Recurring concern
Unreliable patient risk-assessment processes
- Reports that mention this concern
- 4
- Times this concern has been raised
- 5
- Stated actions linked to this concern
- 7
What this concern includes
Includes failures in patient risk-assessment processes and their dedicated safety-summary or assurance controls, including incomplete assessments or summaries, failure to complete assessments within required timescales, inadequate checking or auditing of completion, and related deficiencies that leave patient risks unavailable for safe care and protection decisions.
What is not included
- Excludes generic documentation, staffing, training or governance deficiencies unless they directly constitute or undermine a patient risk-assessment process.
- Excludes condition-specific or named risk systems, such as mental-health risk assessment, safeguarding assessment or hazard-specific assessments, when that narrower system provides the more specific supported boundary.
- Excludes failures to implement protective actions after a patient risk assessment has been completed and reliably communicated.
- Excludes general clinical assessment, diagnosis or treatment failures where patient risk assessment is not the deficient control.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 4 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised2
Failure of care staff to notice missing risk assessments when assessing patients’ daily needs and requirements
Inadequate auditing of assessment completion
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Incomplete Risk Assessment/Safety Summary process for assessing and protecting patients
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- Tees, Esk and Wear Valleys NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Tees, Esk and Wear Valleys NHS Foundation Trust
Implement an out-of-area patient checklist covering information gathering, care-team sharing, Safety Summary updates and forwarding information to admitting wards.
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Tees, Esk and Wear Valleys NHS Foundation Trust
Review, clarify and streamline clinical risk assessment and management processes and confirm organisation-wide risk-assessment standards.
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Tees, Esk and Wear Valleys NHS Foundation Trust
Review care documentation to assure that patient risks are assessed and safety plans meet the agreed standard.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Department of Health and Social Care
Operational processes for locally commissioned mental health services are the responsibility of local NHS providers and their commissioning partners.
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Department of Health and Social Care
Enforcement action was not required because the regulator concluded there was no ongoing risk to service users.
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Concerns raised1
Lack of alerts to staff when required patient safety assessments are incomplete
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to routinely include carers and actively seek their views and knowledge in risk assessment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- The Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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The Trust
Provide family-inclusion training across the service line to frontline staff on engaging with families and carers.
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The Trust
Develop Open Dialogue training so selected staff attend residential training and disseminate their learning to others.
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The Trust
Embed learning on engaging separately with patients and carers through clinician meetings, patient-safety meetings, face-to-face meetings and written guidance or policy updates.
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The Trust
Complete and report an audit of care plans and risk assessments for evidence of carer involvement.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026