First reported 16 Dec 2013•Latest report 10 Mar 2026
Definition
What this concern includes
Includes failures to recognise when capacity assessment is required, conduct or document the assessment, record its outcome and rationale, and make the result available for subsequent care or decision-making.
Not included
Excludes general care-record deficiencies where mental capacity is not the material subject.
Excludes Mental Capacity Act best-interests, deprivation-of-liberty and advocacy failures when the capacity-assessment and recording process itself is not deficient.
Excludes failures to follow a valid capacity assessment after it has been completed and recorded.
Excludes generic consent or treatment-decision failures that do not concern assessment or recording of the patient’s mental capacity.
Reports
35
Distinct published reports
Individual concerns
39
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
90
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.
Department of Health and Social Care7
Care Quality Commission3
Greater Manchester Mental Health NHS Foundation Trust3
London Borough of Redbridge2
Manchester University NHS Foundation Trust2
Ministry of Justice2
NHS England2
Norfolk and Suffolk NHS Foundation Trust2
Tameside and Glossop Integrated Care NHS Foundation Trust2
Abbey Court Independent Hospital1
A & B Healthcare Limited1
Achieve Together Limited1
Bolton Borough Council1
Brunswick Ward at Lindridge1
Cambridge Nursing Home Ltd1
NHS trust21
Ministerial department10
Healthcare site7
Integrated care board4
Private limited company4
Type not available4
English county council3
English metropolitan district council3
Executive non-departmental public body3
Health and social care service regulator3
London borough council3
English unitary authority2
Local health board2
Multi-service care provider2
Coronial office1
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 Wales Central
Concerns raised1
Failure to devise and implement a clear plan for assessing capacity to refuse food or fluid
This report raised 12 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
Provide basic life support, mental capacity and bespoke prison-nursing training, with the bespoke programme underway from May 2024.
Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 25 March 2024.
Action
Provide mental capacity assessment training to medical staff and plan annual refresher updates.
Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 25 March 2024.
East London
Concerns raised1
Failure to undertake or consider a formal Mental Capacity Act 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.2
Action
Provide mental-capacity assessment training to all health and social care staff.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 September 2023.
Action
Complete mental-capacity assessments in complex cases.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 September 2023.
South Wales Central
Concerns raised1
Failure of the WARRN assessment tool to prompt consideration and recording of advocacy referrals and capacity assessments
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.
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
Continue six-monthly Welsh Applied Risk Research Network record audits by Powys Teaching Health Board.
Stated by Powys County Council and Powys Teaching Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Reinstate advocacy clinics in community mental-health teams and inpatient units.
Stated by Powys County Council and Powys Teaching Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Welsh Applied Risk Research Network form cannot be altered because it must remain in its original evidence-based form.
Stated by Powys County Council and Powys Teaching Local Health BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised1
Failure to carry out mental capacity 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Worcestershire
Concerns raised1
Failure to apply the correct Mental Capacity Act 2005 test when assessing capacity for medication decisions
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.
Mid Kent and Medway
Concerns raised1
Lack of formal mental capacity assessments for treatment decisions
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.5
Action
Implement a streamlined Mental Capacity Assessment process for physical-health interventions and monitor compliance through Mental Health Act Committee and CLiQ checks.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Deliver and monitor mandatory Mental Capacity Act training for clinical staff.
Stated by Kent and Medway Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 December 2021.
Action
Commission and complete an audit of consent and mental capacity practices.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Introduce a clinical advisor role and appoint a Mental Capacity Act clinical practitioner to support complex capacity cases.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Provide mandatory tailored capacity-assessment training and conduct Trust-wide audit and monitoring.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Manchester City
Concerns raised1
Failure to complete and properly record formal mental capacity assessments
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.2
Action
Trigger formal Mental Capacity Assessments and Best Interest Meetings for inpatient concerns about capacity to consent to or refuse physical-health treatment, and disseminate the process.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2021.
Action
Deliver face-to-face Mental Capacity Act training to CMHT staff using case studies.
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 13 October 2021.
Manchester South
Concerns raised1
Failure to adequately assess patients’ mental capacity for care decisions
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.12
Action
Maintain and expand the Trust’s Mental Capacity Act improvement programme, led by a dedicated Senior Mental Health Nurse.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Establish a multi-agency Mental Capacity Act group with the local authority to review and benchmark policies, procedures, strategy and training.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 September 2021.
Action
Review the revised Mental Capacity Act Code of Practice and develop aligned audit processes, audit cycles and training linked to Liberty Protection Safeguards.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 September 2021.
Action
Deliver a continuing Trust-wide Mental Capacity Act learning and awareness programme using masterclasses, e-learning, briefings, podcasts, animations and related resources.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 September 2021.
Action
Launch the Trust’s Mental Capacity Act awareness campaign and assess staff knowledge and confidence through surveys and scheduled monitoring.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Monitor the Mental Capacity Act improvement project through safeguarding, quality and governance committees and revised multi-agency audit arrangements.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Develop and roll out electronic patient-record prompts and alerts to support capacity assessment, vulnerability recognition and safe discharge planning.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Include Betty’s Story and its learning in recurrent multi-professional induction and training, and develop a live-play version for organisational dissemination.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Embed the Mental Capacity Act in adult social care practice through forums, social-work training, quality assurance and workforce-development programmes.
Stated by Tameside Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2021.
Action
Update Mental Capacity Assessment and Best Interest documentation and link it with needs and risk assessments in social work practice.
Stated by Tameside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 17 September 2021.
Action
Implement a quality assurance framework incorporating the Mental Capacity Act Competency Framework and a skills and knowledge audit for social workers and managers.
Stated by Tameside Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 17 September 2021.
Action
Embed multidisciplinary roles and responsibilities in staff induction, clinical supervision, multi-agency procedures and standards, and refresh related capacity procedures and training.
Stated by Tameside Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 17 September 2021.
Norfolk
Concerns raised1
Failure to adequately assess under the Mental Capacity Act
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Queen Elizabeth Hospital should respond to the concerns outside the second part of the first concern.
Stated by Norfolk and Suffolk NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
For physical health decisions requiring capacity assessment, the physical health expert is the decision maker.
Stated by Norfolk and Suffolk NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Mid Kent and Medway
Concerns raised1
Failure to reassess fluctuating mental capacity
This report raised 12 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 to recognise when capacity assessment is required, conduct or document the assessment, record its outcome and rationale, and make the result available for subsequent care or decision-making.
