Recurring concern
Failure to update risk assessments after material changes or safety events
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Request correctionFirst reported 12 Feb 2015•Latest report 1 Jun 2026
What this concern includes
Includes failures to review or update a risk assessment after a material change, deviation from an agreed safety plan, significant deterioration, suspected overdose, intoxication, injury, incident or other safety event that should trigger reassessment, including failures to maintain a reliable process for timely updating.
Not included
- Excludes deficiencies limited to completing an initial risk assessment where no failure to update after a material change or safety event is identified.
- Excludes failures in a separately named risk-assessment system or hazard when that named system supplies the more specific supported recurring concern.
- Excludes generic care planning, documentation, training or staffing deficiencies unless they directly result in failure to update a risk assessment after a material change or safety event.
- Excludes failures to implement risk-reduction actions after an otherwise current risk assessment unless updating the assessment is also deficient.
- Reports
- 28
- Individual concerns
- 30
- Date range
- 2015–2026
- Stated actions
- 63
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to update nursing care plan risk assessments in response to changes in clinical presentation and falls
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 concernsEach 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
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Action
Continue ward accreditation assessments, including care-plan and patient-record reviews, feedback, action planning and governance reporting.
Stated by Portsmouth Hospitals University NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing ward accreditation and clinical audit processes are considered sufficient to address nursing documentation and care-plan completion concerns.
Stated by Portsmouth Hospitals University NHS Trust
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Concerns raised1
Failure to complete and update risk assessments in a timely manner by suitably experienced staff
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 concernsEach 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.8
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Action
Remind staff to complete contemporaneous risk assessments through communications, supervision and appraisals.
Stated by Priory Group -
Action
Triangulate incidents with patient risk assessments and care plans through ward checks and daily flash-meeting confirmation.
Stated by Priory Group -
Action
Update and reissue Policy H35 to require prompt post-incident risk review and handover communication of resulting care-plan changes.
Stated by Priory Group
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Action
Add a Datix prompt requiring confirmation that incident-related risk assessments and care plans have been reviewed.
Stated by Priory Group -
Action
Audit incident reports against risk assessments and care plans weekly and review results at hospital governance meetings.
Stated by Priory Group -
Action
Continue compliance inspections comparing patient risk assessments with incident reports.
Stated by Priory Group -
Action
Update Quality Walk Round checks to compare CareNotes risk assessments with patients’ incident profiles.
Stated by Priory Group -
Action
Review, update and roll out risk-assessment and risk-management training covering contemporaneous documentation and real-time risk sharing.
Stated by Priory Group
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Concerns raised1
Failure to update risk assessments after deviation from an agreed Safety Plan
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Position
There was no deviation from the safety plan; a dynamic, though informal, risk assessment was undertaken.
Stated by North East London NHS Foundation Trust
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Concerns raised1
Failure to update risk assessments after a suspected overdose
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to update residents' falls risk 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 concernsEach 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
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Action
Display a named nurse list and have the manager and deputy manager monitor and plan evaluations and risk assessments when nurses are unavailable.
Stated by Cole Valley Nursing Home
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Concerns raised1
Failure to update risk screens after significant changes in presentation
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 concernsEach 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
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Action
Monitor the trust’s ligature-risk and care-planning improvements through monthly leadership meetings and weekly progress reports.
Stated by Care Quality Commission
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Concerns raised2
Failure to update falls risk assessments and care plans after every fall
Failure to update falls risk assessments and care plans after every fall
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Stated by Care Quality Commission
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Concerns raised1
Failure to update care plans and risk assessments with material overdose information and information from clinical reviews and contacts
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 concernsEach 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
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Action
Maintain current risk assessments and care plans for Care Programme Approach patients and share them with patients and families as appropriate.
Stated by OHFT -
Action
Review electronic care-record processes for recording and reviewing risk formulations and assessments, including family views and best-practice family involvement.
Stated by OHFT -
Action
Embed multidisciplinary team care-plan reviews for patients at risk of suicide.
Stated by OHFT
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Action
Have the Quality Improvement team consider family involvement, enhanced risk formulation and suicide-risk assessment within thematic improvement work.
Stated by OHFT -
Action
Include risk-assessment and care-plan quality in Trust audits during the coming year.
Stated by OHFT
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Concerns raised1
Failure to update risk assessments when risk scores or behaviour change
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Improve clinical record keeping to ensure care plans, risk assessments and clinical reasoning are documented clearly and electronically.
Stated by Ministry of Defence -
Action
Strengthen senior-clinician oversight of record-keeping quality and regularly review clinicians whose performance falls below the required standard.
Stated by Ministry of Defence -
Action
Introduce enhanced risk-management training for all Department of Community Mental Health clinical staff, including tools for recognising, assessing and managing mental-health risks.
Stated by Ministry of Defence
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The care plan was updated and risk levels were reviewed, contrary to the concern that neither had been updated as risk escalated.
Stated by Ministry of Defence
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Concerns raised1
Failure to undertake violence risk assessments after admission or incidents
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026