Recurring concern
Failure to reliably develop and review risk-reduction plans
Pin
Get email alerts
Request correctionFirst reported 21 Aug 2013•Latest report 2 Jun 2026
What this concern includes
Includes failures of the risk-reduction or safety-planning process where a required plan is missing, not implemented, not assessed for appropriateness, or changed or ended without the risk review needed to maintain effective protection.
Not included
- Excludes generic risk-assessment failures where no risk-reduction or safety plan is involved.
- Excludes failures to implement unrelated organisational action plans, audit recommendations or post-incident actions.
- Excludes failures of a separately named hazard-specific or end-to-end safety system where risk planning is only an incidental component.
- Excludes clinical or operational outcomes where no deficiency in developing, reviewing or maintaining a risk-reduction plan is identified.
- Reports
- 48
- Individual concerns
- 50
- Date range
- 2013–2026
- Stated actions
- 80
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.
-
Concerns raised1
Failure to update care and behavioural support plans to reflect aggression, risk and risk-reduction measures
This report raised 3 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.2
-
Action
Conduct monthly audits of resident care and behavioural support plans.
Stated by Adept Care Homes Limited -
Action
Issue management instruction reaffirming plan reviews, amendments and supporting risk assessments.
Stated by Adept Care Homes Limited
-
Concerns raised1
Failure to maintain collaborative, complete and accurate risk assessments and care plans
This report raised 11 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.
-
Concerns raised1
Lack of up-to-date care plans and risk assessments for significant self-harm risk
This report raised 18 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.2
-
Action
Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Review and document MDT decisions on anti-ligature clothing and bedding through regular MDT and ward-review processes.
Stated by Essex Partnership University NHS Foundation Trust
-
Concerns raised1
Lack of appropriate care plans and risk assessments for known self-harm risk
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.
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
-
Action
Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.
Stated by Mid and South Essex NHS Foundation Trust
-
Concerns raised1
Lack of a relapse prevention or risk management plan developed with the patient and family members
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.
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
-
Action
Review and strengthen risk assessment and management processes, including clinical-recording-system changes and staff training.
Stated by East London NHS Foundation Trust
-
Concerns raised1
Uncertainty about when formal safety plans or care plans should be completed
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 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
-
Action
Update the Haven Operational Policy to clarify care-plan timing and require recorded care planning from admission.
Stated by Sussex Partnership NHS Foundation Trust
-
Concerns raised1
Lack of care plans addressing identified physical healthcare risks
This report raised 1 other concern. 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.4
-
Action
Implement Dialog+ Care Planning across inpatient services to document physical-health risks, mitigation actions and review plans.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Strengthen ward-level Dialog+ audits, including checks that physical-health risks have documented action plans and follow-up, with feedback to clinical teams.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Implement and audit Inpatient MDT standards to support follow-up of actions identified in physical-health action plans.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
-
Action
Share learning from the case across inpatient teams on medication-related physical-health risks and documenting risks such as sleep apnoea, obesity and positional asphyxia.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
-
Concerns raised1
Failure to reinforce safety plans during waits for beds
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 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.
-
Concerns raised1
Absence of an MDT plan to address anti-psychotic depot medication non-concordance
This report raised 3 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
-
Action
Reinforce medication non-concordance policies and procedures requiring weekly MDT discussion and comprehensive electronic-record documentation of missed depot injections or adherence concerns.
Stated by East London NHS Foundation Trust -
Action
Embed depot-medication compliance auditing and weekly monitoring, with findings reported through local and Directorate governance and escalated where required.
Stated by East London NHS Foundation Trust -
Action
Formalise MDT risk oversight for medication non-adherence through risk-register inclusion, weekly RAG review, senior multidisciplinary attendance and recording of decisions and responsible clinicians.
Stated by East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
Strengthened medication non-concordance procedures, auditing, monitoring and training are considered sufficient; no further action is required.
Stated by East London NHS Foundation Trust
-
Position
Weekly MDT review, risk-register oversight, escalation and documented accountability are considered sufficient; no further action is required.
Stated by East London NHS Foundation Trust
-
Concerns raised1
Failure of safety plans to provide additional support responsive to identified needs
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026