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.
Avon
Concerns raised1
Failure to check risk assessments before downgrading a well-known patient’s suicide risk
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.8
Action
Complete a full multi-professional review of autonomous working and safe patient care.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 July 2021.
Action
Update and implement the action plan supporting consistent application of systems, policies, procedures and guidelines.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 July 2021.
Action
Use the new care-plan and risk-supervision tool during monthly management supervision to audit records and address identified concerns.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 July 2021.
Action
Develop a face-to-face training package on risk assessment and management, including suicidality, self-injury and complex behaviours.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 July 2021.
Action
Deliver the procured 4Mental Health training package, including co-produced safety plans, to an initial 60 staff members.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 July 2021.
Action
Develop autism, risk-assessment and suicide-prevention guidance for the Clinical Toolkit and RiO Clinical Support.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 July 2021.
Action
Hold a suicide-prevention workshop featuring specialist autism guidance on supporting people experiencing complex or suicide risk.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 July 2021.
Action
Share learning from the circumstances of the death more widely with colleagues.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 July 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A policy change is not considered necessary because existing quality-improvement work addresses risk-assessment practice.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Derby and Derbyshire
Concerns raised1
Failure to undertake meaningful mental health or 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Lack of a shared definition of high-risk mental health patients between acute and mental health trusts
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.3
Action
Implement a triage assessment tool guiding emergency-department nurses toward appropriate pathways based on patient risk and presentation.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
Action
Implement a joint risk-assessment tool that stratifies risk and determines the level of emergency-department observation required.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
Action
Embed a standard operating procedure across both organisations reflecting shared-care principles.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Risk assessments should be personalised rather than based on shared definitions or standardised tools, which are poor predictors of suicide or specific behaviour.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure to update risk screens after significant changes in presentation
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
Monitor the trust’s ligature-risk and care-planning improvements through monthly leadership meetings and weekly progress reports.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 30 March 2021.
Inner West London
Concerns raised2
Failure to assess suicide risk during the current treatment episode
Lack of staff training in suicide 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex
Concerns raised1
Failure to carry out adequate mental-health risk assessments
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.3
Action
Review inpatient care plans, risk assessments and clinical documentation, and maintain compliance through audits and competency plans.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 January 2021.
Action
Deliver staff safety days with training on clinical risk assessment, professional responsibility, accountability and clinical curiosity.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 January 2021.
Action
Conduct daily risk-assessment, huddle and clinical-notes audits with Ward Manager oversight from senior leadership.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 January 2021.
Inner South London
Concerns raised1
Lack of a centralised, formulated risk record
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
Introduce the Risk Assessment document as the central risk record and add a mandatory formulation summary that flows to the MDT template and inpatient care plan.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 January 2021.
Action
Reinforce that every professional must record identified risks immediately in the Risk Assessment document.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 January 2021.
Action
Require each MDT meeting to decide risk, allocate responsibility for updating records, and update the Risk Assessment and associated care-plan management after identified risks.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 January 2021.
Action
Remove the Responsible Clinician’s policy responsibility and assign post-MDT risk-record updates to a professional allocated during the meeting.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 January 2021.
Action
Require all clinicians to update the Risk Assessment whenever risk changes between MDT meetings.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The MDT template must remain separate from the Risk Assessment document because weekly meetings cannot realistically update and summarise risk.
Stated by Oxleas NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East London
Concerns raised1
Failure to safeguard downgrading of suicide risk by staff unfamiliar with the patient
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
Introduce referral to the on-call psychiatrist when presenting risk significantly differs from another clinician’s same-day assessment.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 December 2020.
Action
Amend the Psychiatric Liaison Service assessment template to prompt documentation of concerns, protective factors and the risk management plan.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 December 2020.
Action
Review Clinical Risk Advanced training to include differing clinical opinion scenarios and guidance on addressing them.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 December 2020.
North East Kent
Concerns raised3
Failure to update risk assessments when risk scores or behaviour change
Lack of risk assessment for virtual mental health appointments during service changes
Failure to document disclosures relevant to mental health risk
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.3
Action
Improve clinical record keeping to ensure care plans, risk assessments and clinical reasoning are documented clearly and electronically.
Stated by Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 29 December 2020.
Action
Strengthen senior-clinician oversight of record-keeping quality and regularly review clinicians whose performance falls below the required standard.
Stated by Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 29 December 2020.
Action
Introduce enhanced risk-management training for all Department of Community Mental Health clinical staff, including tools for recognising, assessing and managing mental-health risks.
Stated by Ministry of DefenceStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The care plan was updated and risk levels were reviewed, contrary to the concern that neither had been updated as risk escalated.
Stated by Ministry of DefenceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Lincolnshire
Concerns raised1
Inadequate evaluation of history, vulnerabilities, circumstances and drug misuse indicators for relapse signatures
This report raised 13 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 a prompt system at every NSP visit to assess presentation, health, housing, harm reduction, substance use and treatment referrals.
Stated by WithYouStated completedThe respondent said that this action was complete when they made their response on 26 October 2020.
Action
Implement an enhanced NSP questionnaire to identify complex health issues and mental-health concerns, informing risk assessment and decisions.
Stated by WithYouStated completedThe respondent said that this action was complete when they made their response on 26 October 2020.
Action
Roll out revised suicide-prevention training covering history, accommodation, relationships and substance and alcohol misuse risk factors.
Stated by Lincolnshire Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2020.
Action
Review training and competencies to cover dual-diagnosis presentations, risk assessment and information sharing.
Stated by Lincolnshire Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2020.
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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.
