Recurring concern
Failure to reliably develop and review risk-reduction plans
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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.
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Concerns raised1
Failure to follow falls-risk care plans
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
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Action
Conduct weekly documentation audits, assurance meetings, metrics reviews and ward action planning across all six divisional wards.
Stated by Barts Health NHS Trust -
Action
Provide ward-based falls and enhanced-care risk-assessment training with senior-nurse oversight and refresher documentation sessions for staff.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to provide falls minimisation plans for residents at risk of falls
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.6
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Action
Complete falls risk assessments and multifactorial assessments and minimisation plans for residents identified as at risk.
Stated by Avery Healthcare Group -
Action
Train the General Manager in the organisation’s falls-minimisation protocols and policies.
Stated by Avery Healthcare Group -
Action
Cascade further falls-risk training to strengthen staff knowledge and risk-management documentation.
Stated by Avery Healthcare Group
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Action
Disseminate updated falls-prevention policies and multifactorial falls-risk screening tools to managers for team implementation.
Stated by Avery Healthcare Group -
Action
Hold weekly clinical-risk meetings to analyse incidents, review risks and care plans, and assign actions with ownership and timescales.
Stated by Avery Healthcare Group -
Action
Introduce an internal audit framework covering call-bell response times and falls-minimisation plans, with results shared with staff.
Stated by Avery Healthcare Group
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Concerns raised1
Failure of My Safety Plans to clearly convey suicide risk
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.
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
Formal risk documentation and information-sharing procedures are considered sufficient; My Safety Plan is not intended to record or share clinical suicide risk.
Stated by Surrey and Borders Partnership NHS Foundation Trust
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Concerns raised1
Failure of transport crew to read and understand patient safety plans
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
Publish statutory guidance strengthening local-authority arrangements for children’s home-to-school travel, including medical-needs risk assessment, suitable support and staff training.
Stated by Department for Education
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Concerns raised1
Failure to conduct timely risk assessments with complementary risk management plans
This report raised 24 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.4
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Action
Deliver revised risk-assessment training to new practitioners and introduce new training for experienced staff.
Stated by HM Prison and Probation Service -
Action
Deliver further risk-assessment training events for practitioners responsible for managing people in the community.
Stated by HM Prison and Probation Service -
Action
Develop, pilot and launch the Continuing Professional Development risk-learning product for experienced practitioners.
Stated by HM Prison and Probation Service
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Action
Develop and roll out the ARNS digital assessment and sentence-planning service with supporting staff learning.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to conduct an adequate risk assessment before ending a safety plan
This report raised 9 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
Deliver monthly Tower Hamlets training on Dialog+ care planning, safety plans and risk formulations using group scenarios.
Stated by East London NHS Foundation Trust
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Concerns raised1
Lack of consistent and clear fall-risk mitigation requirements in care plans and risk assessments
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.3
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Action
Revise care plans and risk assessments to provide person-focused, consistent falls-risk management guidance.
Stated by Norfolk Care Homes -
Action
Review and update falls-related policies, procedures and auditing processes to identify inconsistencies and improve staff guidance.
Stated by Norfolk Care Homes -
Action
Implement monthly care-plan and risk-assessment audits covering at least 10% of the home.
Stated by Norfolk Care Homes
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Concerns raised1
Failure to review prolonged prescribing of dependency-forming drugs and formulate dosage-reduction plans
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
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Action
Risk-score opioid and gabapentinoid patients, recall them for face-to-face structured medication reviews, and provide follow-up supporting safe dose reduction.
Stated by Kirby Road Surgery -
Action
Recruit a specialist prescribing pharmacist with pain-clinic experience to conduct structured medication reviews.
Stated by Kirby Road Surgery -
Action
Train three in-house clinical pharmacists with the specialist pharmacist to develop their capability to conduct structured medication reviews.
Stated by Kirby Road Surgery
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Action
Update, externally review, approve and ratify the opioid and gabapentinoid prescribing policies.
Stated by Kirby Road Surgery
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Concerns raised1
Failure to include risk management and contingency planning in care plans
This report raised 9 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 review risk management plans when risks change or after 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.5
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Action
Review risk management plans and clarify documentation, review, updating and clinical-rationale expectations for staff.
Stated by Care UK -
Action
Remind staff of reassessment triggers, including after hospital discharge and return to the home.
Stated by Care UK -
Action
Review accident and incident reports to identify required responses and further falls-mitigation measures.
Stated by Care UK
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Action
Discuss accidents and incidents in weekly clinical reviews and assign actions to update assessments and management plans.
Stated by Care UK -
Action
Have the Deputy Manager review assessments and plans to triangulate care and verify completion of assigned clinical-review actions.
Stated by Care UK
Data last updated 7 September 2026