First reported 21 Aug 2013•Latest report 2 Jun 2026
Definition
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
Distinct published reports
Individual concerns
50
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
80
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.
Department of Health and Social Care6
Essex Partnership University NHS Foundation Trust4
NHS England4
East London NHS Foundation Trust3
Tees, Esk and Wear Valleys NHS Foundation Trust3
Birmingham and Solihull Mental Health NHS Foundation Trust2
Surrey and Borders Partnership NHS Foundation Trust2
Sussex Partnership NHS Foundation Trust2
ADAPT, Bexley Locality Community Mental Health Team1
Adept Care Homes1
All family members1
Avery Healthcare Group1
Barts Health NHS Trust1
Beechwood Lodge1
Bexley ADAPT Service1
NHS trust25
Ministerial department9
Executive non-departmental public body4
Residential care home4
Type not available4
Healthcare site3
Nursing home3
Company2
English county council2
English metropolitan district council2
Integrated care board2
Care-home operator1
Clinical commissioning group1
Company limited by guarantee1
Executive agency1
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.
County Durham and Darlington
Concerns raised1
Failure to complete Safety Plans in all cases
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 concerns
Each 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.10
Action
Deliver additional training on completing safety summaries and safety plans to crisis staff.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Check and discuss every patient’s safety summary and safety plan during daily Crisis Team huddles, assigning required updates.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Provide regular bespoke safety-summary and safety-plan training, including training for new team members.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Conduct monthly QA5 audits of safety-summary and safety-plan quality, risk mitigation documentation, and completion, with corrective action and clinical supervision.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Implement monthly caseload-management supervision supported by an electronic caseload dashboard and review of essential care documents.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Apply the national triage tool to new or otherwise eligible crisis-service patients and develop interim safety plans with patients and carers.
Stated by Tees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Provide additional training for crisis staff on completing safety summaries and safety plans.
Stated by Tees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Check and discuss every patient’s safety summary and safety plan during daily Crisis Team huddles, assigning staff to complete required updates.
Stated by Tees, Esk and Wear Valleys NHS FTStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Deliver regular bespoke safety-summary and safety-plan training, including training during induction for new team staff.
Stated by Tees, Esk and Wear Valleys NHS FTStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Conduct monthly QA5 audits of safety-summary and safety-plan quality, risk mitigation documentation and completion, with corrective action and clinical supervision where needed.
Stated by Tees, Esk and Wear Valleys NHS FTStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Immediate emergency responses are requested through 999 emergency services in line with national guidance.
Stated by Tees, Esk and Wear Valleys NHS FTRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East London
Concerns raised1
Failure to establish a risk management plan when weaning Clonazepam medication
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised1
Incomplete recording of multidisciplinary decisions, observation rationale and risk-management plans
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Roll out electronic observations across the Trust while maintaining review and assurance of observation records and multidisciplinary observation-level decisions.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Undertake horizon scanning on multidisciplinary-team communication and patient-risk management, then review findings and take required actions.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Manchester North
Concerns raised1
Failure of Recovery and Discharge Plans to address online medication procurement risks
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Gwent
Concerns raised1
Lack of a documented contingency plan for managing patients when staffing shortages prevent their assessed level of care
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 concerns
Each 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
Introduce the Safecare Programme across wards covered by section 25B of the Nurse Staffing Levels (Wales) Act.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 20 February 2023.
North Yorkshire and York including North Yorkshire Western District
Concerns raised1
Failure to provide a care coordinator and effective care 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 concerns
Each 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
Require autism-informed care, treatment, safety summaries and safety plans within multidisciplinary team processes, including patient and advocate involvement where possible.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Action
Develop and embed an autism-informed care-planning process with evaluation and sustainability work for person-centred holistic plans.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Monitor the action plan requiring flexible, cross-service decisions to meet individual patient needs.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Adopt nationally recommended collaborative care planning using holistic, individualised recovery plans based on the DIALOG model.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Dorset
Concerns raised1
Absence of a composite risk assessment and care plan
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 concerns
Each 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
Apply AGAI 110 Vulnerability Risk Management within the Unit.
Stated by Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 7 December 2021.
Action
Use holistic composite Care Assessment Plans and VRMIS to consolidate risk information, update carers and notify them of changes.
Stated by Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 7 December 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing Chain of Command-led multidisciplinary processes and disagreement protocols provide holistic risk management without adopting a MARM or MARAC model.
Stated by Ministry of DefenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Newcastle upon Tyne
Concerns raised1
Lack of a written safety policy covering guest protection, conduct expectations and event risks
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex
Concerns raised1
Failure to establish definitive plans to address junction safety issues
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 concerns
Each 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
Undertake a feasibility study and options appraisal for improving the crossing point, including bridge and traffic-light-controlled crossing options.
Stated by West Sussex County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2021.
Manchester West
Concerns raised1
Failure to specify a date for future review
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
