Recurring concern
Failure to reconcile conflicting information in safety assessments
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Request correctionFirst reported 17 Jan 2014•Latest report 26 Apr 2023
What this concern includes
Includes failures within safety assessments to identify, compare, investigate and resolve material inconsistencies between referral information, historical records, observations, collateral reports, recent concerns or other relevant evidence before reaching or approving an assessment conclusion.
Not included
- Excludes generic clinical record, handover or communication deficiencies where no material conflict within a safety assessment is identified.
- Excludes incomplete assessments where the issue is missing assessment content but not failure to reconcile conflicting information.
- Excludes failures to act on a correctly reconciled assessment when the assessment process itself was reliable.
- Excludes generic diagnostic disagreement or confirmation-bias concerns unless the report specifically identifies unreconciled conflicting information within a safety assessment.
- Reports
- 5
- Individual concerns
- 5
- Date range
- 2014–2023
- Stated actions
- 9
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 identify and assess conflicting evidence about alcohol provision
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.
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
The toxicology report would not have affected whether the safeguarding enquiry should be reopened because no provider concerns were identified.
Stated by Lincolnshire County Council
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Position
Reopening the enquiry could not determine which evidence was reliable or whether the provider acted inappropriately.
Stated by Lincolnshire County Council
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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
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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
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Position
CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.
Stated by Royal Free London NHS Foundation Trust
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Concerns raised1
Failure to consider the whole person and reconcile or communicate missing and discordant information during proforma completion
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.6
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Action
Publish AMHP guidance requiring direct scrutiny of police custody records and logs.
Stated by Hampshire County Council and Portsmouth City Council -
Action
Publish AMHP guidance requiring direct scrutiny of detained persons’ medical forms.
Stated by Hampshire County Council and Portsmouth City Council -
Action
Publish AMHP guidance requiring direct discussion with police custody officers during each custody-centre assessment.
Stated by Hampshire County Council and Portsmouth City Council
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Action
Require AMHPs to obtain written medical reports when assessments do not result in detention recommendations.
Stated by Hampshire County Council and Portsmouth City Council -
Action
Establish a governance framework monitoring police-custody assessment outcomes, information sharing, relative communication and AMHP training records.
Stated by Hampshire County Council and Portsmouth City Council -
Action
Review professional development opportunities for AMHPs conducting police-custody assessments.
Stated by Hampshire County Council and Portsmouth City Council
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Concerns raised1
Failure to reconcile assessments with referral and historical information
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.2
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Action
Disseminate the internal management review, action plan and lessons learned to managers and relevant frontline staff for discussion and implementation.
Stated by London Borough of Tower Hamlets -
Action
Deliver targeted Critical/Cumulative Analysis training to staff.
Stated by London Borough of Tower Hamlets
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Concerns raised1
Failure to reconcile reassurance about mood stabilisation with recent concerns about wellbeing
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.
Data last updated 7 September 2026