First reported 20 Oct 2015•Latest report 26 Mar 2024
Definition
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.
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
6
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2015–2024
First to latest report issue date
Stated actions
12
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.
ADAPT, Bexley Locality Community Mental Health Team1
Bexley ADAPT Service1
Cambridge Nursing Home Ltd1
Care UK1
Frimley Health NHS Foundation Trust1
Leicestershire Partnership NHS Trust1
London Borough of Redbridge1
LPFT Legal Services1
NAViGO Health and Social Care CIC1
NHS North East London Integrated Care Board1
Oxleas NHS Foundation Trust1
Pentonville Prison1
Recipient name withheld1
Surrey and Borders Partnership NHS Foundation Trust1
The Evergreen Surgery, Wanstead1
NHS trust3
Healthcare site2
Sub-organisation2
Independent healthcare provider1
Integrated care board1
London borough council1
Multi-service care provider1
Prison or young offender institution1
Private limited company1
Type not available1
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.
East London
Concerns raised1
Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state
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 concerns
Each 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
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.
Stated by The Local AuthorityStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
Action
Inform care staff that local mental health teams accept referrals from patients, carers and other medical professionals.
Stated by The Evergreen Surgery, WansteadStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A mental-health referral required the consent of a patient assessed as having capacity, and depended on his willingness to consent.
Stated by The Evergreen Surgery, WansteadUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Hampshire, Portsmouth and Southampton
Concerns raised1
Failure to undertake a mental health assessment following self-harm or suicidal ideation
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 concerns
Each 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.6
Action
Update and ratify the Psychiatric Liaison Services Standard Operating Policy and referral criteria.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
Action
Continue reviewing Psychiatric Liaison Services referral criteria as part of continuous improvement.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2024.
Action
Update Emergency Department digital triage to ask all patients about mental health or self-harm within 15 minutes of arrival.
Stated by Frimley Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
Action
Conduct nurse-led mental health assessments for patients disclosing mental health issues or self-harm, assessing immediate risk, abscondence risk and enhanced-care needs.
Stated by Frimley Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
Action
Provide Emergency Department clinicians with mental health triage training during induction and supervised shadowing before independent assessment.
Stated by Frimley Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
Action
Maintain joint governance arrangements with Psychiatric Liaison services for integrated physical and mental healthcare, including shared records, referral pathways, assessment, safeguarding and observation procedures.
Stated by Frimley Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing referral and assessment measures for mental health presentations were considered adequate, with timely response expected when a referral was received.
Stated by Surrey and Borders Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Lincolnshire
Concerns raised1
Failure to undertake face-to-face assessment after recent suicide attempts
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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
No systems or process changes are needed because the assessment followed recognised practice and decisions depend on individual circumstances.
Stated by NAViGO Health and Social Care CICNo action considered necessaryThe respondent said that no further action was needed.
Position
Follow-up after hospital assessment was assigned to local LPFT services, with NAViGO recommending face-to-face contact.
Stated by NAViGO Health and Social Care CICRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South London
Concerns raised1
Over-reliance on alcohol and drug use in assessing suicidal ideation
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 concerns
Each 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
Share the root-cause analysis report and investigation learning with the involved team and across the Trust to support reflection by similar teams.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
Inner North London
Concerns raised1
Failure to explore potential triggers for disclosed suicidal thoughts
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 concerns
Each 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
Review, approve and implement a revised first-night mental-health risk assessment with staff training, SystmOne integration and advisory clinical-judgement guidance.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2016.
Leicester City and South Leicestershire
Concerns raised1
Failure to conduct a Mental Health Assessment after a person expressing suicidal intention was safely escorted from railway lines
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 concerns
Each 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
Revise the Triage Car Mental Health Act assessment protocol to require consideration and documentation of decisions and reasons.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 October 2015.
Action
Audit compliance with the revised Mental Health Act assessment protocol and report findings and further actions.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 October 2015.
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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.
