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 record the basis for reduced risk-of-self-harm assessments
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
-
Action
Triage SCARF referrals by checking factual content, risks, vulnerabilities, warnings, previous referrals and escalation needs, with risk ratings adjusted and justified where necessary.
Stated by Surrey Police
-
Concerns raised1
Failure to distinguish denial of a suicide plan from refusal to answer
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to reconcile and challenge contradictory suicide-risk information
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
Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.
Stated by Royal Free London 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
CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.
Stated by Royal Free London NHS Foundation Trust
-
Concerns raised2
Failure to complete SASH forms for risk information emerging outside current court detention
Failure to complete SASH forms for relevant recent self-harm or suicide risk
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 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
Use the next custody newsletter to reinforce PER completion, inspection, warning-page, envelope, risk-marker and external-information responsibilities.
Stated by Hampshire and Isle of Wight Constabulary -
Action
Review force policies and procedures and add the notice’s issues to relevant documents where necessary.
Stated by Hampshire and Isle of Wight Constabulary
-
Concerns raised1
Failure of healthcare/mental healthcare staff to apply the lower ACCT threshold distinctly from clinical suicide and self-harm risk assessment
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.3
-
Action
Deliver the rolling SASH programme, mandate existing healthcare staff attendance, and provide new starters with training within six months.
Stated by Inspire Better Health -
Action
Incorporate an ACCT overview into the induction process for new staff, including documented acknowledgement of understanding.
Stated by Inspire Better Health -
Action
Reinforce SASH requirements through monthly team meetings using bite-sized ACCT-opening scenarios and discussion.
Stated by Inspire Better Health
-
Concerns raised1
Inadequate assessment of patients’ risk of suicide
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.
-
Concerns raised1
Failure to accurately record self-harm or suicide 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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Over-reliance on inpatient status as a protective factor in suicide risk assessment
Failure to conduct full self-harm and suicide risk assessments after concerning incidents
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 identify less obvious suicide and self-harm risk factors at initial screening
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Failure of suicide risk guidance to include irrational behaviour indicative of psychosis
Lack of descriptions of symptoms of undiagnosed mental illness in suicide risk guidance
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.
Data last updated 7 September 2026