Recurring concern
Unreliable assessment of suicide and self-harm risk
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Request correctionFirst reported 5 May 2013•Latest report 27 May 2026
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.
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.
- Reports
- 77
- Individual concerns
- 94
- Date range
- 2013–2026
- Stated actions
- 132
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
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
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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
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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.
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 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
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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.
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
Participate in the national Culture of Care Programme pilot on personalised approaches to suicide risk.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.
Stated by South London and Maudsley NHS Foundation Trust
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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.
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 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.
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 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.
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
Assess with DHSC and stakeholders whether additional regulation under the Poisons Act would be effective, proportionate and appropriately led.
Stated by Home Office
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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.
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
Engage online platforms and retailers to encourage voluntary removal of pure-form substances and vigilance for purchases linked to self-harm or suicide.
Stated by Home Office -
Action
Improve supplier awareness of suspicious-activity reporting obligations and promote safer sales practices, including declaration-of-use forms.
Stated by Home Office
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
Individual substances are not routinely highlighted in guidance because doing so could draw widespread attention; existing general controls and targeted engagement are relied upon.
Stated by Home Office
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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.
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
Assess with DHSC and stakeholders whether additional regulation under the Poisons Act would be effective, proportionate and appropriately led.
Stated by Home Office
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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.
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 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.
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
If an appropriate organisation requires a standardised suicidal-behaviour question, the GPhC would monitor its inclusion through inspections.
Stated by Department of Health and Social Care
Data last updated 7 September 2026