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 South London
Concerns raised1
Failure to fully assess recurrent impulsive self-harm risks in post-sentencing situations
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
Revise the probation suicide and self-harm guide to assess current suicide-risk concerns and relevant historic information.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 December 2021.
Action
Add guidance to the EQUiP process map directing court staff to complete a Suicide Risk Form when a current concern is identified.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 December 2021.
Action
Remind London probation staff to follow the risk-to-self process maps and complete a Suicide Risk Form when a current concern is identified.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 December 2021.
Action
Disseminate the directive on following risk-to-self process maps and completing Suicide Risk Forms across the Probation Service nationally.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 December 2021.
Berkshire
Concerns raised1
Failure to identify key suicide risk factors
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 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
Introduce digital tools explaining how personnel can identify suicide risk factors.
Stated by ArmyStated completedThe respondent said that this action was complete when they made their response on 29 November 2021.
Action
Deliver mental resilience and mental fitness training across all career-stage courses and ranks.
Stated by ArmyStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2021.
West Yorkshire Eastern
Concerns raised1
Failure to sufficiently consider the significance of potential farewell behaviour
This report raised 13 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.
Surrey
Concerns raised1
Failure to verify the safety of distressed students from 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 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.5
Action
Implement enhanced safeguarding processes, including a safeguarding policy, broader training access and consideration of all students as potential safeguarding concerns.
Stated by University of SurreyStated completedThe respondent said that this action was complete when they made their response on 1 December 2022.
Action
Implement student concern reporting, repeated follow-up and escalation processes, including escalation to health, security or police services when appropriate.
Stated by University of SurreyStated completedThe respondent said that this action was complete when they made their response on 1 December 2022.
Action
Provide personalised, student-led action plans for students at risk to support individual safety needs and risk management.
Stated by University of SurreyStated completedThe respondent said that this action was complete when they made their response on 1 December 2022.
Action
Use risk assessments as working documents with students to mitigate risk, establish action plans, support follow-up and enable earlier escalation or information sharing.
Stated by University of SurreyStated completedThe respondent said that this action was complete when they made their response on 1 December 2022.
Action
Deliver suicide-awareness, mental-health, distressed-student and safeguarding training, including ASIST for relevant security staff and training for personal tutors.
Stated by University of SurreyStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
CWB staff followed the internal processes then in place to reassure themselves about the student’s safety from self-harm.
Stated by University of SurreyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner West London
Concerns raised2
Failure to assess suicide risk during the current treatment episode
Lack of staff training in suicide risk assessment
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.
Inner South London
Concerns raised1
Failure of the prisoner arrival form to provide a clear self-harm and suicide risk assessment and response pathway
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 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
Implement a revised immediate-needs form with clearer guidance for identifying, communicating and documenting suicide or self-harm risks.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 February 2021.
East London
Concerns raised3
Failure to obtain and document a second psychiatric opinion before downgrading suicide risk
Failure to consult the referring general practitioner before downgrading suicide risk
Failure to safeguard downgrading of suicide risk by staff unfamiliar with the patient
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
Introduce referral to the on-call psychiatrist when presenting risk significantly differs from another clinician’s same-day assessment.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 December 2020.
Action
Review Clinical Risk Advanced training to include differing clinical opinion scenarios and guidance on addressing them.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 December 2020.
Action
Amend the Psychiatric Liaison Service assessment template to prompt documentation of concerns, protective factors and the risk management plan.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 December 2020.
East London
Concerns raised1
Failure to complete a self-harm or suicide risk assessment
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 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
Trial the THRIVE+ vulnerability assessment framework to assess and document vulnerability, including suicidal thoughts, and support ongoing risk review and information sharing.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2020.
Action
Introduce a mandatory enhanced SOIT risk assessment covering suicide, cultural complexities and honour-based violence, with police-indices review, CRIS recording and supervisor escalation.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
Lancashire and Blackburn with Darwen
Concerns raised1
Failure to reassess altered self-harm risk
This report raised 19 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.
Central Hampshire
Concerns raised2
SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information
Lack of effective SystmOne training and competency in suicide and deliberate self-harm risk assessment
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.6
Action
Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2020.
Action
Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 March 2020.
Action
Train all staff during induction to use SystmOne’s problem functionality and audit its use through quarterly care-quality meetings.
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 9 March 2020.
Action
Deliver SystmOne training through induction and the Learning and Development Zone, including additional training identified through supervision.
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 9 March 2020.
Action
Require annual Suicide and Self Harm and ACCT training, with successful testing before staff are signed off as compliant.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2020.
Action
Audit mental-health risk assessments and resulting care plans quarterly and during the annual medical-records audit.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
SystmOne’s contract is managed by NHS England, while system developments are for NHS England and TPP to consider.
Stated by Central and North West London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Clinicians are not reliant solely on patients’ disclosed answers or presentation when assessing suicide and self-harm risk.
Stated by Central and North West London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
