Recurring concern
Unreliable assessment of suicide and self-harm risk
Pin
Get email alerts
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.
-
Concerns raised1
Failure to assess the risk of suicide or self-harm upon release
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.2
-
Action
Implement a Health and Justice risk-assessment procedure covering suicide and self-harm assessment, information sharing, Police IT recording, verbal-feedback documentation, and recording declined assessments.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Deliver mandatory three-level suicide-mitigation training to Health and Justice clinical staff through e-learning and taught sessions.
Stated by Midlands Partnership University NHS Foundation Trust
-
Concerns raised1
Failure to recognise imminent suicide risk after a patient absconds
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.
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
Review the Risk Assessment policy in light of recent NICE guidance.
Stated by East London NHS Foundation Trust -
Action
Seek external expert opinion on proposed changes to risk assessment policy and procedures before implementation work begins.
Stated by East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
Stated by NHS England
-
Concerns raised1
Failure to incorporate available clinical information into self-harm risk assessments
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.
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
Use live RiO records for handovers, daily run-throughs and MDT ward rounds.
Stated by North East London NHS Foundation Trust -
Action
Audit compliance with live-record use and risk-assessment processes.
Stated by North East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social Care
-
Concerns raised1
Failure of ambulance triage to assess presenting mental-health and self-harm 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 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.
-
Concerns raised1
Superficiality of suicide risk assessments
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
-
Action
Allocate three shared Key Workers using clinical-risk and staff-availability criteria, with regular caseload audits to confirm allocation.
Stated by The Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The 16 July 2021 risk assessment was not flawed; two experienced clinicians considered relevant static and dynamic risk factors before grading risk.
Stated by The Trust
-
Concerns raised1
Failure to update suicide self-harm 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.2
-
Action
Introduce Advanced Clinical Practitioners to support care planning, risk management and identification of Care and Treatment Plan deficiencies.
Stated by Central and North West London NHS Foundation Trust -
Action
Review the Clinical Risk Assessment and Safety Policy and mandate its associated e-learning for staff.
Stated by Central and North West London NHS Foundation Trust
-
Concerns raised1
Lack of a clear protocol for responding to short-term suicide risk after a trigger event
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
-
Action
Update the Supportive Observation and Engagement Policy to require automatic senior review when non-registered staff identify a trigger event.
Stated by Cheshire and Wirral Partnership NHS Foundation Trust -
Action
Provide face-to-face clinical risk training using formulation and SystmOne application to all inpatient staff.
Stated by Cheshire and Wirral Partnership NHS Foundation Trust
-
Concerns raised1
Failure to incorporate autism into assessment and management of self-harm risk
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 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
-
Position
TEWV is responsible for delivering mental health services and making autism-related reasonable adjustments under its contract.
Stated by NHS England
-
Concerns raised2
Failure of the WARRN assessment tool to prompt consideration and recording of advocacy referrals and capacity assessments
Failure of the WARRN documentation to clearly and accessibly record fluctuating self-harm risk and reassessments
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
-
Action
Continue six-monthly Welsh Applied Risk Research Network record audits by Powys Teaching Health Board.
Stated by Powys County Council and Powys Teaching Local Health Board -
Action
Reinstate advocacy clinics in community mental-health teams and inpatient units.
Stated by Powys County Council and Powys Teaching Local Health Board -
Action
Improve inpatient staff WCCIS access and training so staff can complete risk documentation without duplicate Word templates.
Stated by Powys County Council and Powys Teaching Local Health Board
-
Action
Update WCCIS to record risk chronologies and significant self-harm events, supporting dynamic reassessment.
Stated by Powys County Council and Powys Teaching Local Health Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The Welsh Applied Risk Research Network form cannot be altered because it must remain in its original evidence-based form.
Stated by Powys County Council and Powys Teaching Local Health Board
-
Concerns raised1
Failure to ask about or document suicidal ideation and self-harm
This report raised 11 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
-
Action
Share suicide and self-harm documentation and assessment learning with all Frimley GP practices through bulletins, meetings, clinical leads and prescribing updates.
Stated by NHS Frimley ICB -
Action
Deliver a recorded virtual training session on mental health assessment and documentation, then distribute the recording to all practices.
Stated by NHS Frimley ICB -
Action
Attend a CPD course on recognising mental-health suicide risks for reminder and ongoing professional development.
Stated by Farnham Park Health Group and Recipient name withheld
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
-
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality Commission
-
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality Commission -
Position
Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Stated by Care Quality Commission -
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical Council -
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical Council -
Position
The GP disputes that no mental health risk assessment occurred, stating that he asked about suicidal ideation and self-harm.
Stated by Farnham Park Health Group and Recipient name withheld
Data last updated 7 September 2026