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 provide thorough post-court assessments for prisoners at elevated self-harm or suicide risk
This report raised 1 other concern. 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 and routinely use a reception checklist to acknowledge risk information and support self-harm and suicide risk assessment after court returns.
Stated by HM Prison and Probation Service -
Action
Trial revised national and local Prisoner Escort Records in the South Central Area, incorporating suicide and self-harm alerts and prominent red-flag risk information pages.
Stated by HM Prison and Probation Service
-
Concerns raised1
Failure to properly assess and record self-harm and 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.1
-
Action
Remind staff to record risk assessments in the correct electronic patient-record section.
Stated by South London and Maudsley 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
Risk was assessed during admission but recorded in the wrong electronic-record location, rather than not being assessed.
Stated by South London and Maudsley NHS Foundation Trust
-
Concerns raised1
Failure to assess the risk of suicide
This report raised 1 other concern. 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
Revise the local ACCT case-review process, including enhanced reviews for prisoners with complex needs.
Stated by HM Prison and Probation Service -
Action
Issue staff guidance and notices covering revised ACCT reviews, suicide and self-harm triggers, and learning from recent custody deaths.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing processes are considered comprehensive and effective for identifying and assessing prisoners at risk of suicide or self-harm.
Stated by HM Prison and Probation Service
-
Concerns raised1
Failure to assess and identify suicidal or other self-harming behaviour in clinicians subject to investigative processes
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.
-
Concerns raised1
Failure to ask patients about thoughts of taking their life
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
Require clinical staff to ask every patient about suicidal thoughts or plans, reinforced through supervision and monitoring of clinical standards.
Stated by North London NHS Foundation Trust -
Action
Commission acute inpatient suicide-prevention training from King’s College London for all inpatient services.
Stated by North London NHS Foundation Trust
-
Concerns raised1
Failure to recognise and act on suicide or serious self-harm 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
-
Action
Monitor urgent referrals against the four-hour standard through daily reporting, senior oversight, and clinical review of contact and minimum telephone-contact requirements.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Audit the assessment structure and clinicians’ judgements to support further development of suicide-risk assessment.
Stated by Norfolk and Suffolk NHS Foundation Trust
-
Concerns raised2
Lack of structured assessment and recording of self-harm risk factors
Use of unhelpful high, medium and low risk categories in self-harm risk assessment
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing NICE clinical guidelines sufficiently address assessing immediate self-harm and suicide risk.
Stated by Department of Health and Social Care
Data last updated 7 September 2026