Recurring concern

Failure to provide timely and competent mental health assessment after self-harm

First to latest report 20 Oct 2015 — 26 Mar 2024

Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
12

What this concern includes

Includes failures in the process of providing mental health assessment after self-harm or disclosure of suicidal ideation, including failure to arrange an appropriately experienced assessor, omission or delay of assessment, inadequate assessment arrangements and failure to ensure assessment before discharge or other consequential care decisions.

What is not included
  • Excludes general mental health assessment deficiencies without a self-harm or suicidal-ideation context.
  • Excludes physical assessment, treatment or discharge failures after an adequate mental health assessment has been completed, unless the assessment process itself was deficient.
  • Excludes suicide-risk assessment concerns where the report does not identify a broader failure to provide the required mental health assessment after self-harm.
  • Excludes failures confined to telephone or face-to-face assessment when the wider self-harm-related mental health assessment process is not deficient.
  • Excludes general mental health service capacity or staffing deficiencies that do not directly impair provision of the required assessment.

Reports and published responses 6 reports

See individual reports that have raised this concern, and the actions taken in response

  1. East London

    AI-generated summary

    Mark Wolfe Kinzley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mark Wolfe Kinzley, a 61-year-old man with a neurological disorder, mental health problems and a history of self-harm, was found unresponsive at his nursing home on 30 October 2023 after suspending himself by a coat hanger. He died in hospital on 1 November 2023 from complications of the injuries sustained at the nursing home. The concerns included whether the care setting was appropriate, the absence of a formal capacity assessment, and the lack of a mental health assessment despite his history and deteriorating mental state.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state

    Wider context from the report

    “3. During the same period, Mr Kinzley was not referred for a mental health assessment despite. a. His history of mental illness. b. His history of deliberate self-harm. c. His history of accidental self-harm when agitated. d. His deteriorating mental state during the month prior to his death. ”

    Source location

    Mark Wolfe Kinzley · Prevention of Future Deaths report
    Page 3 · concerns

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver targeted provider training on safeguarding, escalation processes and risk identification, including notifying the Local Authority and making safeguarding referrals for identified self-harm or other health risks.

    Verbatim wording from the response

    “The Local Authority will deliver targeted training to care providers regarding safeguarding, escalation processes/and risk identification.”

    Source location

    Response from NELFT and Redbridge Council
    Page 2 · response
    Published 3 April 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Inform care staff that local mental health teams accept referrals from patients, carers and other medical professionals.

    Verbatim wording from the response

    “Following the inquest, our named clinician, Dr Barker, for the care home has made the care staff aware that the local mental health teams, also accept referrals from patients, carers, and other medical professionals, in addition to referrals from a GP. This may be appropriate for any future cases as it would allow the care home to make a referral without waiting for a GP assessment, such as patients with fluctuating capacity or emergency situations.”

    Source location

    Response from Evergreen Surgery
    Page 3 · response
    Published 3 April 2024

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A mental-health referral required the consent of a patient assessed as having capacity, and depended on his willingness to consent.

    Verbatim wording from the response

    “Whilst we recognise the importance of mental health assessments and referrals for individuals with a history of mental health issues, we emphasise that any referral to mental health services in this situation would have required Mr. Kinzley's consent. He was deemed to have capacity at the times he was assessed, and therefore any referral would have been contingent upon his willingness to consent to such services.”

    Source location

    Response from Evergreen Surgery
    Page 3 · response
    Published 3 April 2024

    Open published response

  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Ryan John EVANS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ryan John EVANS died after being found hanging in the communal area of his accommodation on 3 April 2018. The concerns included that, despite evidence of self-harm and suicidal ideation, no mental health assessment was carried out at hospital, and that mental health information and referrals were not effectively documented or communicated during his time in police custody.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to undertake a mental health assessment following self-harm or suicidal ideation

    Wider context from the report

    “An emergency department consultant at Frimley Park gave evidence which suggested that no mental health assessment was or would have been necessary where Ryan’s presenting complaint was recorded as chest pains rather than of self-harm and/or suicidal ideation. Although self-harm had been noted in the records, no explanation could be provided for why Ryan’s suicidal ideation had not been recorded. The consultant was further questioned in relation to the 2006 NICE Guidelines “Self-Harm: the short term physical and psychological management and secondary prevention of self-harm in primary and secondary care” which are national guidelines that ought to feed into practice at the hospital. These guidelines provide that “Following triage patients who have self-harmed should receive the requisite treatment for their physical condition, undergo risk and full psychosocial needs assessment and mental state examination, and referral for further treatment and care as necessary” and “All people who have self harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.” Evidence received during the course of the Inquest was not able to reconcile the contradiction between the NICE guidelines on self-harm and Mr. EVANS having had no mental health assessment despite obvious signs of self-harm and further evidence of disclosure of suicidal ideation. The jury in their Narrative Conclusion found that ‘Despite evidence of self-harm, no mental health assessment was carried out at this point.’ I remain concerned as to how such a situation would be avoided if a patient presented again in similar manner to Mr. EVANS. The additional evidence on PFD matters provided by Frimley Health NHS Foundation Trust does not refer to or address the NICE guidelines on self-harm or explain what would now be done differently were a patient such as Mr. EVANS were to be seen again. The Frimley Health NHS Foundation Trust additional evidence refers to matters being in the process of introduction and new referral criteria with Surrey and Borders Partnership NHS Foundation Trust, but this does not explain how this would prevent the future risk of a patient such as Mr. EVANS leaving the hospital without a mental health assessment. ”

    Source location

    Ryan John EVANS · Prevention of Future Deaths report
    Page 4 · concerns

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update and ratify the Psychiatric Liaison Services Standard Operating Policy and referral criteria.

    Verbatim wording from the response

    “As part of our continuous improvement work, we are constantly reviewing the PLS referral criteria. The Standard Operating Policy (dated February 2019) was most recently updated and ratified in October 2023. The Mental Health Lead at Frimley Park Hospital provided input as part of this process. The referral criteria provides guidance to clinicians but cannot prescribe for every scenario that may be presented. This is attached, as an aide memoir, to the referral form. The referral form allows for sufficient information to be shared with the PLS clinician assessing the referral. There is a low threshold for acceptance of referrals. A sense of clinical judgment and relationships between the PLS and clinicians at Frimley Park Hospital are important aspects of decision making in this context.”

    Source location

    Response from Surrey NHS
    Page 2 · response
    Published 8 January 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue reviewing Psychiatric Liaison Services referral criteria as part of continuous improvement.

    Verbatim wording from the response

    “As part of our continuous improvement work, we are constantly reviewing the PLS referral criteria. The Standard Operating Policy (dated February 2019) was most recently updated and ratified in October 2023. The Mental Health Lead at Frimley Park Hospital provided input as part of this process. The referral criteria provides guidance to clinicians but cannot prescribe for every scenario that may be presented. This is attached, as an aide memoir, to the referral form. The referral form allows for sufficient information to be shared with the PLS clinician assessing the referral. There is a low threshold for acceptance of referrals. A sense of clinical judgment and relationships between the PLS and clinicians at Frimley Park Hospital are important aspects of decision making in this context.”

    Source location

    Response from Surrey NHS
    Page 2 · response
    Published 8 January 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update Emergency Department digital triage to ask all patients about mental health or self-harm within 15 minutes of arrival.

    Verbatim wording from the response

    “In response to this NICE guideline and additional guidance from the Royal College of Emergency Medicine (RCEM), ‘Mental Health in Emergency Department’s – A Toolkit for Improving care’, April 2021, the Trust has now updated its digital triage assessment of all patients attending the Emergency Department to include a mandatory question about a patient’s history of mental health and/or self-harm. This question is asked of all patients attending the Emergency Department within 15 minutes of their arrival regardless of the reason for their presentation.”

    Source location

    Response from Frimley Health
    Page 2 · response
    Published 8 January 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct nurse-led mental health assessments for patients disclosing mental health issues or self-harm, assessing immediate risk, abscondence risk and enhanced-care needs.

    Verbatim wording from the response

    “Whenever a patient reveals a history of mental health issues or self-harm, either by overt presentation or by disclosing it when asked at triage, a further mental health assessment is undertaken by a nurse within the Emergency Department. Please find attached a copy of the Mental Health Triage Tool now used in the Emergency Department.”

    Source location

    Response from Frimley Health
    Page 2 · response
    Published 8 January 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide Emergency Department clinicians with mental health triage training during induction and supervised shadowing before independent assessment.

    Verbatim wording from the response

    “Clinicians in the Emergency Department are now provided with training on mental health triage assessment during their induction and go on to shadow other staff completing the mental health triage assessments before carrying them out independently.”

    Source location

    Response from Frimley Health
    Page 3 · response
    Published 8 January 2024

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Maintain joint governance arrangements with Psychiatric Liaison services for integrated physical and mental healthcare, including shared records, referral pathways, assessment, safeguarding and observation procedures.

    Verbatim wording from the response

    “In accordance with paragraph 1.1.17 of the NICE guideline [NG225] Frimley Park Hospital and Surrey and Borders Partnership ensure that appropriate joint governance arrangements are in place so that physical and mental healthcare can be delivered together in the emergency department at Frimley Park Hospital. As set out in the NICE guideline this includes the following:”

    Source location

    Response from Frimley Health
    Page 4 · response
    Published 8 January 2024

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing referral and assessment measures for mental health presentations were considered adequate, with timely response expected when a referral was received.

    Verbatim wording from the response

    “In the PFD report, you highlighted a concern relevant to the Trust and Frimley Health NHS Foundation Trust (“Frimley”). In particular, you outline the additional evidence provided at the inquest by Frimley Health NHS Foundation Trust. We believe that the Trust did have adequate measures in place at the time of Mr Evans’ admission to Frimley Park Hospital and that, had we received a referral, we would have responded in a timely manner.”

    Source location

    Response from Surrey NHS
    Page 1 · response
    Published 8 January 2024

    Open published response

  3. Lincolnshire

    AI-generated summary

    Vincenzo Joseph Michael LIPPOLIS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Vincenzo Joseph Michael LIPPOLIS, aged 21, died on 1 November 2021 after being found hanging in woodland at Sand Dunes, Mablethorpe. Concerns were raised about why he was not admitted under the Mental Health Act after a recent suicide attempt and why a recommended face-to-face assessment was replaced by a telephone call, after which the case was closed the same day.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to undertake face-to-face assessment after recent suicide attempts

    Wider context from the report

    “In the NAVIGO report of 22nd October 2022 in response to the mother's request as to "why Vincenzo wasn't sectioned under the Mental Health Act after his detrimental (suicide) attempt on 16th October if only for observation" the SW replies "An admission to a mental health unit would not provide a therapeutic benefit as Vinny's social stressors would still be present in the future". The response does not seem to consider/reflect the admission criteria under s.2 or s.3 of the MHA. Please clarify the rational as the family believe an opportunity has been lost and a death could have been averted. In addition, the recommendation was for a face-to-face meeting with the deceased. Please explain why LPFT made only a telephone call on 17th October when if face to face observations and a more effective analysis had been undertaken particularly after the recent suicide attempts a more effective analysis could have been undertaken. As it was the case was closed on the same day. ”

    Source location

    Vincenzo Joseph Michael LIPPOLIS · Prevention of Future Deaths report
    Page 3 · concerns

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No systems or process changes are needed because the assessment followed recognised practice and decisions depend on individual circumstances.

    Verbatim wording from the response

    “11 NAViGO does not propose to take any action in relation to its systems or processes in response to the concern raised. The response above sets out the rationale for the decision. It followed an assessment of Mr Lippolis in line with nationally recognised practice by two experienced practitioners. The decision was based on Mr Lippolis’ responses and presentation at the time and the professional judgement of the practitioners. For the reasons given above there is, in NAViGO’s judgement, no change to systems or processes that need be made in order to avoid deaths in future. Decisions will always depend on the particular circumstances of each individual assessment.”

    Source location

    Response from NAViGO
    Page 5 · response
    Published 28 October 2022

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Follow-up after hospital assessment was assigned to local LPFT services, with NAViGO recommending face-to-face contact.

    Verbatim wording from the response

    “6 The only observation made on the second concern is that NAViGO's Hospital Liaison Psychiatric Team contacted the relevant LPFT services after the assessment at the Hospital and requested a face to face follow-up with Vincenzo Joseph Michael Lippolis by his local services (as detailed in the written report of ████████, NAViGO Liaison Practitioner, dated 22 October 2022, provided to the Coroner).”

    Source location

    Response from NAViGO
    Page 2 · response
    Published 28 October 2022

    Open published response

  4. South London

    AI-generated summary

    Billy James Jenkins · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Billy James Jenkins was found hanging by the neck in a hotel room bathroom on 12 August 2019, following a history of low mood, alcohol and cocaine abuse, suicidal ideation and previous suicide attempts. The concerns included limited information gathering during his mental health assessment, a decision that he did not have a mental health condition without further assessment, inadequate documentation and planning, and possible over-reliance on alcohol and drug use as the explanation for his suicidal ideation. The inquest concluded that he took his own life following an assessment after which he felt helpless because there had been no clear mental state examination and a potential missed opportunity to consider an appropriate referral.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Over-reliance on alcohol and drug use in assessing suicidal ideation

    Wider context from the report

    “(2) The Community Mental Health Nurse did not document her formulation or impression. The plan moving forward was not robust and did not explore protective factors or minimisation of harm and there was an over-reliance on alcohol and drug use as the cause of his suicidal ideation. There appeared to be no proforma of questions to ask. ”

    Source location

    Billy James Jenkins · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Share the root-cause analysis report and investigation learning with the involved team and across the Trust to support reflection by similar teams.

    Verbatim wording from the response

    “Since the death of Mr Jenkins the RCA report has been shared with the team and across the Trust so that similar Teams can reflect on the lessons learnt. The actions arising from the investigation have also been implemented including areas addressed above. Additional learning reflects the need to ensure that all service users who are receiving care and treatment from Oxleas mental health services and also use drugs and or alcohol have equal access to all strands of treatment available to those who are not using substances. Only if there is clear evidence that the use of substances will impact on the ability to clinically benefit from any treatment would a decision be made to withhold treatment and in these instances this would be reviewed regularly with the service user and the team.”

    Source location

    2020-0068-Response-from-Oxleas-NHS-Foundation-Redacted
    Page 3 · response
    Published 27 March 2020

    Open published response

  5. Inner North London

    AI-generated summary

    Terence Darren ADAMS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Terence Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to explore potential triggers for disclosed suicidal thoughts

    Wider context from the report

    “4. Mr Adams told the GP that he had been suicidal on and off for twenty years, but she did not explore with him the potential triggers for this. In fact, one such trigger was incarceration. ”

    Source location

    Terence Darren ADAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review, approve and implement a revised first-night mental-health risk assessment with staff training, SystmOne integration and advisory clinical-judgement guidance.

    Verbatim wording from the response

    “Response: There is an expectation that nurses undertaking reception duties within the prison complete an assessment of a person’s current risk of self-harm and suicidality when they are initially received into custody. This is particularly relevant as it is known that, for some prisoners, the early days of custody prove particularly stressful and so increase their risk. You heard the evidence of the Deputy Head of Healthcare who explained that, following another recent death in custody, we were already undertaking a review of the current risk assessment that is in use in reception in an attempt to improve its efficacy.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 26 July 2016

    Open published response

  6. Leicester City and South Leicestershire

    AI-generated summary

    William Abel · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    William Abel, who had paranoid schizophrenia and was receiving mental health treatment, died after stepping in front of a train on 9 February 2015. The report raised concerns that he was not given a mental health assessment after being removed from the railway lines the previous night, and that inadequate communication with his family left them unaware of professional concerns about a relapse and the expectation that they would keep him safe.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to conduct a Mental Health Assessment after a person expressing suicidal intention was safely escorted from railway lines

    Wider context from the report

    “1. Mr Abel had a diagnosis of paranoid schizophrenia and he was still under the care of the Mental Health services at the time he was found in the vicinity of the railway lines, expressing suicidal intention. He had missed appointments and there was a history of non-compliance with medication. Staff were available to have conducted a Mental Health Assessment, on the night he was safely escorted from the railway lines, but this was not done. ”

    Source location

    William Abel · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise the Triage Car Mental Health Act assessment protocol to require consideration and documentation of decisions and reasons.

    Verbatim wording from the response

    “The protocol for Mental Health Practitioners working with the Triage Car is being revised so that where there are clear indicators which prompt a discussion with a patient about the possibility of an admission to an Acute Hospital and a patient refuses to consider an informal admission, a Mental Health Act Assessment will be considered. If the assessment is not undertaken, the reasons for this decision taken within the context of the patient’s presentation and the conferences of the contact with the services, will be clearly documented. The changes to the protocol have been communicated via email to the Triage Car and Crisis Team via the service and team managers and the final revised protocol will be discussed in both team meetings. The communication exercise was completed during November 2015.”

    Source location

    2015-0406-Response-by-Leicester-Partnership-NHS-Trust
    Page 2 · response
    Published 20 October 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Audit compliance with the revised Mental Health Act assessment protocol and report findings and further actions.

    Verbatim wording from the response

    “We will undertake an audit to monitor compliance of the revised protocol in December 2015 and report the audit and further actions to be taken in January 2016.”

    Source location

    2015-0406-Response-by-Leicester-Partnership-NHS-Trust
    Page 2 · response
    Published 20 October 2015

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026