Recurring concern

Unclear accountability for safety risk assessments

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First reported 9 May 2014•Latest report 24 Oct 2022

Definition

What this concern includes

Includes failures to assign, communicate or maintain clear individual, team or organisational responsibility for conducting, reviewing, updating or overseeing safety risk assessments, including responsibility for identifying changing self-harm or suicide risks.

Not included

  • Excludes deficiencies in the content, criteria or quality of a risk assessment where responsibility for the process is clear.
  • Excludes generic governance, staffing or accountability failures that are not directly tied to conducting, reviewing or maintaining safety risk assessments.
  • Excludes failures to implement protective actions after responsibility for the risk assessment process has been clearly assigned.
  • Excludes assessments belonging to a separately named system or hazard where that named concern provides the more specific supported boundary.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2022

First to latest report issue date

Stated actions
3

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.

Avon and Wiltshire Mental Health Partnership NHS Trust1
Capita Business Services Ltd1
Capita PLC1
Care Quality Commission1
Ministry of Defence1
South London and Maudsley NHS Foundation Trust1
Widow of the deceased1

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.

  1. Birmingham and Solihull

    AI-generated summary

    Kamil Iddrisu and Youngson Nkhoma · 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

    Kamil Iddrisu and Youngson Nkhoma collapsed during separate military selection runs at Whittington Barracks and later died after being taken to hospital. Both were found to have metabolic acidosis, acute kidney injury, rhabdomyolysis and sickle cell trait; the final causes of death remained under investigation, with the most likely cause of collapse described as sickle cell trait combined with military exercise. The principal concern was the risk of death or harm to non-UK selection candidates, including the need to consider screening for sickle cell trait.

    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

    Lack of clear lines of responsibility for organisation-wide health and safety risk assessment and incident information gathering

    Wider context from the report

    “Sickle cell trait (SCT) screening process and identifying SCT in candidates: 1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective. 2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective. Training and Education 1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT. 2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable . 3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT. 4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate. Reporting and investigation 1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process. 2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective. 3. There is no system to audit whether incidents are being correctly processed and investigated. 4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically. 5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety. 6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses. Medical response: 1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale. 2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · Prevention of Future Deaths report
    Page 3 · 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

    Operate joint Army–Capita health-and-safety governance forums and shared risk-management processes.

    Verbatim wording from the response

    “Recruiting Group acts as one entity for health and safety issues through joint (Army and Capita) forums including a Joint Risk Management Board, the Joint Lessons Learned Panel, Clinical Oversight Board, quarterly Joint Health, Safety and Environment reviews and the quarterly Joint Assurance Group. Policies and procedures are reviewed and approved by both partners to ensure clarity and coherence. This joint governance framework supports a proactive and coherent approach to risk management and a more robust, timely and effective response to reported incidents and organisational learning.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 15 · response
    Published 30 December 2019

    Open published response

  2. Avon

    AI-generated summary

    Mr. Masoud Ghaderi · 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

    Mr. Masoud Ghaderi, who had severe depression and was an informal inpatient at Lime Unit, was found hanging by a belt from a bathroom door on 10 April 2014 and died on 12 April 2014 after life support was withdrawn. The report identified concerns about inconsistent records of engagement, the absence of overarching responsibility for reviewing risk assessments, and ward-round reliance on brief nursing summaries that could result in errors or omissions.

    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

    Lack of overarching responsibility for reviewing risk assessments

    Wider context from the report

    “(2) There was no one member of staff with overarching responsibility for reviewing any risk assessments. Therefore any trends in changing risk, e.g. increasing risk of self-harm or suicide, could not be identified. The Trust should consider designating a member of staff with this responsibility in the same manner as it has one member of staff with responsibility for ensuring the care plan(s) are reviewed and maintained up-to-date. ”

    Source location

    Mr. Masoud Ghaderi · Prevention of Future Deaths report
    Page 2 · 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

    Commission an audit of risk-assessment reviews across inpatient units.

    Verbatim wording from the response

    “The Clinical Executive appreciates the Coroners comments re responsibility for reviewing and as a result have commissioned an audit of reviewing risks across inpatient units. The Clinical Executive will take the information from this audit and design a framework of staff responsibilities for all staff to follow.”

    Source location

    2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 3 · response
    Published 17 July 2015

    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

    Use the risk-review audit findings to design a framework of staff responsibilities.

    Verbatim wording from the response

    “The Clinical Executive appreciates the Coroners comments re responsibility for reviewing and as a result have commissioned an audit of reviewing risks across inpatient units. The Clinical Executive will take the information from this audit and design a framework of staff responsibilities for all staff to follow.”

    Source location

    2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 3 · response
    Published 17 July 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing processes, including daily risk review and weekly multidisciplinary review, coordinate inpatient risk information without requiring one overarching reviewer.

    Verbatim wording from the response

    “The Trust has in place processes and procedures for the co-ordinating of risk assessment information for inpatients.”

    Source location

    2015-0283-Response-by-Avon-and-Wiltshire-NHS-Trust
    Page 2 · response
    Published 17 July 2015

    Open published response

  3. Inner South London

    AI-generated summary

    Gary Richards · 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

    Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.

    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

    Lack of clarity of responsibility for risk assessment

    Wider context from the report

    “(2) After discharge in May, he was not followed up, as there was no address and his mobile phone number was not recorded. After attendance in June, again there was a failure to contact him for follow up, reported to be due to a phone failure. The failure to ensure reliable communication pathways for follow up is a potential risk for vulnerable patients. (3) The Serious Untoward Incident Report (Acute Mental Health Comprehensive Level Two Report, 10th October 2012) found seven areas of concern and service delivery problems, including weaknesses in risk assessment and recognition of suicide plan, lack of clarity of responsibility for risk assessment, inadequate 7 day follow up and communications with GP and problems in support as no mental illness. A plan was adopted which required review of clinical pathway focusing on risk assessment, staff induction and a review of homeless services and interagency working. Despite the intervening eighteen months, progress on these was not evident and it was clear that these actions had not been completed. ”

    Source location

    Gary Richards · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Risk was assessed during admission but recorded in the wrong electronic-record location, rather than not being assessed.

    Verbatim wording from the response

    “It is correct that there is no formal documentation of risk in the correct location on the PJS (our electronic patient record system) either at the point of his presentation under Section 136 or whilst on the Triage Ward. This was noted in the Trust’s investigators in their report. However, there is clear evidence in the clinical records that risk was assessed and is documented in the detailed entries made by the ward medical staff during his admission. It was acknowledged that there was a risk of suicide but this was not linked to mental illness but rather the difficult circumstances he found himself in, in particular, his homelessness.”

    Source location

    2014-0212-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 9 May 2014

    Open published response
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Data last updated 7 September 2026