First reported 20 May 2015•Latest report 13 Mar 2025
Definition
What this concern includes
Includes failures in training, knowledge, experience, judgment or competence assurance that directly impair mental health assessment, including recognition of suicide or self-harm risk, application of relevant statutory powers and interpretation of the assessment's safety implications.
Not included
Excludes generic staff-training or clinical-competence deficiencies where mental health assessment is not the affected process.
Excludes failures in mental health treatment, follow-up, admission or discharge after an adequately competent assessment has been completed.
Excludes failures limited to the availability, content or documentation of a risk-assessment tool where assessor competence is not deficient.
Excludes condition-specific competence concerns, such as eating-disorder management, unless they directly concern competence in the same mental health assessment process.
Reports
9
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
29
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 England5
Department of Health and Social Care2
Oxleas NHS Foundation Trust2
ADAPT, Bexley Locality Community Mental Health Team1
Bexley ADAPT Service1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Coldingley Prison1
Essex Partnership University NHS Foundation Trust1
HM Prison and Probation Service1
Mid and South Essex NHS Foundation Trust1
Ministry of Justice1
NHS Humber and North Yorkshire Integrated Care Board1
Nottinghamshire Healthcare NHS Foundation Trust1
Parole Board1
NHS trust8
Executive non-departmental public body5
Ministerial department3
Prison or young offender institution2
Executive agency1
Health and social care service regulator1
Healthcare site1
Integrated care board1
Registered provider of social housing1
Sub-organisation1
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.
South London
Concerns raised1
Gaps in mental health professionals’ knowledge and clinical judgment
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
Providers are responsible for ensuring staff competence, appropriate training and support to deliver safe, effective care.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Failure to provide necessary clinical knowledge for overnight mental health 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.
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 re-commissioned prison healthcare services, including seven-day mental health provision, on-site attendance and out-of-hours urgent referral protocols.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
Action
Require relevant managers to consider out-of-hours mental-health support options, including NHS 111, when concerns are raised.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
Essex
Concerns raised1
Lack of specialist mental health training among acute care healthcare professionals for mental health assessment
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 ongoing mental health training for MSE staff covering enhanced supervision, engagement, de-escalation, risk assessment and risk management.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Comprehensive mental-health and associated risk assessments are provided by EPUT; acute-trust staff are expected to identify when assessments are needed.
Stated by Mid and South Essex NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Failure to ensure specialist mental health assessment of patients triaged by telephone workers
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 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.10
Action
Review and refresh helpline workers’ roles, referral escalation, training, supervision, monitoring and audit arrangements.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Agree a standard operating procedure governing helpline referrals to the Crisis Team.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Ensure helpline workers and their team leader understand the referral standard operating procedure.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Introduce additional monitoring and audits to check compliance with the referral procedure and address variance promptly.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Agree a competency framework covering staff confidence in handling calls and escalating risk.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Update the Recovery Worker competency assessment to strengthen competence in call management, systems use, and risk and safety escalation.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Review local UK Mental Health Triage Scale guidance and establish a more robust process for escalating call-transfer difficulties.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Review and disseminate the Urgent Access line Standard Operating Procedure to relevant staff through email, supervision, and team meetings.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Introduce a digital telephony system that records calls and enables regular audit of call activity.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Introduce monthly sampling and auditing of telephone recordings to assess SOP compliance and provide training or remedial action where needed.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
North Yorkshire and York including North Yorkshire Western District
Concerns raised1
Failure to avoid attributing an undiagnosed personality disorder to an autistic patient
This report raised 9 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.7
Action
Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Communicate learning from Zoe’s death and subsequent inquiries, including the need to validate or review EUPD diagnoses, to relevant clinical and senior medical staff.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Action
Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Communicate learning from Zoe’s death and inquiries, including the need to validate or review EUPD diagnoses, to clinical and senior medical staff.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Action
Review 134 patients’ autism and EUPD diagnoses, communications, withdrawals, reasonable adjustments and treatment options.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Require registered providers to ensure staff receive role-appropriate learning disability and autism training.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Central Hampshire
Concerns raised1
Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment
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.4
Action
Train all staff during induction to use SystmOne’s problem functionality and audit its use through quarterly care-quality meetings.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 March 2020.
Action
Deliver SystmOne training through induction and the Learning and Development Zone, including additional training identified through supervision.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 March 2020.
Action
Require annual Suicide and Self Harm and ACCT training, with successful testing before staff are signed off as compliant.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2020.
Action
Audit mental-health risk assessments and resulting care plans quarterly and during the annual medical-records audit.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2020.
South London
Concerns raised1
Over-reliance on alcohol and drug use in assessing suicidal ideation
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.1
Action
Share the root-cause analysis report and investigation learning with the involved team and across the Trust to support reflection by similar teams.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
South Yorkshire (Eastern)
Concerns raised1
Lack of universal recognition among mental health practitioners of suicide risk patterns in middle-aged males and socio-economic factors
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.2
Action
Deliver three workshops for IAPT teams on findings from the Confidential Inquiry into Suicides and Homicides.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2016.
Action
Develop and disseminate a newsletter and Trust-wide communications message summarising suicide risk factors, including risks affecting middle-aged men.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 March 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Identifying middle-aged male status alone is considered insufficient to translate into a suicide-prevention intervention without other risk factors.
Stated by Rotherham Doncaster and South Humber NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Sussex
Concerns raised1
Lack of staff awareness of relevant mental health policies
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.2
Action
Load a shortcut to SASH policies onto Psychiatric Liaison staff computers.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 May 2015.
Action
Make the SASH translation-services policy mandatory reading for staff working at East Surrey Hospital.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 May 2015.
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Includes failures in training, knowledge, experience, judgment or competence assurance that directly impair mental health assessment, including recognition of suicide or self-harm risk, application of relevant statutory powers and interpretation of the assessment's safety implications.
