Recurring concern
Unreliable patient risk-assessment processes
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Request correctionFirst reported 27 Jan 2016•Latest report 2 Jun 2021
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.
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.
- Reports
- 4
- Individual concerns
- 5
- Date range
- 2016–2021
- Stated actions
- 7
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach 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
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Action
Implement an out-of-area patient checklist covering information gathering, care-team sharing, Safety Summary updates and forwarding information to admitting wards.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust -
Action
Review, clarify and streamline clinical risk assessment and management processes and confirm organisation-wide risk-assessment standards.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust -
Action
Review care documentation to assure that patient risks are assessed and safety plans meet the agreed standard.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust
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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Position
Operational processes for locally commissioned mental health services are the responsibility of local NHS providers and their commissioning partners.
Stated by Department of Health and Social Care
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Position
Enforcement action was not required because the regulator concluded there was no ongoing risk to service users.
Stated by Department of Health and Social Care
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach 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
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Action
Provide family-inclusion training across the service line to frontline staff on engaging with families and carers.
Stated by The Trust -
Action
Develop Open Dialogue training so selected staff attend residential training and disseminate their learning to others.
Stated by The Trust -
Action
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.
Stated by The Trust
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Action
Complete and report an audit of care plans and risk assessments for evidence of carer involvement.
Stated by The Trust
Data last updated 7 September 2026