First reported 18 Aug 2014•Latest report 27 May 2026
Definition
What this concern includes
Includes failures in mental health or related care processes to accurately record, update or retain clinically or safety-relevant mental health information, including risk history, significant concerns, care-relevant objections and other information needed by staff making later decisions.
Not included
Excludes generic clinical or care record deficiencies where the information is not specifically mental health or mental-health-risk information.
Excludes failures to communicate or share accurately recorded information where the recording process itself was reliable.
Excludes failures in mental health assessment, treatment, referral or follow-up where no deficiency in recording safety-critical mental health information is identified.
Excludes routine administrative information and non-safety-relevant mental health notes.
Reports
51
Distinct published reports
Individual concerns
54
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
61
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 Care4
NHS England4
Birmingham and Solihull Mental Health NHS Foundation Trust3
Care Quality Commission3
East London NHS Foundation Trust3
Essex Partnership University NHS Foundation Trust3
Midlands Partnership University NHS Foundation Trust3
Avon and Wiltshire Mental Health Partnership NHS Trust2
Care UK2
Cornwall Council2
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust2
Greater Manchester Mental Health NHS Foundation Trust2
Hampshire and Isle of Wight Healthcare NHS Foundation Trust2
HM Prison and Probation Service2
Lancashire & South Cumbria NHS Foundation Trust2
NHS trust43
Healthcare site7
Ministerial department5
Executive non-departmental public body4
Integrated care board4
English unitary authority3
Executive agency3
Health and social care service regulator3
Multi-service care provider2
Police force2
Prison or young offender institution2
Company limited by guarantee1
English county council1
English district council1
Health-system partnership1
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.
Manchester South
Concerns raised1
Failure to record objections to sharing confidential medical information
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.3
Action
Require Care Coordinators to assess risk-based information sharing with Personal Assistants and document this in wellbeing care plans.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2017.
Action
Disseminate and deliver a briefing on Personal Assistant involvement in care planning and information-sharing records.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Discuss adding Personal Assistant care-planning and information-sharing guidance as an addendum to each community team’s operational policy at the Tier 4 meeting.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Manchester City
Concerns raised1
Lack of a reception checklist for identifying and recording mental health and self-harm or suicidal ideation information
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Preston and West Lancashire
Concerns raised1
Failure to record referrals concerning psychiatric state in the medical record
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to record assessment of mood and suicidal thoughts during prison triage
This report raised 15 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
Concerns 2, 3 and 4 relate to BEH-MHT services rather than the services addressed by this response.
Stated by Care UKOutside remitThe respondent said that this matter was outside its role or authority.
Worcestershire
Concerns raised1
Failure to record suicide risk assessment in risk assessment documents
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.
Derby and Derbyshire
Concerns raised1
Lack of GP awareness and use of EMIS Special Patient Note and Right Care Plan facilities for mental health risk information
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
Review the PARIS discharge-letter format after the audit and determine necessary changes.
Stated by Derbyshire County Council and Derbyshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 January 2015.
Action
Remind practices to use Special Patient Notes and Right Care Plans for patients with mental health conditions.
Stated by NHS England Medical Directorate Derbyshire & Nottinghamshire Area Team (NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 January 2015.
Wiltshire and Swindon
Concerns raised1
Failure to assess, record and monitor the urgency of mental health 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.
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
Amend the mental health assessment matrix so similar self-harm presentations trigger amber-risk classification and mental health assessment before Emergency Department discharge.
Stated by Royal United Hospitals Bath NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2015.
Action
Implement a PCLS referral pathway using a standard operating procedure, telephone triage and a triage decision-support tool.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2015.
Action
Set response-time standards for urgent and routine assessments and record triage outcomes in electronic patient records.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2015.
Action
Record referral and assessment times and monitor significant delays in Mental Health Act assessments.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 June 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing policies and processes for family involvement, triage, communication, recording and monitoring address the identified assessment and care concerns.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Wiltshire and Swindon
Concerns raised1
Failure to record information obtained from mental health patients, including perceived risk and assessment urgency
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.4
Action
Implement the College of Emergency Medicine mental health risk assessment tool for ED suicide and self-harm risk assessment and urgency documentation.
Stated by Salisbury NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 February 2015.
Action
Implement a mental health referral proforma to record risk, assessment timeframe, accepting practitioner and agreed actions for out-of-hours referrals.
Stated by Salisbury NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2015.
Action
Incorporate the mental health referral proforma into the upgraded ED electronic system for electronic transfer and storage by the end of 2015.
Stated by Salisbury NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2015.
Action
Conduct a joint root cause analysis with Salisbury District Hospital and the Armed Forces, including review of relevant policies and procedures.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Further advice on the specific concerns cannot be provided because Public Health England is not in a position to advise further.
Stated by Public Health EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Department of Health, Ministry of Defence and NHS England will address the specific concerns through their ongoing discussions.
Stated by Public Health EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The mental health providers named in the report are expected to comment on the particular case and address concerns locally.
Stated by Public Health EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local mental health providers are expected to address the specific case and concerns from their local perspective.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure of crisis team records to capture valuable information received during referrals
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.
Surrey
Concerns raised1
Failure to record the outcome of mental state assessments after inpatient leave
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.
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 in mental health or related care processes to accurately record, update or retain clinically or safety-relevant mental health information, including risk history, significant concerns, care-relevant objections and other information needed by staff making later decisions.
