First reported 28 Apr 2015•Latest report 30 Mar 2026
Definition
What this concern includes
Includes failures by staff responsible for safety assessment or care to investigate further when a person’s presentation, behaviour, withdrawal, history or reported account should prompt additional enquiry, collateral information gathering or assessment; include the anchor, over-reliance on a prisoner's presentation in ACCT work, and failure to recognise withdrawal as a significant risk.
Not included
Excludes failures belonging to a separately named assessment, observation or risk-management system when that system provides the more specific supported parent boundary.
Excludes generic professional-curiosity, communication or training concerns where no failure to investigate a concerning presentation or risk beyond initial appearance or self-report is identified.
Excludes failures limited to the quality of treatment, escalation or follow-up after a sufficiently thorough assessment has been completed.
Excludes ordinary reliance on a patient's account or presentation where no concerning feature, change or risk required further investigation.
Reports
19
Distinct published reports
Individual concerns
20
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
37
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.
Cornwall Council2
Cygnet Health Care Limited2
Department of Health and Social Care2
Ministry of Justice2
NHS Cornwall and the Isles of Scilly Integrated Care Board2
Bolton Cares1
British Sub-Aqua Club1
Cambridgeshire and Peterborough NHS Foundation Trust1
Cornwall Partnership NHS Foundation Trust1
Derby City Council1
Derbyshire Constabulary1
Derbyshire Healthcare NHS Foundation Trust1
General Medical Council1
Glen Parva Young Offender Institution1
Greater Manchester Mental Health NHS Foundation Trust1
NHS trust8
Ministerial department4
English unitary authority3
Healthcare site3
Integrated care board3
Prison or young offender institution3
Police force2
Private limited company2
Type not available2
Company limited by guarantee1
Executive agency1
Executive non-departmental public body1
Health and care professional regulator1
Independent healthcare provider1
Maritime sector body1
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.
Inner North London
Concerns raised1
Over-reliance of prison staff on a single presentation for ACCT knowledge
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.1
Action
Deliver continuous suicide and self-harm prevention training through the reintroduced Pentonville Speed School.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.
Stated by Practice Plus GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cornwall and Isles of Scilly
Concerns raised1
Lack of culturally informed professional curiosity in infant feeding 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.8
Action
Instruct staff to record specific feeding details when nutrition may be linked to a child’s attendance.
Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2025.
Action
Deliver mandatory infant-feeding training covering cultural practices, professional curiosity, interpreters and safe formula guidance, including recorded catch-up.
Stated by Cornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 18 December 2025.
Action
Update infant-feeding training materials to reflect guidance on terminology, professional curiosity and bottle feeding.
Stated by Cornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 18 December 2025.
Action
Add targeted quality-assurance checks on bottle-content recording and interpreter use.
Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 18 December 2025.
Action
Share the case across the organisation to increase professional awareness and confidence in asking about infant feeding.
Stated by Royal Cornwall Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2025.
Action
Change Emergency Department feeding questions from “bottle” to “formula” and update paediatric clerking proformas accordingly.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 December 2025.
Action
Embed routine enquiry about bottle contents in the inpatient children’s admission documentation.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 December 2025.
Action
Ask a mandatory question about the exact nature of bottle feeding during maternity care whenever safely possible.
Stated by Royal Cornwall Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2025.
West Sussex, Brighton and Hove
Concerns raised1
Overreliance on self-declaration questionnaires without further enquiry or access to previous medical history
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
Include immersion pulmonary oedema in the diving medical screening declaration.
Stated by Sub-Aqua AssociationStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Remind members at renewal and through periodic newsletters to complete medical declarations accurately.
Stated by Sub-Aqua AssociationStated plannedThe respondent said that this action was planned when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Revised medical screening forms and existing training changes are considered sufficient to mitigate the risk of immersion pulmonary oedema in diving.
Stated by Sub-Aqua AssociationExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure of staff to recognise when a patient is becoming withdrawn
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
Recruit 24 additional Registered Nurses and implement a three-nurse, two-support-worker day-shift staffing ratio across acute inpatient wards.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Action
Implement the Perfect Day model with standardized ward timetables, daily electronic handover templates and documentation of multidisciplinary and observation decisions.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Progress ward Culture of Care recommendations arising from multidisciplinary away days and senior leadership review.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Action
Progress Topaz ward’s quality-improvement programme on therapeutic engagement through the division-wide improvement programme.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Staff understand therapeutic engagement and professional curiosity, although staffing, time and documentation barriers have affected implementation.
Stated by North London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester West
Concerns raised1
Failure to apply professional curiosity when evaluating assumptions about service-user safety
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
Deliver refresher toolbox training requiring staff to remain physically present during supervision and check unusual behaviour, including when service users fall asleep.
Stated by Bolton CaresStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
Inner North London
Concerns raised1
Insufficient professional curiosity among clinicians
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cornwall and Isles of Scilly
Concerns raised1
Lack of professional curiosity about drug-taking and its clinical contribution
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Integrated Care Board is expected to respond to concerns about the specific care provided.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Derby and Derbyshire
Concerns raised1
Over-reliance on self-reporting by a manipulative patient about relationships and risk
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.9
Action
Publish guidance for supervising conditionally discharged patients in the community.
Stated by Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Introduce a system to identify domestic violence and prompt specific risk questions throughout patients’ movement through hospital.
Stated by Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Continue identifying opportunities to enhance guidance and share knowledge with stakeholders.
Stated by Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Action
Add the manipulation measurement tool as an HCR-20 addendum and use it for male service users.
Stated by Cygnet Health Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 22 February 2024.
Action
Review the potential manipulation measurement tool at CPA and section 117 meetings and complete an audit by 31 May 2024.
Stated by Cygnet Health Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 22 February 2024.
Action
Assess new Forensic Community Mental Health Team patients through two-staff assessment, multidisciplinary discussion and structured risk and diagnostic tools.
Stated by Derbyshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Provide additional training to officers and staff on self-reporting and disguised compliance, with MOSOVO personnel completing the national course.
Stated by Derbyshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Deliver vulnerability training to frontline officers and staff covering controlling and coercive behaviour and disguised compliance.
Stated by Derbyshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Recruit a Digital Media Investigator to strengthen MOSOVO compliance monitoring through digital-device checks during unannounced visits.
Stated by Derbyshire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
South Yorkshire (Western)
Concerns raised1
Failure to critically explore allegations and trauma-related experiences
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Suffolk
Concerns raised1
Insufficient professional curiosity around risk and suicidal ideation
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures by staff responsible for safety assessment or care to investigate further when a person’s presentation, behaviour, withdrawal, history or reported account should prompt additional enquiry, collateral information gathering or assessment; include the anchor, over-reliance on a prisoner's presentation in ACCT work, and failure to recognise withdrawal as a significant risk.
