Recurring concern
Unreliable assessment of suicide and self-harm risk
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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.
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Concerns raised1
Failure to complete appropriate risk assessments before high-risk patients leave the acute ward
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 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.5
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Action
Review and update policies and flowcharts guiding risk assessment and supervision of inpatients at high risk of self-harm.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Include Section 5(2) Mental Health Act guidance in the Trust’s Mental Health policy for high-risk patients attempting or intending to leave the ward.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Raise awareness of the updated Section 5(2) guidance through the Nurses’ Grand Rounds programme.
Stated by Mid and South Essex NHS Foundation Trust
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Action
Deliver Section 5(2) Mental Health Act training to FY2 doctors every six months during induction.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Add Section 5(2) Mental Health Act assessment to the Trust’s monthly online Mental Health Act training.
Stated by Mid and South Essex NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
MSE is responsible for responding to the risk of high-risk self-harm patients leaving the acute ward without appropriate risk assessment.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to carry out holistic formulations of risk to self
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.1
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Action
Deliver and expand face-to-face risk-formulation training across acute, rehabilitation and borough-based staff, including new starters.
Stated by North East London NHS Foundation Trust
-
Concerns raised1
Failure to understand and assess risk in ACCT processes and risk assessments
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.4
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Action
Provide regular staff training and guidance on operating the ACCT process.
Stated by HM Prison and Probation Service -
Action
Disseminate ACCT guidance covering when to open an ACCT and when to hold a review after risk changes.
Stated by HM Prison and Probation Service -
Action
Use a booking system to ensure required ACCT case reviews occur within an appropriate timescale.
Stated by HM Prison and Probation Service
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Action
Operate a three-stage quality assurance process to identify individual or wider ACCT upskilling needs.
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
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Position
Responsibility for delivering suicide and self-harm risk management and the ACCT process at HMP Ranby sits with the Head of Safety.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure of hospital and police custody risk assessments to identify suicide or self-harm risk before release
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.1
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Action
Audit pre-release risk assessments monthly to monitor and improve their quality.
Stated by West Midlands Police
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Mental-health input for people in police custody is provided through the locally organised Liaison and Diversion Service between police and mental-health services.
Stated by the Royal Wolverhampton NHS Trust
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Concerns raised1
Failure to robustly consider red-flag risk factors in risk assessments
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 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.4
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Action
Complete the review of the clinical risk-assessment competency framework and audit tool to strengthen monitoring of risk-assessment and formulation documentation.
Stated by Leicestershire Partnership NHS Trust -
Action
Present the risk-assessment review outcomes to the Urgent Care Quality and Safety Meeting to inform required changes.
Stated by Leicestershire Partnership NHS Trust -
Action
Update the Central Access Point Standard Operating Procedure to require clinicians to review records, assess referrals and prioritise triage calls by risk, urgency and availability.
Stated by Leicestershire Partnership NHS Trust
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Action
Redesign the Safe and Well template with staff input, obtain clinical safety sign-off and make it available within the electronic patient record.
Stated by Leicestershire Partnership NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Red-flag risk factors alone do not establish likelihood of self-harm or suicide; risk decisions should be based on clinical formulation.
Stated by Leicestershire Partnership NHS Trust
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Concerns raised1
Failure to recognise elevated suicide risk from prolonged refusal to eat or drink
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.5
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Action
Hold a reflective multidisciplinary away day using food-and-drink case studies to strengthen holistic clinical risk assessment.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Discuss food-and-drink risk assessment in clinical supervision and review it in future team meetings.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Use daily team huddles to prompt consideration of eating and drinking in holistic clinical risk assessments.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Action
Revise SBAR handover records to capture eating-and-drinking quantity, not only appetite, for clinical risk assessment.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Develop and deliver bespoke training linking suicide prevention with malnourishment, with subject-matter expert support.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Failure to adequately assess the risk of impulsive suicide
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.
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
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Action
Issue guidance reminding staff to consider consultant psychiatrist assessment for people with complex emotional needs and suicide risk.
Stated by Central and North West London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Responding to the Coroner’s specific concerns falls outside NHS England’s remit.
Stated by NHS England
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Position
The Trust is responsible for responding to the Coroner’s specific concerns.
Stated by NHS England
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Concerns raised1
Inadequate exploration of matters affecting suicide risk
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 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
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Action
Train staff in suicide awareness, risk formulation and collaborative safety planning across the organisation.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Include families and carers in collaborative safety planning.
Stated by Midlands Partnership University NHS Foundation Trust
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Concerns raised1
Failure to identify or recognise suicide risk during referral screening
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 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.
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Concerns raised1
Lack of a formal mental health and suicide or self-harm risk assessment at PCR delivery
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.1
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Action
Develop a policy requiring supervised, documented risk assessments before issuing PCRs to recordable-offence suspects, including risk management and decisions on personal service.
Stated by Metropolitan Police Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Current pre-charge bail arrangements and guidance provide further opportunities to assess suicide risk, so additional assessment at postal charge requisition is not identified.
Stated by College of Policing
Data last updated 7 September 2026