Recurring concern

Unreliable assessment of suicide and self-harm risk

First to latest report 5 May 2013 — 27 May 2026

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.

Reports and published responses 77 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Stephen Ian William Tidey · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stephen Ian William Tidey was found deceased on 22 December 2016, having been found hanging from a tree outside the cabin where he was residing, with self-inflicted wounds to both wrists. The report raised concerns that a high-risk MASH referral, made after he lost his job, was not followed up and that there were no safeguards to ensure referrals were acted upon, including outside normal office hours.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record the basis for reduced risk-of-self-harm assessments

    Wider context from the report

    “He was assessed by a member of the Criminal Liaison and Diversion Service (CLDS) on the same day and was initially assessed by them as being at risk of self-harm. The member of the CLDS subsequently telephoned the Home Treatment Team to discuss referring him to the service. Mr Tidey was then re-assessed by the same member of the CLDS who stated he appeared calmer and was no immediate risk to himself. No notes were recorded on the Police or Mental Health Service computer system to record how this assessment of reduced risk of self-harm had been reached. ”

    Source location

    Stephen Ian William Tidey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Triage SCARF referrals by checking factual content, risks, vulnerabilities, warnings, previous referrals and escalation needs, with risk ratings adjusted and justified where necessary.

    Verbatim wording from the response

    “Police Officers submit a risk assessment form called a Single Combined Assessment of Risk Form (SCARF) to the Police MASH where it is triaged.”

    Source location

    2018-0140-Response-by-Surrey-Police
    Page 1 · response
    Published 1 July 2018

    Open published response

  2. Inner North London

    AI-generated summary

    Siân Louise WITHERIDGE · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis team.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to distinguish denial of a suicide plan from refusal to answer

    Wider context from the report

    “5. There seemed a lack of understanding by the staff of the difference between a patient answering positively that they have no suicide plan and a patient simply refusing to answer a question about a suicide plan. False reassurance appeared to have been drawn from the latter. No arrangement was made for the crisis team to meet Ms Witheridge on 30 May. ”

    Source location

    Siân Louise WITHERIDGE · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    Jonathan Anthony MEANEY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jonathan Anthony Meaney took an overdose on 13 March 2017 and was assessed at hospital, where inpatient treatment was recommended but no bed was found. He was discharged on 15 March after expressing a wish to leave and took his own life the following day; his medical cause of death was morphine and alcohol toxicity. Concerns included the prolonged wait for a bed, aspects of the pre-discharge mental health assessment, lack of consultation with another team member, and uncertainty about whether a proposed GP referral was made.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to reconcile and challenge contradictory suicide-risk information

    Wider context from the report

    “2. When the mental nurse assessed Mr Meaney before discharge on Wednesday, 15 March, he did not question Mr Meaney’s assertion that he had not intended to take an overdose two days before. This was despite the fact that Mr Meaney had told the assessing doctor that he had been trying to kill himself and he had written notes of intent. ”

    Source location

    Jonathan Anthony MEANEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.

    Verbatim wording from the response

    “It follows that the Matters of Concern will need to be addressed substantively by CANDI, which we note has received your Prevention of Future Deaths Report. We understand that CANDI are undertaking a Serious Incident investigation and we are committed to working closely with CANDI, as necessary, to assist them in completing this investigation, developing and implementing an action plan to prevent similar incidents in future and to otherwise assist them in preparing their response to your Prevention of Future Deaths Report. Additionally, we have asked to be provided with copies of CANDI’s final Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately.”

    Source location

    2017-0244-Response
    Page 1 · response
    Published 1 October 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.

    Verbatim wording from the response

    “We have carefully considered the Matters of Concern, all of which relate to care that was delivered by the Camden & Islington NHS Foundation Trust’s Mental Health Liaison service, based within the Royal Free Hospital Emergency Department. The staff working within the Mental Health Liaison service are employed by the Camden & Islington NHS Foundation Trust (“CANDI”), not this Trust (the Royal Free London NHS Foundation Trust), and CANDI manage the Mental Health Liaison service. If a patient attending the Trust’s Emergency Department is considered to have a mental health problem (pertinent to the attendance) or requires a mental health assessment, they are referred to the Mental Health Liaison service, which will then assess the patient and take responsibility for referring onwards to either CANDI’s inpatient facilities or another mental health trust, as appropriate.”

    Source location

    2017-0244-Response
    Page 1 · response
    Published 1 October 2017

    Open published response

  4. Central Hampshire

    AI-generated summary

    Michael Folley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to complete SASH forms for risk information emerging outside current court detention

    Wider context from the report

    “I was also left with a concern that GEOAmey staff would only complete a SASH form if the current risk was identified during Mr Folley’s detention at Portsmouth magistrates’ court and not if anything came to the attention of the court detention officer to indicate there was a risk of self-harm or suicide within the last month before arrest. ”

    Source location

    Michael Folley · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to complete SASH forms for relevant recent self-harm or suicide risk

    Wider context from the report

    “h) The suicide/self harm warning alert (SASH) at page 9 of the PER was meant to be completed if there was a risk of self-harm or suicide since arrest or within the last month. In other words, it was felt the relevant period to be considered was not just the current period of detention but also anything relevant within a month before arrest. In this case the SASH form was never completed. ”

    Source location

    Michael Folley · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use the next custody newsletter to reinforce PER completion, inspection, warning-page, envelope, risk-marker and external-information responsibilities.

    Verbatim wording from the response

    “Force Custody publishes a quarterly newsletter to all custody officers and detention officers. The next publication is due in September 2019 and will reinforce the issues addressed in this Regulation 28 Notice.”

    Source location

    2019-0230-Response-by-Hampshire-Constabulary
    Page 2 · response
    Published 18 July 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review force policies and procedures and add the notice’s issues to relevant documents where necessary.

    Verbatim wording from the response

    “Force Custody is currently conducting a full review of our Force Policies and Procedures. The issues raised in this Regulation 28 Notice will be reviewed and added to relevant policies and procedures if not already included.”

    Source location

    2019-0230-Response-by-Hampshire-Constabulary
    Page 2 · response
    Published 18 July 2019

    Open published response

  5. Avon

    AI-generated summary

    Callum Oliver SMITH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Callum Oliver SMITH was in the care of HMP Bristol when he was found hanging in his cell and died from hanging. The inquest concluded that his death was caused by suicide while he was suffering extreme anxiety and distress. Concerns included inadequate risk assessment and mental health assessment, poor communication and record-sharing, and repeated failures to open an ACCT due to training and staff-understanding issues.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment

    Wider context from the report

    “1. At the conclusion of the inquest I expressed my concern in relation to assessing risk of suicide and self-harm and how from the evidence heard it appeared that there was a possible conflict between how healthcare/mental healthcare staff assess risk in this area and the requirements of the ACCT policy for all staff working with prisoners to follow the requirements of PSI 64/2011. 2. There was evidence that healthcare/mental healthcare staff needed to be reminded of the lower threshold for opening an ACCT and that this is fundamentally different to the way that they carry out an assessment and/or risk assessment of a patients risk of suicide or self harm for medical/mental health care and treatment as per PSI 64/2011. 3. I was concerned that staff who apparently had been trained did not appear to consider that they had when giving evidence and therefore I would ask that this is reviewed to ensure that healthcare/mental healthcare staff receive detailed training on the ACCT process as it is clear an important and recognized policy in preventing a risk of self-harm or suicide. 4. I indicated that I would ensure that this report was copied to the prison as they would need to be aware of this, as it is often they who provide the ACCT training for healthcare/mental healthcare staff. ”

    Source location

    Callum Oliver SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver the rolling SASH programme, mandate existing healthcare staff attendance, and provide new starters with training within six months.

    Verbatim wording from the response

    “All healthcare staff will therefore revisit the PSI through Suicide and Self Harm (SASH) training and local training/meetings.”

    Source location

    2017-0185-Response-by-Prison-Health-Services
    Page 1 · response
    Published 9 August 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Incorporate an ACCT overview into the induction process for new staff, including documented acknowledgement of understanding.

    Verbatim wording from the response

    “ACCT overview to be incorporated into new staff induction process.”

    Source location

    2017-0185-Response-by-Prison-Health-Services
    Page 2 · response
    Published 9 August 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reinforce SASH requirements through monthly team meetings using bite-sized ACCT-opening scenarios and discussion.

    Verbatim wording from the response

    “SASH training requirements to be at reinforced monthly team meetings.”

    Source location

    2017-0185-Response-by-Prison-Health-Services
    Page 2 · response
    Published 9 August 2017

    Open published response

  6. City of London

    AI-generated summary

    Charlotte Anne Agnew · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Charlotte Anne Agnew became psychiatrically unwell and expressed suicidal ideation. After referrals to psychiatric services, her care was not effectively transferred, her suicide risk was not sufficiently assessed or managed, and no care plan was put in place; she died on 25 March 2016 after ingesting high levels of alcohol and medication and jumping in front of a London Underground train. The report identified an ongoing risk that similar failures in timely assessment, treatment, care transfer and suicide-risk management could recur.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate assessment of patients’ risk of suicide

    Wider context from the report

    “It was apparent from the evidence that there were five principal failures by the Trust in relation to the treatment and care provided to the Deceased. These were: (1) The Deceased was first assessed by the Trust’s Early Intervention and Assertive Psychosis Team who recognised that she was in need of psychiatric treatment and care by another team but, despite referring her on to other psychiatric teams within the Trust, made no effective transfer of her care before discharging her back to her General Practitioner and closing her case. A significant number of clinical and managerial staff were involved in this process and none of them prevented the Deceased’s premature discharge. (2) Prior to the Deceased’s discharge no sufficient assessment was made of her risk of suicide. Despite at least two clinical staff being involved, there was insufficient evidence gathering, including from the Deceased’s family, and a wholly inadequate assessment was made despite the use of the Trust’s electronic assessment tool (which was not properly completed). Further, no plan was put in place to manage the Deceased’s recognised risk of suicide. (3) Prior to the Deceased’s discharge no care plan was put in place and no single person had responsibility for ensuring care was properly assessed, co-ordinated and delivered prior to discharge. (4) The Deceased was discharged back to the care of her General Practitioner with a recommendation for the prescription of psychiatric medication without her having been seen or assessed by the psychiatrist who made the recommendation and with no means of monitoring its subsequent effectiveness. (5) Despite the matters set out in (1) to (4), the General Practitioner’s request, made on 15 March 2016, for an urgent assessment was not granted and the Trust’s Access and Assessment Team provided an appointment for a date five weeks later on 20 April 2016. I was told by witnesses from the Trust (and in submissions made on behalf of the Trust) that the Trust had adequate relevant policies and procedures in place at the time and that the failings set out above occurred because all the staff involved failed to follow those policies and procedures. It was said that there had been no subsequent amendment of the policies and procedures but, in summary, that staff have been reminded of them and what ought to happen (by email) and there is now an increased level of monitoring of compliance. Whilst the staff directly involved, who gave oral evidence at the inquest, told me that they now understand that the above failings ought not to have happened and would not occur now, I remain concerned that one or more of the above failings could recur in the future. Although the Trust has taken steps to inform current staff of what went wrong in the Deceased’s case, it has not taken steps to ensure that the above failings could not occur again (whether by amendment or clarification of its policies and/or procedures or sufficient training of staff or otherwise). Most particularly, the evidence provided to me did not satisfy me that the Trust’s policies and procedures, and the training given upon them, now ensure that every patient who is referred to the Trust will be assessed and treated in a timely manner, even if transfer between teams is necessary. Nor did it satisfy me that every patient’s risk of suicide is now properly assessed and managed so as to ensure the risk is minimised. In all the circumstances I consider that there is an ongoing risk that any one or more of the above failings could recur. If that risk is permitted to continue, it could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives. ”

    Source location

    Charlotte Anne Agnew · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Inner North London

    AI-generated summary

    John WILLIAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to accurately record self-harm or suicide assessments

    Wider context from the report

    “1. The first reception nurse who saw Mr Williams when he entered HMP Pentonville gave evidence that he had no thoughts of self harm or suicide, but she recorded that he had. It appears she may benefit from additional training and/or supervision. ”

    Source location

    John WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Manchester South

    AI-generated summary

    Rachel Morgan · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rachel Morgan, who had post-natal depression with psychotic symptoms and was considered at high risk of suicide, was found with a ligature around her neck on 16 April 2016 and died from severe anoxic brain injury on 24 April 2016. The principal concerns were delays in reviewing her medication, failures to update risk assessments after information about her suicide risk was received, insufficient observation levels, and a lack of clarity about observation procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Over-reliance on inpatient status as a protective factor in suicide risk assessment

    Wider context from the report

    “(5) As the Serious Incident Review highlighted, I am also concerned that staff at the Medlock Ward placed an over-reliance on the fact that Rachel was an inpatient as a protective factor. The evidence I have heard confirms the findings of the SIR that during her time on the Medlock Ward Rachel’s feelings of hopelessness and constant thoughts of self-harm did not reduce during her time and although her means for ending her own life were reduced, they were not entirely removed. There was evidence available to nursing staff that could indicated that Rachel was still thinking about ending her life whilst an inpatient and was considering the means that would allow her to do so. The jury have found that this was not adequately addressed by implementing enhanced observations. ”

    Source location

    Rachel Morgan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to conduct full self-harm and suicide risk assessments after concerning incidents

    Wider context from the report

    “(2) I am concerned that on 2 occasions matters came to the attention of the nursing staff that gave them cause for concern regarding Rachel’s risk of self-harm/ suicide and that neither of these incidents generated a full risk assessment to be conducted. Those incidents were the incident with the Nicorette Inhalator on the 14th April 2016 and the phone call from Rachel’s mother on the 15th April 2016. ”

    Source location

    Rachel Morgan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Cambridgeshire and Peterborough

    AI-generated summary

    Peter Lawrence · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter Lawrence was remanded into custody at HMP Peterborough and, on 02.02.15, was found in a prison workshop toilet cubicle having stabbed himself with a chisel; he was taken to hospital where death was confirmed. The concerns related to identifying and recording suicide or self-harm risks during the initial screening of first-time prisoners, and to the absence of meaningful interaction with a custodial officer who could help identify and manage such risks.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to identify less obvious suicide and self-harm risk factors at initial screening

    Wider context from the report

    “(1) The inquest heard a great deal of evidence relating to the process for identifying, managing and recording risk at the first point of contact between new prisoners and prison/healthcare staff. Mr Lawrence had not been in prison before and there was very little background information available to enable staff to identify less obvious risk factors, particularly in relation to the nature of the alleged offences. It was accepted in evidence that it was of particular importance at the initial screening to identify risk by other means and to record any observations in a comprehensive manner for future reference. HMP Peterborough has put in place a number of measures in recognition of the concern that suicide/self harm risk is identified at the earliest stage, even if no ACCT document is opened. The concern that risk factors may be missed or inadequately recorded has been addressed locally but there may be scope to expand awareness that individuals entering prison for the first time may be accompanied by only limited information. The situation is worsened where there is limited information available about the nature of the alleged offending. The identification and communication of less obvious risk factors is crucial; ”

    Source location

    Peter Lawrence · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Isle of Wight

    AI-generated summary

    Stephen St Clair · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stephen St Clair, a prisoner at HMP Isle of Wight, was found in his cell on 4 November 2013 with a severe cut to his throat and was pronounced dead at 05.55 hours. The report describes concerns about signs of paranoia and possible psychosis not being recognised as suicide or self-harm risk, and about the absence of corresponding wording in the Prison Service suicide risk guidance, which may have contributed to an ACCT not being opened.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of suicide risk guidance to include irrational behaviour indicative of psychosis

    Wider context from the report

    “2. The next section in PSI 64/2011 deals with “Risk Factors for Self-Harm” and includes a sub-heading entitled “Current Context” where the following is included: “Irrational behaviour, out of touch with reality”. 3. I am concerned that the “Risk Factors for Suicide” does not actually include words to the effect of “Irrational behaviour, out of touch with reality” as the evidence from the Consultant Forensic Psychiatrist suggested that this behaviour was strongly suggestive of psychosis, and as such, the prisoner was in need of additional monitoring to keep him safe and to protect him from self-harm or suicide. ”

    Source location

    Stephen St Clair · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of descriptions of symptoms of undiagnosed mental illness in suicide risk guidance

    Wider context from the report

    “1. The Prison Service Instruction (“PSI”) 64/2011 (Management of prisoners at risk of harm to self, to others and from others (Safer Custody)) addresses the “Risk Factors for Suicide”. There are various subheadings, including “Clinical History” where the following point is made: “Mental illness diagnosis (e.g. depression, bipolar disorder, schizophrenia)” but there is no description of the possible symptoms which might be displayed by those who may be suffering from as yet undiagnosed conditions. ”

    Source location

    Stephen St Clair · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026