Recurring concern

Inadequate safety planning for acute mental-health deterioration and suicide risk

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First reported 19 Feb 2014•Latest report 27 May 2026

Definition

What this concern includes

Includes failures to establish, individualise, communicate, review or maintain safety plans for acute mental-health deterioration, suicidal intent or self-harm risk, including plans covering deterioration, increased suicidal thoughts, access to means, urgent escalation, follow-up and coordination with carers or services.

Not included

  • Excludes treatment-selection or psychotherapy-planning failures where the unsafe condition is not deficient safety planning for acute deterioration or suicide risk.
  • Excludes generic risk-assessment, documentation, communication or staffing failures unless they directly result in an inadequate safety plan for acute mental-health deterioration or suicide risk.
  • Excludes failures limited to access controls for specific self-harm means or implementation of a protective measure when the safety-planning process itself is not deficient.
  • Excludes general care plans for physical deterioration without an acute mental-health, suicidal-intent or self-harm-risk context.
Reports
8

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2014–2026

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.

Central and North West London NHS Foundation Trust1
Cornwall Partnership NHS Foundation Trust1
Essex Partnership University NHS Foundation Trust1
Greater Manchester Mental Health NHS Foundation Trust1
Herefordshire and Worcestershire Health and Care NHS Trust1
Mid and South Essex NHS Foundation Trust1
North East London NHS Foundation Trust1
Tees, Esk and Wear Valleys NHS Foundation Trust1

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. Essex

    AI-generated summary

    Abbigail Louise SMITH · 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

    Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

    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 up-to-date care plans and risk assessments for significant self-harm risk

    Wider context from the report

    “10. There were no up-to-date care plans and risk assessments in place for Abbi during her detention and when she was discharged to the community on 14 February 2022 to mitigate a known significant risk. Abbi had tied multiple tight ligatures during her 11-day admission under detention of the Mental Health Act and her usual clothing removed on 4 February due to her risks, the precise date her clothing was returned, and the rationale was not recorded. ”

    Source location

    Abbigail Louise SMITH · Prevention of Future Deaths report
    Page 4 · 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

    Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.

    Verbatim wording from the response

    “Management Teams and staff also have access to an electronic Trust dashboard which is specific to each ward and provides a full oversight of relevant ward information about their current patients (including records, risk assessments and care plans), this supported the identification of any record gaps that can then be promptly addressed. These are printed on a daily basis for staff.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    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

    Review and document MDT decisions on anti-ligature clothing and bedding through regular MDT and ward-review processes.

    Verbatim wording from the response

    “In the interests of safety and based on risk assessment, it is noted that Abbi was issued with anti-ligature clothing during her admission (with her clothes being returned after discharge); during this time her attempts at ligatures were reduced.”

    Source location

    Response from Essex Partnership University NHS Trust
    Page 9 · response
    Published 13 August 2026

    Open published response

  2. Essex

    AI-generated summary

    Abigail Louise SMITH · 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

    Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after attempting to suspend herself; resuscitation was unsuccessful and she was pronounced deceased at 00:08 on 16 February 2022. The report identifies concerns about inadequate trained staffing and observation, unsuitable care arrangements, access to ligature materials, insufficient risk assessments and care plans, communication adjustments for autism and learning disability, and an unsafe discharge from hospital.

    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 appropriate care plans and risk assessments for known self-harm risk

    Wider context from the report

    “3. Abbi at times had to be physically and chemically restrained due to the level of distress and harm to herself. During her admissions Abbi was able to access ligature material that she tied around her neck on multiple occasions over multiple days including her socks, cords from her clothing and pull cords in the bathroom. There were no appropriate care plan and risk assessments to mitigate a significant known risk. ”

    Source location

    Abigail Louise SMITH · Prevention of Future Deaths report
    Page 3 · 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

    Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.

    Verbatim wording from the response

    “I understand that the Court has been provided with an updated copy of the Trust’s Policy for Enhanced Supervision and Engagement. This policy strengthens our assessment and guidance for patients requiring enhanced supervision as per the attached tool.”

    Source location

    Response from Mid & South Essex NHS Foundation Trust
    Page 2 · response
    Published 13 August 2026

    Open published response

  3. North Yorkshire and York

    AI-generated summary

    Victoria Anne TAYLOR · 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

    Victoria Anne Taylor’s mental health deteriorated between May and October 2024, involving suicidal ideation, self-harm and binge drinking. She was reported missing on 1 October 2024, and her body was recovered from the River Derwent on 22 October 2024. The principal concerns were that mental health services did not offer a treatment pathway addressing reported childhood trauma, provided limited safety planning, and did not suggest or convene a multi-agency approach despite knowing that several agencies were involved.

    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 of safety plans to provide additional support responsive to identified needs

    Wider context from the report

    “Ms Taylor was assessed on three separate occasions between mid-May 2024 and the end of August 2024 by members of the Crisis and Acute Hospitals Liaison Teams. Ms Taylor was clear during all three assessments that her episodes of binge drinking and impulsive acts of self harm were the result of unresolved childhood trauma. Despite that, secondary mental health services considered there was no role for them in offering support or a treatment pathway to her. The safety plans agreed following these assessments were therefore limited and offered Ms Taylor no additional support beyond that which she was already accessing through the Horizons service. The assessment documents contained no discussion of treatment pathways for addressing trauma which might be accessed through the Community Mental Health Team, and no indication that such pathways had been offered to Ms Taylor and rejected by her. Instead, it was suggested at the second assessment that Ms Taylor may wish to refer herself to a named private psychotherapy service at some point in the future. There was no rationale included in the second assessment for naming this service, and no explanation of what it might provide or why this could not be offered on the NHS via the CMHT. When Ms Taylor indicated at her third assessment that she had left a message with this private provider and received no response from them, the third safety plan simply suggested she try again. Mental Health services were aware at the time of the second and third assessments that a number of agencies were involved with Ms Taylor, but no multi-agency meeting or approach was suggested or called by them to consider the most appropriate support for Ms Taylor. ”

    Source location

    Victoria Anne TAYLOR · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. East London

    AI-generated summary

    Evelina Vilkiene · 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

    Evelina Vilkiene, who was receiving mental health services, was found hanging at her home on 7 June 2022 and was pronounced dead at the scene. The report identified concerns about the absence of detailed risk assessments and jointly agreed risk-management plans during care transitions and when clonazepam was reduced, as well as the lack of subsequent care-coordinator reviews.

    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 establish a risk management plan when weaning Clonazepam medication

    Wider context from the report

    “2. On the 26th May 2022 when a decision was made to wean Evelina from the Clonazepam medication there was no detailed risk assessment or risk management plan. It was agreed in evidence that there was an increased risk to self at this time. No additional steps were put in place to ensure insofar as possible, that Evelina was kept safe. ”

    Source location

    Evelina Vilkiene · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Cornwall and Isles of Scilly

    AI-generated summary

    Kirsty Marie Doodes · 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

    Kirsty Marie Doodes, who had a history of mental ill-health, was discharged from hospital on 18 March 2020 and later deteriorated at home. She died from her injuries on 27 March 2020 after being taken to hospital. The concerns included insufficient note-keeping, inadequate detail about the future care plan and management of acute deterioration, and insufficient involvement of her carer in the discharge process.

    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 establish a detailed plan for managing acute deterioration

    Wider context from the report

    “i) Insufficiency of note-keeping. ii) ████████ The note made by Dr ████████ in the RiO records was described by an independent expert, Dr ████████, as extremely brief. I accept that medical notes should not be defensive in nature but there is nothing at all in it to justify the view expressed that Kirsty was safe to go home. In a context where she has, over a very recent period, attempted to ████████ on five occasions, the rationale explaining how it was felt she was safe to go home should, in my view, have been set out. Of perhaps more significance is that there was nothing in the note to assist clinicians with understanding how the future care plan was to be organised. That was in a context where a national lockdown was imminent. Given the unprecedented circumstances, it seems apparent to me that there was all the more reason to provide detail in this regard. The fact it was not set out, it seems to me, implies that there was doubt on the part of Dr ████████ about the plan to continue treating Kirsty was to be organised. My fear is that this simply passed the burden of the management of the risk to ████████. This reached an entirely foreseeable crisis in the early hours of 23 March. Kirsty had deteriorated to the point she was described as very suicidal. ████████ was exhausted from his desperate efforts to keep his safe. He rang the ward for assistance. There was no one available to help him. ████████ was advised to call the emergency services. He rang the police who told him to ring the ambulance service who told him to ring the CMHT in the morning. This should not have happened. A detailed plan with how to manage an acute deterioration could have prevented it. At the time, Doctor ████████ was effectively carrying the burden of two consultant psychiatrists in that Dr ████████ was away from work. I indicated at inquest that if this was due to under-resourcing of the Trust, I would write to those responsible for funding. I was advised that, in fact, the problem may be due to a scarcity of consultant psychiatrists nationally. I would be grateful if you could please let me know the position. ”

    Source location

    Kirsty Marie Doodes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester City

    AI-generated summary

    Antony Declan Schofield · 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

    Antony Declan Schofield, who had recurrent depressive disorder and a history of suicidal thoughts and behaviour, was found dead at home on 27 August 2019 after taking an overdose. The report identified concerns about incomplete risk assessment before discharge, inadequate transfer and communication to the community team, insufficient review of escalating suicide risk, missed opportunities to assess changes in presentation, and deficiencies in records, auditing and the subsequent investigation.

    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 clear plan for deterioration, increased suicidal thoughts and access to means of suicide

    Wider context from the report

    “1. a. No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the deceased prior to his discharge from the inpatient unit. This was not identified before he left the ward and it was not discovered by the HBTT when they took over his care. b. The transfer and communication process from inpatient care to the HBTT appeared inadequate. b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated. c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it. d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this. e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile. f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews. g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off. ”

    Source location

    Antony Declan Schofield · 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

    Update inpatient and HBTT procedures to require risk assessments at entry, discharge, identified intervals, and when risks change.

    Verbatim wording from the response

    “During the period under review the Manchester services had recently changed to a new patient clinical record system, Paris, and were in the process of implementing the associated documents such as the Star V2 Risk Assessment which meant that there were some gaps in the services adhering to the Trust Policy. The Standard Operating Procedures (SOP) for both the Inpatient wards and the HBTT have been updated to reflect the Trust Clinical Risk Policy and when staff should be completing a risk assessment. This includes on entry and discharge from a service as well as identified periods in between and in response to any changes to a person’s risks. The Safire SOP clearly outlines that a patient’s risk assessment should be reviewed and updated prior to discharge from the ward and that a crisis plan should be in place.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 2 · response
    Published 5 October 2021

    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

    Put a 72-hour HBTT care plan in place and share it with service users after initial assessment.

    Verbatim wording from the response

    “The HBTT SOP states that there should be an up-to-date Star V2 Risk Assessment in place for people who are referred to HBTT, this was in place when Safire referred to HBTT. The HBTT SOP has been updated to clearly articulate the requirements of the HBTT staff on initial assessment which includes a review of and update of the Star V2 Risk Assessment and initial assessment are completed on the day of the assessment. This will lead to a 72 hour care plan being put into place by HBTT which will be shared with the service user.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 2 · response
    Published 5 October 2021

    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

    Introduce a structured HBTT note format prompting documentation of visit purpose, presentation, and risk to self and others.

    Verbatim wording from the response

    “Following the Trust’s review into Mr Schofield’s death it was acknowledged that the documentation was not always in keeping with Trust Record Keeping Policy in respect of the notes being recorded in the clinical record and that they did not always reflect the discussions that were occurring with the patient and so had the potential to impact on communication and decision making within the team. The HBTT SOP has been updated and states that clinical risk and management are reviewed at each contact with the service user and changes responded to where necessary and escalated to the MDT if necessary. Since the review, in addition to the daily MDT meetings, HBTT have introduced a structured note format to prompt staff to review and record the purpose of the HBTT visit, how the patient was presenting and specific prompts in respect of assessing risk to self and others.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 4 · response
    Published 5 October 2021

    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

    Crisis pathways, continuing support and follow-up appointments were discussed, providing a plan if the patient's condition deteriorated.

    Verbatim wording from the response

    “During the visit by HBTT staff on the late afternoon of 20 August 2019, crisis pathways were discussed with Mr Schofield and he was aware of pathways and support that he could access in the event of any deterioration and an increasing experience in ████████ thoughts. During this visit, the HBTT staff further discussed ongoing support that Mr Schofield could access, and which would be provided. This included an agreement that there would be a further HBTT visit in two days, 22 August 2019 and a psychology appointment the following week, which took place on 26 August 2019. Crisis pathways were discussed with Mr Schofield and details provided to Mr Schofield should he need support in the intervening period.”

    Source location

    2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
    Page 3 · response
    Published 5 October 2021

    Open published response

  7. Manchester City

    AI-generated summary

    Alistair Patrick McDonald · 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

    Alistair Patrick McDonald, who had disclosed suicidal thoughts and a history of deliberate self-harm, was found dead on 14 May 2018, hanging by a ligature secured to a door frame. The concerns included the assessment and management of his suicidal ideation and self-harm, lack of follow-up and clear referral plans, communication with him and his family, and failure to recognise the wider significance of his presentation.

    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 plan to review and manage the patient’s combined self-harm, suicidal intent and stress-related difficulties

    Wider context from the report

    “1. Whether or not the specific deliberate self-harm or suicidal ideation criteria need to be reviewed and redrafted 2. The lack of a specific plan for referrals to other services which proved unsuccessful 3. The opportunity to take a broader view of the whole position and have an assessment by an experienced psychiatrist. 4. Ensuring a proper line of communication with the patient and the patient’s family to ensure appropriate reviews if the patient’s mental state deteriorates 5. Obtaining detailed feedback from services the patient is referred to, to check on attendance and progress 6. Recognising that some patients will only make partial disclosure of their true symptomology and history. 7. Loss of opportunity to see the bigger picture, which was of an academically bright student but who nonetheless was disclosing physical self-harm and suicidal intent, as well as an inability to deal with stress or pressure; and have a plan to review and deal with this 8. Ensuring if there were any failed communications with the patient or the family, to have a plan to take specific action to deal with this. ”

    Source location

    Alistair Patrick McDonald · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  8. South London

    AI-generated summary

    Simon William McAndrew · 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

    Simon William McAndrew died in hospital on 3 July 2011 after being found hanging from a tree at the residential home where he lived and subsequently suffering severe brain injury. The principal concerns were poor communication and confusion between services about responsibility for his psychiatric care, including the sharing of key information and provision of appropriate crisis guidance to the residential home.

    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 formal written care plans with clear crisis-management guidance for distant residential homes

    Wider context from the report

    “Please will you also consider whether a formal, written care plan should be provided to the distant residential home with clear guidance as to what is to happen in defined circumstances of crisis. If the staff at Jordan Lodge had had the benefit of a care plan, they might have contacted the acute psychiatric team on 30th June 2011 to seek advice as how best to manage the immediate crisis. In the absence of a care plan, and with residential home staff who are not mental health professionals, the staff who were on duty on the day were left to deal with the crisis as best they could. Is that state of affairs capable of improvement? ”

    Source location

    Simon William McAndrew · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
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Data last updated 7 September 2026