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 provide detailed and documented shared risk assessments and care plans in acute settings
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.3
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Action
Design and implement integrated care pathways linking liaison psychiatry teams with community mental-health services, including timely information sharing.
Stated by Department of Health and Social Care -
Action
Use joint assessment, handover and working-plan documentation to record risk, observation levels, clinical plans and handovers between liaison and emergency-department teams.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Embed a standard operating procedure across both organisations reflecting shared-care principles.
Stated by NHS Greater Manchester Integrated Care Board
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
Local clinicians and operational managers are responsible for the safety of handover and patient management between acute and mental health services.
Stated by Department of Health and Social Care
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Concerns raised1
Overriding care plans without assessment by decision-makers and review of the risk assessment
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
Operate the established Neurodevelopmental Specialist Service to provide autism diagnosis, post-diagnostic support, training, assessment advice, care planning and crisis support.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Emphasise accurate documentation of changed care plans, discussion, rationale and risk review in staff feedback.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Operate the established Neurodevelopmental Case Discussion Forum for clinicians to present complex cases and obtain advice.
Stated by Nottinghamshire Healthcare NHS Foundation 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
Discharge from crisis care was based on immediate needs, an open mental health referral, and the option to re-refer if circumstances changed.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised1
Lack of written risk-management plans for informal patients leaving the unit
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.2
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Action
Develop a standalone written policy governing informal-patient leave, including risk assessment, leave decisions, risk management, recording and missing-person reporting.
Stated by Surrey and Borders Partnership NHS Foundation Trust -
Action
Roll out a competency framework to train staff on the new and updated leave policies and their practical application.
Stated by Surrey and Borders Partnership NHS Foundation Trust
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Concerns raised1
Lack of a published plan for mitigating lifeguard-cover shortfalls
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.2
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Action
Work with Surf Life Saving GB on additional beach safety services and public risk-awareness provision.
Stated by Maritime and Coastguard Agency -
Action
Deploy additional HM Coastguard vehicle patrols to high-risk coastal areas during the busy summer season.
Stated by Maritime and Coastguard Agency
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Responsibility for beach users’ safety rests with the landowner or occupier, rather than the RNLI.
Stated by Royal National Lifeboat Institution
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Position
Beach lifeguard provision is outside the respondent’s statutory and specific responsibilities for beach safety.
Stated by Maritime and Coastguard Agency
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Concerns raised1
Failure to develop robust plans addressing protective factors and harm minimisation
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.2
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Action
Strengthen community mental-health assessment oversight, including further face-to-face assessment where diagnoses differ and monthly quality audits.
Stated by Oxleas NHS Foundation Trust -
Action
Establish a Trust-wide rolling programme delivering STORM and DICES training on suicide prevention, risk assessment, safety planning and risk management.
Stated by Oxleas NHS Foundation Trust
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Concerns raised2
Lack of care plans addressing identified high fall risk
Failure to plan measures to prevent wheelchair falls
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
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Action
Implement organisation-wide multifactorial falls risk assessments, including reassessment, care planning, documentation and review requirements.
Stated by Hc-One Limited
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
Falls among older people cannot always be prevented, although risks can be minimised and staff responses improved.
Stated by Hc-One Limited
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Concerns raised1
Failure to undertake falls prevention care plans
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
Add safety-equipment risk assessments to care plans, including whether equipment is used and reasons for non-use.
Stated by Beechwood Lodge
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Concerns raised1
Lack of a process for completing risk assessment plans when residents’ needs changed from care to nursing needs while awaiting a bed
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
Implement a multi-agency risk assessment for residents awaiting transfer from residential to nursing care.
Stated by Stockport NHS Foundation Trust
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Concerns raised2
Unstructured risk review and intervention planning without a collaboratively developed understanding of risk
Lack of process to monitor completion and currency of risk management and care plan documentation
This report raised 14 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
Absence of a risk mitigation plan before S17 leave
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
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Action
Publish and apply a revised Mental Health Act Code of Practice strengthening family involvement and robust risk assessment, including for leave of absence.
Stated by Department of Health and Social Care
Data last updated 7 September 2026