Recurring concern
Failure to reliably escalate suicidal intent information
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Request correctionFirst reported 13 Feb 2014•Latest report 18 Jun 2024
What this concern includes
Includes failures of healthcare, care or police processes specifically dedicated to recognising, transferring, reviewing or escalating expressed or recorded suicidal intent or related imminent self-harm information, including delayed escalation, omitted handover information and failure to act on documented suicidal intent.
Not included
- Excludes general mental-health deterioration, suicide-risk assessment, observation, treatment or safeguarding failures where suicidal-intent information escalation is not the specific unsafe condition.
- Excludes generic communication, documentation or handover deficiencies without an identified suicidal-intent or imminent self-harm information context.
- Excludes failures to escalate unrelated clinical abnormalities, welfare concerns or staffing problems.
- Excludes failures concerning access to self-harm means or protective-factor provision where the information-escalation process is not deficient.
- Reports
- 10
- Individual concerns
- 12
- Date range
- 2014–2024
- Stated actions
- 12
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 pass on suicidal ideation information to foster carers or other relevant people
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.2
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Action
Deliver comprehensive safeguarding, confidentiality, disclosure, welfare and mental-health training to Independent Visitor volunteers.
Stated by Calderdale Borough Council -
Action
Require Independent Visitor volunteers to follow a safeguarding code and health-and-safety procedure specifying when concerns must be reported or disclosed.
Stated by Calderdale Borough Council
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
Relevant information was promptly passed to the Pathways Team, and no imminent risk justified sharing it with the foster carer.
Stated by Calderdale Borough Council
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Concerns raised1
Failure to record suicidal ideation on Person Escort Records and Suicide and Self-Harm Warning forms
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
Inform investigation and custody staff, anonymously, about the omission of relevant suicidal-ideation information.
Stated by Dyfed-Powys Police -
Action
Instruct custody officers to ask interviewing officers about information relevant to ongoing detainee risk assessment.
Stated by Dyfed-Powys Police -
Action
Remind investigators to inform custody officers about disclosures relevant to ongoing risk management.
Stated by Dyfed-Powys Police
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Concerns raised1
Failure to communicate the appropriate level of suicide risk to police
This report raised 14 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
Implement the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.
Stated by Metropolitan Police Service
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
Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
Stated by NHS England
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Concerns raised1
Failure to communicate expressed suicidal intent in the handover
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
Trial the THRIVE+ vulnerability assessment framework to assess and document vulnerability, including suicidal thoughts, and support ongoing risk review and information sharing.
Stated by Metropolitan Police Service -
Action
Publish an Operational Notice requiring staff to review police indices before victim contact, communicate identified vulnerabilities, and record them on the CRIS report.
Stated by Metropolitan Police Service -
Action
Introduce a mandatory enhanced SOIT risk assessment covering suicide, cultural complexities and honour-based violence, with police-indices review, CRIS recording and supervisor escalation.
Stated by Metropolitan Police Service
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Concerns raised1
Failure to verbally communicate increased suicidal risk to the responsible nurse
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.
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Concerns raised1
Failure to recognise and act on recorded information about suicidal intent
This report raised 10 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
Create an information-sharing protocol between the Mental Health Liaison Team and Pavillions A&E liaison service.
Stated by Sussex Partnership 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 A&E attendance did not heighten concern because the presentation was previously seen with alcohol use and liaison staff did not recommend re-referral.
Stated by Sussex Partnership NHS Foundation Trust
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Concerns raised2
Failure to train Listeners to pass information about imminent suicide risk to prison staff
Failure of the Listener Scheme protocol to specify an exception to confidentiality for imminent suicide risk
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.
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
Winchester will not add an exception to Listener confidentiality because national confidentiality arrangements are considered necessary to preserve prisoners’ trust.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to communicate custody-recorded suicide and self-harm risks for full MG7 preparation
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.2
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Action
Require the responsible custody sergeant to verify and sign every Prisoner Escort Form before a detainee leaves or moves from custody, ensuring documented risks are communicated.
Stated by West Mercia Police -
Action
Include in mandatory custody-sergeant training the requirement to highlight known risks and concerns to the officer in charge when considering an MG7 remand application.
Stated by West Mercia Police
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Concerns raised1
Failure to share timely information about risk and suicidal or self-harming behaviour between clinical and HMPS staff
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.
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Concerns raised2
Failure to promptly escalate information about patients’ suicidal intent
Lack of training or experience on when and how to escalate information about patients’ suicidal intent
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.
Data last updated 7 September 2026