Recurring concern
Failure to reliably escalate suicidal intent information
- Reports that mention this concern
- 10
- Times this concern has been raised
- 12
- Stated actions linked to this concern
- 12
What this concern includes
Includes failures of healthcare, care or police processes specifically dedicated to recognising, transferring, reviewing or escalating expressed or recorded suicidal intent or related imminent self-harm information, including delayed escalation, omitted handover information and failure to act on documented suicidal intent.
What is not included
- Excludes general mental-health deterioration, suicide-risk assessment, observation, treatment or safeguarding failures where suicidal-intent information escalation is not the specific unsafe condition.
- Excludes generic communication, documentation or handover deficiencies without an identified suicidal-intent or imminent self-harm information context.
- Excludes failures to escalate unrelated clinical abnormalities, welfare concerns or staffing problems.
- Excludes failures concerning access to self-harm means or protective-factor provision where the information-escalation process is not deficient.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 10 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to pass on suicidal ideation information to foster carers or other relevant people
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Calderdale Borough Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Calderdale Borough Council
Deliver comprehensive safeguarding, confidentiality, disclosure, welfare and mental-health training to Independent Visitor volunteers.
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Calderdale Borough Council
Require Independent Visitor volunteers to follow a safeguarding code and health-and-safety procedure specifying when concerns must be reported or disclosed.
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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Calderdale Borough Council
Relevant information was promptly passed to the Pathways Team, and no imminent risk justified sharing it with the foster carer.
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Concerns raised1
Failure to record suicidal ideation on Person Escort Records and Suicide and Self-Harm Warning forms
Linked response
- Dyfed-Powys Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Dyfed-Powys Police
Inform investigation and custody staff, anonymously, about the omission of relevant suicidal-ideation information.
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Dyfed-Powys Police
Instruct custody officers to ask interviewing officers about information relevant to ongoing detainee risk assessment.
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Dyfed-Powys Police
Remind investigators to inform custody officers about disclosures relevant to ongoing risk management.
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Concerns raised1
Failure to communicate the appropriate level of suicide risk to police
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Metropolitan Police Service
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Metropolitan Police Service
Implement the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS England
Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
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Concerns raised1
Failure to communicate expressed suicidal intent in the handover
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Metropolitan Police Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Metropolitan Police Service
Trial the THRIVE+ vulnerability assessment framework to assess and document vulnerability, including suicidal thoughts, and support ongoing risk review and information sharing.
-
Metropolitan Police Service
Publish an Operational Notice requiring staff to review police indices before victim contact, communicate identified vulnerabilities, and record them on the CRIS report.
-
Metropolitan Police Service
Introduce a mandatory enhanced SOIT risk assessment covering suicide, cultural complexities and honour-based violence, with police-indices review, CRIS recording and supervisor escalation.
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Concerns raised1
Failure to verbally communicate increased suicidal risk to the responsible nurse
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring 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 recognise and act on recorded information about suicidal intent
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sussex Partnership NHS Foundation Trust
Stated actions 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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Sussex Partnership NHS Foundation Trust
Create an information-sharing protocol between the Mental Health Liaison Team and Pavillions A&E liaison service.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Sussex Partnership NHS Foundation Trust
The A&E attendance did not heighten concern because the presentation was previously seen with alcohol use and liaison staff did not recommend re-referral.
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Concerns raised2
Failure to train Listeners to pass information about imminent suicide risk to prison staff
Failure of the Listener Scheme protocol to specify an exception to confidentiality for imminent suicide risk
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
HM Prison and Probation Service
Winchester will not add an exception to Listener confidentiality because national confidentiality arrangements are considered necessary to preserve prisoners’ trust.
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Concerns raised1
Failure to communicate custody-recorded suicide and self-harm risks for full MG7 preparation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- West Mercia Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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West Mercia Police
Require the responsible custody sergeant to verify and sign every Prisoner Escort Form before a detainee leaves or moves from custody, ensuring documented risks are communicated.
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West Mercia Police
Include in mandatory custody-sergeant training the requirement to highlight known risks and concerns to the officer in charge when considering an MG7 remand application.
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Concerns raised1
Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Failure to promptly escalate information about patients’ suicidal intent
Lack of training or experience on when and how to escalate information about patients’ suicidal intent
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026