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.
Sunderland
Concerns raised1
Failure to provide detailed analysis and comprehensive reasoning for CJLD assessment conclusions
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.3
Action
Review and update CJLD guidance for recording screening assessments, mental-health concerns, risks, clinical reasoning, referrals and handovers on electronic custody records.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 October 2024.
Action
Circulate the updated operating procedure and train CJLD staff on required electronic-record entries and verbal handover documentation.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 October 2024.
Action
Conduct monthly random audits of every CJLD staff member’s screening records and discuss audit outcomes in monthly clinical supervision to monitor implementation.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 October 2024.
Worcestershire
Concerns raised2
Failure to incorporate self-harm risk referrals into mental-health care prioritisation
Failure to highlight recent mental-health and self-harm risk information in medical records for clinical assessment
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.3
Action
Ensure TAG referrals and healthcare applications are added to and visible in SystmOne.
Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Action
Reinforce reviewing recent electronic patient-record activity before assessment or intervention through incident-meeting messages, governance dissemination, management reminders and supervision.
Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Action
Document patient concerns in SystmOne so subsequent staff can identify raised concerns and plan care and treatment to mitigate risk.
Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Essex
Concerns raised2
Failure to implement national training for assessing risk in patients with mental health concerns
Incomplete risk assessments for patients with mental health concerns
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.2
Action
Roll out risk-formulation training across the Trust, training Acute and Rehabilitation Directorate clinical staff first and achieving full Trust coverage by April 2026.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 October 2024.
Action
Require Home Treatment Team staff to use an agreed home-visit documentation template covering mental state, physical health, safeguarding, risk assessment, and follow-up planning, with fortnightly audits.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 October 2024.
Black Country
Concerns raised1
Failure of hospital and police custody risk assessments to identify suicide or self-harm risk before release
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
Audit pre-release risk assessments monthly to monitor and improve their quality.
Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Mental-health input for people in police custody is provided through the locally organised Liaison and Diversion Service between police and mental-health services.
Stated by the Royal Wolverhampton NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Insufficiently specific guidance for informal patient transport risk assessments
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.1
Action
Update the Transport Policy to require open, thorough discussions with family members, friends or carers before agreeing patient transport by them.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Scoring the proposed transport-risk checklist cannot be undertaken because it would be arbitrary, unsupported by evidence, and could omit relevant risks.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Family-member transport will remain available where appropriate because retaining patient dignity, autonomy, choice and least restrictive practice is considered necessary.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
East London
Concerns raised1
Failure to gather and use comprehensive information in risk assessment
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.5
Action
Provide clinical risk-assessment training and apply the clinical risk policy.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Implement the Health Information Exchange to consolidate access to key information across electronic record systems.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Use the new operating model to strengthen family and carer engagement throughout admission and discharge.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Action
Improve care plans so historical factors, experiences, and risks inform personalised care planning.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Review each patient’s history and electronic-record information at ward multidisciplinary team meetings.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Berkshire
Concerns raised1
Failure to recognise continuing vulnerability and risk from known academic and mental health concerns
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.2
Action
Flag vulnerable students discussing withdrawal or suspension to relevant Student Support Centres and Student Wellbeing Services teams.
Stated by University of ReadingStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.
Action
Circulate guidance instructing welfare officers on prescriptive escalation, clarifying welfare information, and promptly sharing high-risk concerns with SDATs.
Stated by University of ReadingStated completedThe respondent said that this action was complete when they made their response on 29 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The organisation lacks regulatory authority to mandate specific mental-health actions by member universities.
Stated by Universities UKOutside remitThe respondent said that this matter was outside its role or authority.
Position
Individual universities are responsible for their own governance, procedures and decisions on specific mental-health actions.
Stated by Universities UKRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure of Mental Health Liaison to attend acute wards and assess presenting self-harm risks during the assessment waiting period
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.6
Action
Develop a joint EPUT–MSE working protocol defining responsibilities for patients awaiting Mental Health Act assessment.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Action
Continue delivering training to MSE on available support and Mental Health Liaison Team roles.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Action
Update and ratify the Mental Health Liaison Service Operational Policy and SOP to address risk management and support for patients awaiting assessment.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Action
Share the reviewed Mental Health Liaison SOP with all Liaison Team staff to promote awareness and consistent practice.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Action
Review and update the acute hospital mental health admission policy with practical guidance on accessing and escalating to the Mental Health Liaison Team.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 June 2024.
Action
Develop a joint protocol with EPUT covering assessment sequencing, referral expectations, and staff roles and responsibilities.
Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Comprehensive mental-health and associated risk assessments are provided by EPUT; acute-trust staff are expected to identify when assessments are needed.
Stated by Mid and South Essex NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Mental Health Liaison Team provision is commissioned by the ICB under contract with EPUT, requiring those bodies' involvement in service arrangements.
Stated by Mid and South Essex NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Rutland and North Leicestershire
Concerns raised1
Failure to robustly consider red-flag risk factors in 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.4
Action
Complete the review of the clinical risk-assessment competency framework and audit tool to strengthen monitoring of risk-assessment and formulation documentation.
Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2024.
Action
Present the risk-assessment review outcomes to the Urgent Care Quality and Safety Meeting to inform required changes.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 2024.
Action
Update the Central Access Point Standard Operating Procedure to require clinicians to review records, assess referrals and prioritise triage calls by risk, urgency and availability.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024.
Action
Redesign the Safe and Well template with staff input, obtain clinical safety sign-off and make it available within the electronic patient record.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Red-flag risk factors alone do not establish likelihood of self-harm or suicide; risk decisions should be based on clinical formulation.
Stated by Leicestershire Partnership NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure to require attending constables to give particular regard to mental health clinicians’ risk expertise
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.6
Action
Replace Appendix C with a decision-recording form documenting the reasons for critical concern and provide it to attending police officers.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 June 2024.
Action
Work with the National Police Chiefs’ Council to clarify Missing Persons APP communication between police and mental health services, including stronger emphasis on consultation.
Stated by College of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Undertake a full review of the Mental Health APP and include officers’ consideration of mental health clinicians’ expertise.
Stated by College of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Review and update the WMP Missing Person Policy to address daily appraisal attendance, clinician risk assessments, recording, and investigation-closure notifications.
Stated by West Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Update the WMP student training programme to emphasise clinician risk assessments, rationale, recording, and the challenge process.
Stated by West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 6 June 2024.
Action
Develop and publish national Right Care Right Person guidance, toolkit and implementation materials for police forces and partner agencies.
Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 6 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.9
Position
West Midlands Police is responsible for responding to whether attending constables should consider mental health clinicians’ risk assessments.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing APP and toolkit guidance, together with the Mental Health APP review, are considered sufficient to address the highlighted issues.
Stated by College of PolicingExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The mental health trust cannot formally record differing risk opinions because it lacks access to police systems.
Stated by West Midlands PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Each Chief Constable decides whether and when to implement Right Care Right Person and which elements of the national framework to adopt.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The APCC cannot mandate its members to undertake actions in response to the identified safety concerns.
Stated by Association of Police and Crime CommissionersOutside remitThe respondent said that this matter was outside its role or authority.
Position
Operational implementation of Right Care, Right Person is assigned to Chief Constables rather than Police and Crime Commissioners.
Stated by Association of Police and Crime CommissionersRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
RCRP did not apply because the case was treated as a missing person involving immediate risk requiring police response.
Stated by National Police Chiefs’ CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pin
Get email alerts
Request correction
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.
