Recurring concern

Failure to reliably report self-harm and suicide risks to people able to help

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First reported 2 Dec 2013•Latest report 18 Jun 2024

Definition

What this concern includes

Includes failures to establish, encourage, require, make or follow up reports of observed or disclosed self-harm or suicide risk to appropriate teachers, health professionals, safeguarding functions, carers or other people able to provide protective assistance.

Not included

  • Excludes general mental-health communication or information-sharing failures where self-harm or suicide risk is not the material concern.
  • Excludes failures to assess, treat, observe or protect a person after relevant self-harm or suicide-risk information has been reliably reported.
  • Excludes generic incident-reporting or safeguarding failures without a specific self-harm or suicide-risk reporting condition.
  • Excludes routine disclosure of non-safety information and failures involving only the availability of support services without a deficient risk-reporting process.
Reports
7

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2013–2024

First to latest report issue date

Stated actions
6

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.

Department of Health and Social Care3
Department for Education2
Calderdale Borough Council1
College of Policing1
HM Prison Service1
Home Office1
Leeds and York Partnership NHS Foundation Trust1
Manchester Prison1
Ministry of Housing, Communities and Local Government1

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.

  1. South Yorkshire (Western)

    AI-generated summary

    Jacob Lee Shorter · 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

    Jacob Lee Shorter, who was receiving support after leaving long-term foster care, died after entering the train tracks at Heeley Loop in Sheffield on 1 January 2024 and being struck by a train. The report raised concern that an independent visitor’s knowledge of Jacob’s previous suicidal ideation was not shared with his foster carer or other relevant people, and that the training and escalation arrangements for such disclosures were unclear.

    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 pass on suicidal ideation information to foster carers or other relevant people

    Wider context from the report

    “(1) Whilst the Independent Visitor was made aware of previous suicidal ideation this was not passed on to the foster carer or anyone else. Calderdale were unable to tell me of the training they receive or the escalation route for concerns or disclosures of this type. There is a clear risk that if this type of information is not passed on and adequate training is not provided in terms of mental health then this could cause future deaths. ”

    Source location

    Jacob Lee Shorter · 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

    Deliver comprehensive safeguarding, confidentiality, disclosure, welfare and mental-health training to Independent Visitor volunteers.

    Verbatim wording from the response

    “- Training”

    Source location

    Response from Calderdale Council
    Page 5 · response
    Published 26 June 2024

    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

    Require Independent Visitor volunteers to follow a safeguarding code and health-and-safety procedure specifying when concerns must be reported or disclosed.

    Verbatim wording from the response

    “All Independent Visitors Volunteers adhere to the Council’s “Safeguarding Code of Conduct for Independent Visitors.” The Code forms part of the agreement for Independent Visitors to work as a volunteer. The Safeguarding Code is specific and sets out the circumstances in which disclosure should take place by stating:”

    Source location

    Response from Calderdale Council
    Page 4 · response
    Published 26 June 2024

    Open published response

    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

    Relevant information was promptly passed to the Pathways Team, and no imminent risk justified sharing it with the foster carer.

    Verbatim wording from the response

    “The Independent Visitor volunteer called the Independent Visitor team on Monday 4th December 2023 and reported in detail what Jacob had disclosed.”

    Source location

    Response from Calderdale Council
    Page 4 · response
    Published 26 June 2024

    Open published response
  2. Dorset

    AI-generated summary

    Marnie Emma Hill · 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

    Marnie Emma Hill was found collapsed and unresponsive on a bed at a property where she was temporarily residing on 15 May 2022. The report raised concerns that the lack of regulation of counselling could lead to future deaths, including because counsellors are not required to report risks or share records with healthcare professionals.

    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

    Lack of requirements for counsellors to report disclosed risks of self-harm, suicide or harm to others

    Wider context from the report

    “1. During the inquest evidence was heard that: i. There is no regulation of counsellors in England and Wales and this could lead to future deaths. ii. ████████ is a private counsellor with 30 years’ experience who provided support to Marnie prior to her death. She confirmed that counselling is not a regulated professional and there are courses available at a cost of £29 for a 6 week course, after which a person can receive a diploma and call themselves a counsellor. There is no requirement for them to do further training or continual professional development. There are no rules or regulations about how counsellors should operate, for example how they keep and share records. iii. Information shared by an individual to a counsellor may disclose a risk of self harm or suicide, or harm to another and there is no requirement for a counsellor to report that information to any third party. iv. ████████ ████████ gave evidence that the lack of regulation and licensing of counsellors could lead to a lot of damage being done to individuals seeking help and that this could present a risk to life as there is no regulation around informing medical professionals or others who can provided further support and care to the individual. v. Evidence was also given by ████████, one of the GPs who provided care to Marnie, that receipt of records from others such as counsellors, especially at the end of the counselling, would assist her in providing care to patients. 2. I have concerns with regard to the following: i. There is a risk of future deaths occurring due to the lack of regulation of the counselling profession. ”

    Source location

    Marnie Emma Hill · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Training standards and practice requirements set by independent counselling organisations are outside Government oversight.

    Verbatim wording from the response

    “All of the organisations utilising the SCoPEd framework are independent, representative bodies for the practice of counselling and psychotherapy. As such, they do not fall under Government oversight and therefore any decisions about the training standards and practice requirements for the professions they represent are a matter for those organisations and their members.”

    Source location

    Response from Department of Health and Social Care
    Page 3 · response
    Published 30 October 2023

    Open published response

    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

    Independent counselling organisations and their members are responsible for decisions about training standards and practice requirements.

    Verbatim wording from the response

    “All of the organisations utilising the SCoPEd framework are independent, representative bodies for the practice of counselling and psychotherapy. As such, they do not fall under Government oversight and therefore any decisions about the training standards and practice requirements for the professions they represent are a matter for those organisations and their members.”

    Source location

    Response from Department of Health and Social Care
    Page 3 · response
    Published 30 October 2023

    Open published response
  3. West Yorkshire Eastern

    AI-generated summary

    Layla Stephanie Dobson · 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

    Layla Stephanie Dobson, a 23-year-old student with a history of mental health issues, self-harm and suicidal ideation, was found deceased at her home on 11 March 2019. The inquest recorded that she died by hanging and reached a conclusion of suicide. Concerns included the absence of a formalised process to guide practitioners on appropriate support pathways and insufficient flagging of information about current self-harm or suicide in referral decisions.

    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 flag or reference current self-harm or suicide information to relevant decision-makers

    Wider context from the report

    “Whilst the approach to the CMHT was decided upon and actioned, my view upon the evidence was that the area on the form relating to current self-harm/suicide is not further flagged or referenced to those taking relevant decisions and this could strengthen the scrutiny of information when deciding upon which service may be contacted. ”

    Source location

    Layla Stephanie Dobson · 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

    Develop guidance for referral meetings to assess suicide risk, existing support and self-referral status, recommend crisis-support steps, and record its consideration.

    Verbatim wording from the response

    “The Personality Disorder Clinical Network service has carefully considered the matters of concerns outlined and agreed an action plan (appendix 1) at the service Clinical Governance forum held on the 30th January 2020. Firstly the service is developing guidance to further inform the decision making process with regards to referral to relevant crisis support services. The guidance will include for example:”

    Source location

    2019-0425-Response-from-Leeds-and-York-NHS-Trust
    Page 2 · response
    Published 30 December 2019

    Open published response
  4. Manchester South

    AI-generated summary

    Katie Croft · 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

    Katie Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.

    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 provide teachers with relevant information about a pupil's self-harm history and vulnerability

    Wider context from the report

    “6. On the day Katie committed suicide she had attended a GCSE English class. The exam board required poetry syllabus was being studied that day. The lesson included a poem where the contextualisation of it included the use of suicide. The teacher delivering the lesson had no way of understanding the history of self-harm of Katie and her particular vulnerability when delivering a set text in accordance with the exam board requirements. It was unclear what if any guidance is given by the exam board to assist teachers minimising risk to pupils in this scenario. ”

    Source location

    Katie Croft · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Dorset

    AI-generated summary

    Branko Zdravkovic · 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

    Branko Zdravkovic, who was detained at the Immigration Removal Centre, The Verne, was found suspended by a ligature in a toilet cubicle and died on 9 April 2017. The inquest concluded that his death was suicide, with the medical cause recorded as ligature suspension. Concerns were raised that staff were instructed to use ACDT procedures instead of making Rule 35 reports, and that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT.

    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 make statutory Rule 35 reports for detainees with suicidal tendencies

    Wider context from the report

    “The Inquest heard evidence from a Doctor and Psychiatrist and Healthcare staff working at the IRC that they had received training and were told not to make a report under Rule 35(2) of the Detention Centre Rules (SI 2001/238) but instead to use the ACDT procedures to monitor suicidal tendencies. There was also evidence from several witnesses that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT. In the case of a suicidal detainee, the ACDT procedure is necessary and desirable, but it cannot replace the statutory duty to make a report under Rule 35. Rule 35 imposes a requirement to speedily review whether someone should be released because of concerns recorded by the medical practitioner. Without that information being provided the state cannot carry out its obligations under Article 2 ECHR. ”

    Source location

    Branko Zdravkovic · Prevention of Future Deaths report
    Page 1 · 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

    Conduct an internal review of Rule 35(2) reporting effectiveness and use its findings to inform wider policy work.

    Verbatim wording from the response

    “The Home Office keeps the effectiveness of its procedures under review. As part of this continuous improvement the Home Office conducted an internal review to analyse the use”

    Source location

    2019-0047-Response-by-Home-Office
    Page 2 · response
    Published 24 May 2019

    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

    Finalise and introduce new Removal Centre Rules, including updated Rule 35 reporting arrangements.

    Verbatim wording from the response

    “The findings of the initial review have been used to inform our separate work to finalise new Removal Centre Rules to replace the current Detention Centre Rules. We are aiming to introduce the new Rules, which will include updates to the reporting system in Rule 35, by July 2019.”

    Source location

    2019-0047-Response-by-Home-Office
    Page 3 · response
    Published 24 May 2019

    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

    Seek healthcare-provider assurances on correct Rule 35 processes and consult the assurance forum about broader implementation.

    Verbatim wording from the response

    “NHS England commission health services in prisons and other places of detention including IRCs. This is undertaken through six NHS England Health and Justice Teams. Healthcare in IRCs in Scotland is commissioned by the supplier running those centres. The Home Office’s Director of Detention and Escorting Services will write to NHS England (as the commissioning body for IRC healthcare services in England) and to the healthcare providers at Dungavel IRC by the end of April 2019 to seek assurances that all parties are following the correct process. The Home Office IRC Assurance Group forum will be consulted to consider how this can be more broadly implemented.”

    Source location

    2019-0047-Response-by-Home-Office
    Page 3 · response
    Published 24 May 2019

    Open published response

    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

    Home Office training does not direct doctors to substitute ACDT monitoring for Rule 35(2) reporting; the apparent issue was local misunderstanding.

    Verbatim wording from the response

    “Home Office training which touches on Rule 35 reporting in the context of the Adults at Risk policy does not advocate the substitution of Rule 35(2) reporting for the ACDT identification and monitoring procedures. It would appear that there may have been some local misunderstanding on this point at the Verne IRC during the period under examination. There is however no ambiguity that the statutory provision in Rule 35 of the Detention Centre Rules 2001 requires IRC doctors to report certain matters to the manager of the centre and to officials acting on behalf of the Secretary of State. The Detention Centre Rules are unambiguous that only an IRC doctor (‘medical practitioner’) may make a Rule 35 report. The decision to do so in any particular case is solely a matter for the clinical judgment of the IRC doctor.”

    Source location

    2019-0047-Response-by-Home-Office
    Page 2 · response
    Published 24 May 2019

    Open published response

    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

    Only an IRC doctor may submit a Rule 35(2) report, and the decision rests solely with that doctor's clinical judgment.

    Verbatim wording from the response

    “Home Office training which touches on Rule 35 reporting in the context of the Adults at Risk policy does not advocate the substitution of Rule 35(2) reporting for the ACDT identification and monitoring procedures. It would appear that there may have been some local misunderstanding on this point at the Verne IRC during the period under examination. There is however no ambiguity that the statutory provision in Rule 35 of the Detention Centre Rules 2001 requires IRC doctors to report certain matters to the manager of the centre and to officials acting on behalf of the Secretary of State. The Detention Centre Rules are unambiguous that only an IRC doctor (‘medical practitioner’) may make a Rule 35 report. The decision to do so in any particular case is solely a matter for the clinical judgment of the IRC doctor.”

    Source location

    2019-0047-Response-by-Home-Office
    Page 2 · response
    Published 24 May 2019

    Open published response
  6. Manchester West

    AI-generated summary

    Aleysha Martine Karla McLoughlin · 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

    Aleysha Martine Karla McLoughlin, aged 16, died by hanging at her foster home on 3 April 2014 after a history of self-harm, overdoses and assessed ongoing risk of impulsive self-harm. The concerns included training for professionals to recognise self-harm, systems for sharing information when young people self-harm, urgent multi-agency discussions including mental health services, and a formal support pathway for young people who resist engagement.

    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

    Lack of a system encouraging young people to report another young person’s self-harm to those able to help

    Wider context from the report

    “(2) That it should be considered that additional information and encouragement could be offered to young people to inform those able to help for example teachers, nurses, health professionals etc. when a young person becomes aware that another young person is self harming. The shocking self harm to which Aleysha Martine Karla McLoughlin had subjected herself was only revealed when a school friend brought it to the attention of a teacher. There was no evidence that there was any system in place to encourage the passing of such information. ”

    Source location

    Aleysha Martine Karla McLoughlin · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
  7. Manchester City

    AI-generated summary

    Michael James Meyler · 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

    Michael James Meyler died in hospital on 1 January 2011 after being found hanging by the neck in his prison cell on 28 December 2010 and sustaining a hypoxic brain injury. The principal concerns were that information about his recent self-harm and suicide risk was not adequately circulated, read, or attached to his ACCT plan, limiting the ability of prison staff and healthcare personnel to make informed decisions about his welfare.

    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 by Healthcare to read and disseminate important Risk of Self-Harm / Suicide documents

    Wider context from the report

    “5. I am concerned that Healthcare are simply scanning important documents like a Risk of Self-Harm / Suicide document into their system so that they have “a contemporaneous note” rather than actually reading the content. There should be a way of ensuring that these documents are not just scanned to be read in the event that the prisoner has an appointment with someone from Healthcare at a later stage, but that they MUST be read and disseminated in order that they actually make a difference. ”

    Source location

    Michael James Meyler · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    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 ensure that Risk of Self-Harm / Suicide information is read and considered by Senior Wing Officers after prisoner moves

    Wider context from the report

    “2. Furthermore, I am concerned that the information in the Risk of Self-Harm / Suicide document is not brought to the attention to the Senior Officers on Wings which the prisoner may move to at a later stage during their incarceration. I believe that a copy of the Risk of Self-Harm / Suicide document is contained in the prisoner’s physical (buff) folder, which goes with them from Wing to Wing, however there needs to be a safeguard to ensure that this information is read and considered at each stage of the prisoner’s term of imprisonment. ”

    Source location

    Michael James Meyler · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report
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Data last updated 7 September 2026