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 raised3
Lack of written rationale for self-harm and suicide risk assessments
Overreliance on prisoners’ denials and tick-box recording in suicide and self-harm risk assessment
Failure to undertake holistic and updated self-harm or suicide risk assessment
This report raised 18 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
Complete changes to the redesigned ACCT form and guidance and roll them out across the prison estate.
Stated by HM Prison and Probation Service -
Action
Redevelop ACCT training and deliver it to new staff and as refresher training for existing staff.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to identify increased self-harm risk in prisoners due in Court the following morning
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to conduct direct assessment of suicide and self-harm risk during ACCT reviews
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 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 Introduction to Suicide and Self Harm Prevention training to HMPPS staff with prisoner contact and offer it to partner and contractor staff.
Stated by HM Prison and Probation Service
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Concerns raised1
Inadequate specific deliberate self-harm or suicidal ideation criteria
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 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
Failure to assess disclosed risk of self-harm or suicide
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.3
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Action
Review current training and support for recognising risk, escalating concerns and safeguarding adults.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Run a two-day professional leadership forum to reinforce individual responsibility and accountability for patient safety and suicide prevention, with learning cascaded to teams.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Issue a safeguarding newsletter reminder about procedures following disclosures of possible suicidal intent, including the suicide-support leaflet.
Stated by Royal Devon University Healthcare 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
The incident is considered isolated, and staff are considered aware of their safeguarding obligations and required actions.
Stated by Royal Devon University Healthcare NHS Foundation Trust
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Concerns raised1
Lack of guidance for reducing observations of newly arrived prisoners from constant watch
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.7
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Action
Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
Stated by Care UK -
Action
Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
Stated by Care UK -
Action
Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
Stated by Care UK
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Action
Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
Stated by HM Prison and Probation Service -
Action
Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
Stated by HM Prison and Probation Service -
Action
Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
Stated by HM Prison and Probation Service -
Action
Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
Stated by HM Prison and Probation Service
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Concerns raised1
Inadequate risk history-taking during clinical consultation
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
Remind staff through Clinical Board quality, safety and experience structures to take complete, diligent mental-health histories using all available information.
Stated by Cardiff & Vale University LHB
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Concerns raised2
Failure to consider relevant substance use and suicide risk before prescribing Concerta
Failure to obtain sufficient details of a reported suicide attempt
This report raised 9 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
Establish a senior medical decision-making group to review ADHD assessment, diagnosis, questionnaire use and prescribing practice.
Stated by Sussex Partnership NHS Foundation Trust -
Action
Publish a Patient Safety Matters story covering the case and issues surrounding co-morbid substance misuse.
Stated by Sussex Partnership NHS Foundation Trust
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Concerns raised1
Over-reliance on questionnaires causing underestimation of self-harm risk
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 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 raised2
Use of unqualified support workers for suicide risk assessments
Absence of a scoring system or guide for suicide risk assessments
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
Ensure commissioned and provided services deliver high-quality risk assessment continuously, 24 hours a day, seven days a week.
Stated by NHS England
Data last updated 7 September 2026