Recurring concern
Unreliable assessment of suicide and self-harm risk
- Reports that mention this concern
- 77
- Times this concern has been raised
- 94
- Stated actions linked to this concern
- 132
What this concern includes
Includes failures of controls specifically dedicated to assessing suicide or self-harm risk, including identifying relevant factors, completing or updating assessments, assessing disclosed vulnerability or suicidal intent, using appropriate tools or protocols, and documenting the reasoning needed to support safe observation, referral or protective action across healthcare, custody, police and community settings.
What is not included
- Excludes generic mental-health risk assessments where suicide or self-harm risk is not the material concern.
- Excludes failures in observation, treatment, referral, communication or protective measures after suicide or self-harm risk has been reliably assessed, unless the assessment process itself is also deficient.
- Excludes generic staff training, staffing, documentation or communication deficiencies that are not directly dedicated to assessing suicide or self-harm risk.
- Excludes the underlying occurrence of suicide or self-harm where no failure in a dedicated risk-assessment control is identified.
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 77 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- Essex Partnership University 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.2
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Essex Partnership University NHS Foundation Trust
Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.
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Essex Partnership University NHS Foundation Trust
Review and document MDT decisions on anti-ligature clothing and bedding through regular MDT and ward-review processes.
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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.
Linked response
- Mid and South Essex 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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Mid and South Essex NHS Foundation Trust
Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.
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Concerns raised1
Failure to recognise and assess an identified suicide risk
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- South London and Maudsley 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.2
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South London and Maudsley NHS Foundation Trust
Participate in the national Culture of Care Programme pilot on personalised approaches to suicide risk.
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South London and Maudsley NHS Foundation Trust
Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.
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Concerns raised1
Failure to account for recent self-harm, suicidal behaviour or suicidal thoughts when presentation appears improved
This report raised 2 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 evaluate small-quantity purchases for indications of suicide or self-harm
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 evaluate small-quantity purchases for potential suicide or self-harm use
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Home Office
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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Home Office
Assess with DHSC and stakeholders whether additional regulation under the Poisons Act would be effective, proportionate and appropriately led.
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Concerns raised1
Failure to evaluate small-quantity purchases for possible suicide or self-harm intent
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Home Office
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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Home Office
Engage online platforms and retailers to encourage voluntary removal of pure-form substances and vigilance for purchases linked to self-harm or suicide.
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Home Office
Improve supplier awareness of suspicious-activity reporting obligations and promote safer sales practices, including declaration-of-use forms.
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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Home Office
Individual substances are not routinely highlighted in guidance because doing so could draw widespread attention; existing general controls and targeted engagement are relied upon.
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Concerns raised2
Failure to evaluate small-quantity purchases for suicide or self-harm intent
Failure to correctly evaluate increased small-quantity purchases for suicide or self-harm risk
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Home Office
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
-
Home Office
Assess with DHSC and stakeholders whether additional regulation under the Poisons Act would be effective, proportionate and appropriately led.
-
Concerns raised2
Failure to evaluate small-quantity purchases for suicide or self-harm indicators
Failure to correctly evaluate small-quantity purchases for suicide or self-harm indicators
This report raised 5 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 assess suicidal behaviour or thoughts in online consultations
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
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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Department of Health and Social Care
If an appropriate organisation requires a standardised suicidal-behaviour question, the GPhC would monitor its inclusion through inspections.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026