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.
Manchester North
Concerns raised1
Inadequate weekend mental health staffing and risk assessment for late prison transfers
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.5
Action
Instruct Governors not to enter local agreements accepting transferred prisoners on Fridays.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
Action
Strengthen first-night procedures by monitoring every new arrival for 72 hours, including random welfare checks during lock-up periods.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
Action
Open a Challenge Support and Intervention Plan for new prisoners segregated before transfer.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
Action
Require healthcare staff to notify the Orderly Officer when new arrivals miss appointments and record follow-up actions when prisoners refuse attendance.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
Action
Issue HMP Haverigg staff a reminder to confirm transfers with Healthcare so medical records are promptly reassigned and available on arrival.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing weekday transfer schedules, advance warnings and exceptional weekend transfers are considered sufficient; removing Friday transfers would increase pressure and late arrivals.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NHS England is responsible for responding directly to concerns about healthcare processes and mental healthcare provision.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to obtain direct or supported assessment of a person when access is challenged by concerns about police uniforms
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Suggested scene-assessment actions will not be made mandatory because they may be impracticable or inappropriate in some circumstances.
Stated by Metropolitan Police ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Over-reliance on questionnaires causing underestimation of self-harm risk
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised1
Insufficient Care Coordinator capacity to review patient histories and assess 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.2
Action
Ensure commissioned and provided services deliver high-quality risk assessment continuously, 24 hours a day, seven days a week.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 4 October 2018.
Action
Work with partners to address recruitment and retention challenges so services are appropriately resourced.
Stated by NHS Birmingham and Solihull Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 4 October 2018.
Birmingham and Solihull
Concerns raised2
Use of unqualified support workers for suicide risk assessments
Absence of a scoring system or guide for suicide 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.
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
Ensure commissioned and provided services deliver high-quality risk assessment continuously, 24 hours a day, seven days a week.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 4 October 2018.
Somerset
Concerns raised1
Inadequate risk assessment and subsequent risk management
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
London Inner (South)
Concerns raised1
Failure to ask about suicidal ideas or suicide plans
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester West
Concerns raised1
Failure to undertake multidisciplinary case conference reassessment by a forensic psychiatrist
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
Strengthen assessment and multidisciplinary discharge processes for service users who go absent without leave.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 March 2018.
Action
Develop forensic in-reach support for high-risk community patients, including timely advice, risk management and second opinions.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 March 2018.
Shropshire, Telford and Wrekin
Concerns raised1
Subjective risk assessments without reference to defined risk criteria
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.2
Action
Implement a standardised validated clinical risk assessment tool and pathway for responding to changes in risk.
Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 February 2018.
Action
Review practitioners’ caseloads and open cases to ensure appropriate care plans, risk assessments and recording of need levels.
Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Shropshire Community Health NHS Trust was responsible for investigating care because it provided CAMHS services in Shropshire at the relevant time.
Stated by Midlands Partnership University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to distinguish denial of a suicide plan from refusal to answer
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.
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.
