicide thoughts and continued illicit amitriptyline use were not directly explored, and that there was no consideration of input from an alternative healthcare professional despite limited therapeutic engagement.

    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 directly assess thoughts of taking one's life

    Wider context from the report

    “1. Ms McPharlane had a long history of overdoses and self inflicted wounds, her last admission to hospital for treatment for the consequent physical injuries being in May 2013. However, in the year following that until her death, the clinical specialist who looked after never once asked her directly if she had thoughts of taking her life. ”

    Source location

    Noleen Mary McPHARLANE · 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

    Update the clinical risk assessment and management policy.

    Verbatim wording from the response

    “The Trust has a clinical risk assessment and management policy in place. It has been reviewed and updated in September 2014 and is currently being consulted upon. The Trust believes that effective risk assessment and management is crucial to the delivery of high quality services across all parts of the Trust and is a core component of mental”

    Source location

    2014-0370-Response-by-Camden-Islington-NHS
    Page 1 · response
    Published 7 August 2014

    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

    Raise with supervisors that risk-assessment content must be checked during supervision.

    Verbatim wording from the response

    “The Head of the Personality Disorders Service will raise with supervisors in the service that the content of risk assessments are checked during supervision.”

    Source location

    2014-0370-Response-by-Camden-Islington-NHS
    Page 4 · response
    Published 7 August 2014

    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

    Instruct clinical staff to assess risks to self and others and address identified risks in care plans.

    Verbatim wording from the response

    “The Director of Nursing & People and the Interim Medical Director will ensure that all clinical staff are instructed to ensure that the risk assessments of all services users include asking about risks to self and others and, if risks are identified, that these are addressed in care plans. The deadline for this is November 2014.”

    Source location

    2014-0370-Response-by-Camden-Islington-NHS
    Page 4 · response
    Published 7 August 2014

    Open published response

  5. South Lincolnshire

    AI-generated summary

    John William THORPE · 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

    John William THORPE, aged 78, died by drowning after he was found in the Forty Foot Drain on 24 March 2014. Before his death, he had reported low mood, hopelessness and self-harm, was prescribed fluoxetine, and was asked to self-refer to psychological therapy. The concerns included the lack of a direct mental-health referral, the absence of a definite follow-up arrangement, and whether the risks associated with starting antidepressants and his history of suicidal behaviour were adequately considered.

    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 consider suicide-attempt history and antidepressant-associated risk together when assessing treatment risk

    Wider context from the report

    “3 That ████████ knowledge, elicited at the inquest, that "sometimes when anti-depressant is started it can give you more energy" and that Mr Thorpe had a history of a previous suicide attempt was apparently not considered together with the advice in the British National Formulary on suicidal behaviour and treatment with anti-depressants, viz; "the use of anti-depressants has been linked with suicidal thoughts and behaviour; children, young adults and patients with a history of suicidal behaviour are particularly at risk, where necessary patients should be monitored for suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed". ”

    Source location

    John William THORPE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Inner South London

    AI-generated summary

    Gary Richards · 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

    Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.

    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 properly assess and record self-harm and suicide risk

    Wider context from the report

    “(1) Psychiatric staff did not properly assess his risk of self harm, nor communicate his vulnerability to others. At discharge on 10/05 his risk of self harm was not fully measured. On being seen on 14/06 his risk assessment was not recorded and the risk plan not sent to the GP. The consultant explained that the risk was not mitigatable as no mental illness was found. Evidence was heard that his forensic history indicated that he belonged to a group of patients with 80 times the risk of suicide compared with the general population, yet he was considered at low risk. The value of performing a proper risk assessment to demonstrate the risks and vulnerabilities of the patient to other agencies, such as housing and social services, does not seem to have been considered, although it was reluctantly conceded by the consultant to be of value especially as homelessness presented as the primary problem. ”

    Source location

    Gary Richards · Prevention of Future Deaths report
    Page 1 · 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

    Remind staff to record risk assessments in the correct electronic patient-record section.

    Verbatim wording from the response

    “The Trust’s policy on risk assessment is clear in its documentation and staff have been reminded to ensure that when risk is assessed, that this is documented in the correct fashion in the relevant section of the electronic patient record to ensure that this is easily accessible by all clinical staff.”

    Source location

    2014-0212-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 9 May 2014

    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

    Risk was assessed during admission but recorded in the wrong electronic-record location, rather than not being assessed.

    Verbatim wording from the response

    “It is correct that there is no formal documentation of risk in the correct location on the PJS (our electronic patient record system) either at the point of his presentation under Section 136 or whilst on the Triage Ward. This was noted in the Trust’s investigators in their report. However, there is clear evidence in the clinical records that risk was assessed and is documented in the detailed entries made by the ward medical staff during his admission. It was acknowledged that there was a risk of suicide but this was not linked to mental illness but rather the difficult circumstances he found himself in, in particular, his homelessness.”

    Source location

    2014-0212-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 9 May 2014

    Open published response

  7. Worcestershire

    AI-generated summary

    Sean Christopher Seabourne · 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

    Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.

    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 provide timely face-to-face assessment of patients at high risk of concealed suicide

    Wider context from the report

    “(1) The Community Mental Health Team assessed Mr Seabourne as being a man with a definite plan to kill himself which he sought to hide from professionals. The CMHT referred Mr Seabourne on an urgent basis to the Assessment Team making it plain that he was making positive plans and that he should be seen on the same day with a view to a formal assessment to consider a voluntary admission to hospital or Crisis Support. It was stressed by CMHT that Mr Seabourne needed to be seen face to face because of his ability to "dissemble" and thus hide his plans to kill himself. There was no written confirmation of the CMHT duty workers view and requests. (2) The Assessment Team denied being asked to assess Mr Seabourne and although the team member acknowledged that he had been made aware that Mr Seabourne was deliberately concealing settled plans to kill himself he took the view that the matter was not urgent and contends that he was not asked to perform an assessment. The team member concerned indicated that in his judgement a request for crisis support does not require an assessment of the patient. (3) It was clear from the evidence that there was a lack of effective communication between the separate teams which comprise of Mental Health Services within the County with the Team Manager of the Assessment Team being unaware of (upon the end of the 72 hour involvement with Mr Seabourne on the part of his team) whether the CMHT would become automatically involved with onward work with Home Treatment Team. It appears that there are systemic failings in terms of communication and understanding of roles and responsibilities in respect of the patient whom everyone acknowledged was at high risk and with settled plans to kill himself. It appears from the evidence that a lack of formal communication where all details are past from team to team led to a situation where those having contact with Mr Seabourne were unaware of the real risk that he might kill himself. Had all of the concerns of the GP and original psychiatric nurse who referred Mr Seabourne been formally documented and disseminated to each of the new teams then it is likely that he would have been seen face to face and a formal assessment considering whether he should have been admitted to hospital would have been undertaken. This may well have changed the outcome in this case. ”

    Source location

    Sean Christopher Seabourne · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Inner North London

    AI-generated summary

    Abdullahi Sharif ABOKAR · 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

    Abdullahi Sharif Abokar, a 22-year-old patient detained under section 3 of the Mental Health Act, was found hanging from smoke alarm wires on a secure mental health ward on 16 June 2012 and died five days after being taken to hospital. Concerns included staff not asking him about suicidal thoughts and significant shortcomings in the conduct of resuscitation, including compromised ventilatory support and uncertainty about airway management.

    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 ask patients about thoughts of taking their life

    Wider context from the report

    “1. Asking the suicide question Several members of staff looking after him did not ask Mr Abokar if he had thoughts of taking his life. Some, including his ward manager, gave evidence that they thought that asking the question might give a patient the idea of taking his life, though evidence was given by the assistant director of nursing that this thinking is not in accordance with training or accepted practice. One mental health nurse said that, although he would ask the suicide question of a patient who appeared isolated or in low mood, he could not ever remember asking that question, despite his work on a secure mental health ward. ”

    Source location

    Abdullahi Sharif ABOKAR · 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

    Require clinical staff to ask every patient about suicidal thoughts or plans, reinforced through supervision and monitoring of clinical standards.

    Verbatim wording from the response

    “The Trust has implemented the following plan to ensure patient safety through staff having competence and confidence in the assessment of suicidal risk in patients. The Trust expects all its clinical staff to regularly ask every patient about suicide, in terms of thoughts or plans and this issue is explored in clinical supervision and through regular monitoring of clinical standards.”

    Source location

    2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
    Page 2 · response
    Published 23 February 2014

    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

    Commission acute inpatient suicide-prevention training from King’s College London for all inpatient services.

    Verbatim wording from the response

    “d) The Trust will commission Acute In-patient Suicide Prevention training from Kings College, London by March 2014 for all inpatient services.”

    Source location

    2013-0323-Response-by-Camden-Islington-NHS-Foundation-Trust
    Page 4 · response
    Published 23 February 2014

    Open published response
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Data last updated 7 September 2026