Recurring concern

Unreliable recording of safety-critical mental health information

First to latest report 18 Aug 2014 — 27 May 2026

Reports that mention this concern
51
Times this concern has been raised
54
Stated actions linked to this concern
61

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.

What is 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 and published responses 51 reports

See individual reports that have raised this concern, and the actions taken in response

  1. County Durham and Darlington

    AI-generated summary

    Jeffrey Gash · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jeffrey Gash died after hanging himself on 30 September 2013, following contacts with his GP and the Crisis Team while reporting that he was feeling worse and hearing voices. The concerns included insufficient telephone assessment and exploration of his symptoms, failure to arrange or escalate to a face-to-face assessment, unclear policies and recording regarding home visits, and inadequate risk assessment and management.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unclear recording of self-harm risk assessment and conclusions

    Wider context from the report

    “5. The clinical risk assessment and management policy document (Version 5) which was presented in evidence fails to clarify the nature and detail of what form of risk assessment needs to be completed when a one in-person face to face is being undertaken. Thus, the notes entered on the PARIS system were unclear as to their author’s view of risk of self harm where it was accepted in evidence that full details of the assessment of risk and its conclusion are central to the Crisis Team process. The Trust has carried out an SUI. Certain recommendations have been made and are being implemented. The inquest however, as evidenced above, revealed other issues not dealt with by the SUI and therefore a complete re-evaluation of the deceased’s contact with the Trust should be undertaken taking into account the evidence given at the inquest so that a complete overview of Trust policy dealing with the above matters and any other such review might uncover can be considered by management and if agreed, implemented. ”

    Source location

    Jeffrey Gash · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reinforce recording of colleague-reported risks and home-visit decisions in electronic care-record alerts.

    Verbatim wording from the response

    “In relation to recording the information from colleagues, and the individual nurse’s decision making on the shift in question, there is already an ‘alerts’ section in our electronic care record which staff are asked to use to document risks in a way that this information is available to all staff working with a specific patient. The Team Manager has previously highlighted the importance of recording this with the team, but since Mr Gash’s inquest has further reinforced this via team meetings. In addition, the Head of Service for Durham and Darlington AMH Services has asked the Crisis Team Manager to share your recommendations with the Specialty's Acute Care Group in order that the Trust standard operational policy for Crisis Teams can be strengthened accordingly.”

    Source location

    2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
    Page 2 · response
    Published 18 August 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Complete the Trustwide review of clinical risk assessment and management policy and practice, incorporating investigation and inquest information.

    Verbatim wording from the response

    “A Trustwide review of the clinical risk (CRAM) policy and practice is currently underway, with initial reports due in the spring; the information from this Serious Untoward Incident investigation and the inquest will be fed into that review.”

    Source location

    2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
    Page 4 · response
    Published 18 August 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026