First reported 5 May 2013•Latest report 27 May 2026
Definition
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
Distinct published reports
Individual concerns
94
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
132
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.
HM Prison and Probation Service12
NHS England9
Department of Health and Social Care7
Home Office7
Central and North West London NHS Foundation Trust6
North London NHS Foundation Trust5
Metropolitan Police Service4
Ministry of Justice4
North East London NHS Foundation Trust4
Care UK3
Essex Partnership University NHS Foundation Trust3
HM Prison Service3
Midlands Partnership University NHS Foundation Trust3
Avon and Wiltshire Mental Health Partnership NHS Trust2
General Medical Council2
NHS trust44
Ministerial department19
Executive agency12
Executive non-departmental public body9
Police force8
Prison or young offender institution8
Integrated care board4
Sub-organisation4
Multi-service care provider3
Community interest company2
Health and care professional regulator2
Healthcare site2
Local health board2
Company limited by guarantee1
Coronial office1
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.
Inner North London
Concerns raised1
Failure to explore potential triggers for disclosed suicidal thoughts
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 concerns
Each 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
Review, approve and implement a revised first-night mental-health risk assessment with staff training, SystmOne integration and advisory clinical-judgement guidance.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2016.
Preston and West Lancashire
Concerns raised1
Failure of RMNs to make medical-record enquiries about self-harm or suicide responses
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Milton Keynes
Concerns raised2
Failure of healthcare staff to fully participate in suicide and self-harm risk assessment for new prisoners
Failure to identify or properly assess suicide and self-harm risk in newly arrived prisoners
Responses linked to these concerns
Each 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.13
Action
Strengthen the reception screening tool with detailed mental-health, self-harm and suicide-risk questions.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Train reception-screening staff, including agency staff where used, to apply the strengthened screening tool.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Increase experienced mental-health nursing capacity in the First Night Centre to support risk assessment and management.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Introduce a next-day secondary health screen for self-harm risk after the initial reception assessment.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Provide daily Mental Health team risk assessments for prisoners arriving at the First Night Centre.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Develop and complete Trust-wide e-learning on assessing and managing self-harm and suicide risk for HMP Woodhill staff.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Provide ongoing support for prison ACCT training and prison-led ACCT management.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Check daily information-sharing and review ACCT records at each planned review meeting.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Audit and continue monitoring record-keeping for staff attending ACCT reviews to ensure risk information is recorded and shared.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Conduct a comprehensive independent review of safer custody procedures and prison-wide factors affecting prisoner wellbeing.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Conduct an independent review of healthcare services, including mental health and substance misuse provision, alongside the safer custody review.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Implement the Entry to Custody Risk Assessment process through staged reception and first-night screening, including multi-agency review and incorporation into local policy.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 14 December 2015.
Action
Maintain a dedicated mental health team member on the First Night Centre to interview new prisoners and update identified risk factors.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
NOMS holds policy responsibility for suicide prevention and self-harm management.
Stated by Central and North West London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The prison leads the ACCT process and is responsible for regularly assessing prisoners’ risk.
Stated by Central and North West London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
No nationally recognised best-practice risk-assessment tool exists beyond the processes specified in Prison Service Instructions.
Stated by Central and North West London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Inadequate staff understanding and tools for self-harm risk assessment
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Ensure AABIT staff are competent in risk assessment and escalation of risk.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 November 2015.
Avon
Concerns raised1
Failure to appropriately assess service users' risk of suicide or self-harm
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 concerns
Each 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
Revise 136 suite admission paperwork to incorporate Royal College of Psychiatrists’ risk headings for clearer detainee risk identification.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 24 July 2015.
Inner North London
Concerns raised1
Failure to ask patients about thoughts of suicide
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Pilot the mental health assessment proforma and make it available to mental health colleagues.
Stated by Whittington Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The triage assessment was recorded electronically, including the patient’s arrival, assessment, police attendance and high risk of self-harm.
Stated by Whittington Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Peterborough
Concerns raised1
Failure to comprehensively assess suicide and self-harm risk using documented risk factors and information
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Milton Keynes
Concerns raised2
Failure to complete formal self-harm or suicide risk assessments on prison admission
Unavailability of a formal self-harm or suicide risk assessment tool in prisons
Responses linked to these concerns
Each 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 improving risk identification, assessment and management processes.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 29 August 2014.
Action
Remind reception and first-night staff to gather relevant information and consider relevant risk factors.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 29 August 2014.
Action
Improve the healthcare staff risk-assessment process.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 29 August 2014.
Action
Train healthcare staff to use the improved risk-assessment process.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 29 August 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing processes, including limited screening tools, are considered sufficient without a formal risk-assessment tool across the prison estate.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
County Durham and Darlington
Concerns raised1
Unclear recording of self-harm risk assessment and conclusions
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 concerns
Each 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
Reinforce recording of colleague-reported risks and home-visit decisions in electronic care-record alerts.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 August 2014.
Action
Complete the Trustwide review of clinical risk assessment and management policy and practice, incorporating investigation and inquest information.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 August 2014.
Inner North London
Concerns raised1
Failure to directly assess thoughts of taking one's life
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 concerns
Each 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
Update the clinical risk assessment and management policy.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 August 2014.
Action
Raise with supervisors that risk-assessment content must be checked during supervision.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 August 2014.
Action
Instruct clinical staff to assess risks to self and others and address identified risks in care plans.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 August 2014.
Pin
Get email alerts
Request correction
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.
