Recurring concern
Unreliable assessment of suicide and self-harm risk
- 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 77 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
HM Prison and Probation Service
Implement and routinely use a reception checklist to acknowledge risk information and support self-harm and suicide risk assessment after court returns.
-
HM Prison and Probation Service
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.
-
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.
Linked response
- South London and Maudsley NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
South London and Maudsley NHS Foundation Trust
Remind staff to record risk assessments in the correct electronic patient-record section.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
South London and Maudsley NHS Foundation Trust
Risk was assessed during admission but recorded in the wrong electronic-record location, rather than not being assessed.
-
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.
Linked response
- HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
HM Prison and Probation Service
Revise the local ACCT case-review process, including enhanced reviews for prisoners with complex needs.
-
HM Prison and Probation Service
Issue staff guidance and notices covering revised ACCT reviews, suicide and self-harm triggers, and learning from recent custody deaths.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
HM Prison and Probation Service
Existing processes are considered comprehensive and effective for identifying and assessing prisoners at risk of suicide or self-harm.
-
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.
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.
Linked response
- North London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
North London NHS Foundation Trust
Require clinical staff to ask every patient about suicidal thoughts or plans, reinforced through supervision and monitoring of clinical standards.
-
North London NHS Foundation Trust
Commission acute inpatient suicide-prevention training from King’s College London for all inpatient services.
-
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.
Linked response
- Norfolk and Suffolk NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Norfolk and Suffolk NHS Foundation Trust
Monitor urgent referrals against the four-hour standard through daily reporting, senior oversight, and clinical review of contact and minimum telephone-contact requirements.
-
Norfolk and Suffolk NHS Foundation Trust
Audit the assessment structure and clinicians’ judgements to support further development of suicide-risk assessment.
-
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.
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
Existing NICE clinical guidelines sufficiently address assessing immediate self-harm and suicide risk.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026