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.
Essex
Concerns raised1
Failure to consider the risk of psychosis relapse
This report raised 7 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
Take forward MDT learning on documenting and escalating inconsistencies between clozapine assays, adherence reports and clinical stability.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Clinical assessment and the already scheduled psychiatric review were considered sufficient; no earlier appointment was indicated without evidence of deterioration.
Stated by Essex Partnership University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North London
Concerns raised1
Failure to account for recent self-harm, suicidal behaviour or suicidal thoughts when presentation appears improved
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to carry out robust risk assessments
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 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
Use the MaST electronic system in Havering to monitor caseloads, documentation, engagement, risk and care-planning reviews.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Implement the NICE-based risk-formulation approach through co-produced training, updated recording systems and team support.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025.
Action
Recruit trainers to support delivery of the new risk-assessment and management training programme.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Monitor compliance, patient and staff experience, and risk-formulation quality through supervision, meetings and the Risk Formulation Steering Group.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025.
Lancashire and Blackburn with Darwen
Concerns raised1
Limited NHS Pathways mental health triage capability for properly risk assessing serious mental health crises
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 a national urgent clinical review process for suicide-related Category 3 calls, supported by dedicated NHS Pathways disposition coding.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Action
Publish and reissue national operational guidance for assessing lethality and toxicity in overdose and suicidal ideation calls.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Action
Provide substantial training information on assessing patients with mental health conditions.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Action
Keep NHS Pathways clinical content under review as new evidence or guidance emerges.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 11 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS England is not considering further NHS Pathways system changes because national reviews, discussions and mandated changes have already addressed suicide-risk management.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The NHS Pathways triage system elicited the correct information and triggered the nationally approved ambulance response in this case.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised1
Failure to appropriately update and document risk assessments
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.2
Action
Implement the unified NOVA electronic patient record to integrate systems and carry forward risk information.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Action
Provide ward-wide digital clinical dashboards displaying quality, performance and risk-assessment information.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
South London
Concerns raised2
Failure to apply A&E risk assessment and staffing policies to mental health staff
Failure to recognise high-risk mental health patients
This report raised 10 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
Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Essex
Concerns raised1
Failure of mental health liaison to undertake the mental health risk assessment
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.4
Action
Commission and complete an independent safety review of the Mental Health Liaison service.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 February 2025.
Action
Devise an action plan to deliver improvements to the Mental Health Liaison service.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 February 2025.
Action
Develop a Mental Health Liaison service across all hospitals in partnership with the Integrated Care Board and EPUT.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2025.
Action
Move towards a collaborative Safety Planning approach to keeping people safe.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Concerns about care before 6 June 2023 do not relate to the respondent, so it has identified no action concerning them.
Stated by Mid and South Essex NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
No action was identified because the acute Trust nurse appropriately sought advice from the mental health liaison team for the risk assessment.
Stated by Mid and South Essex NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
Position
Mental health risk assessment is a joint responsibility, not exclusively the role of mental health liaison staff.
Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Suffolk
Concerns raised1
Failure to assess suicidal behaviour or thoughts in online consultations
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 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
If an appropriate organisation requires a standardised suicidal-behaviour question, the GPhC would monitor its inclusion through inspections.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Failure to provide necessary clinical knowledge for overnight mental health risk assessment
This report raised 10 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
Implement re-commissioned prison healthcare services, including seven-day mental health provision, on-site attendance and out-of-hours urgent referral protocols.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
Action
Require relevant managers to consider out-of-hours mental-health support options, including NHS 111, when concerns are raised.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
East London
Concerns raised1
Failure to carry out holistic formulations of risk to self
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 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
Deliver and expand face-to-face risk-formulation training across acute, rehabilitation and borough-based staff, including new starters.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 December 2024.
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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.
