Recurring concern
Inconsistent implementation of suicide-prevention systems
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Request correctionFirst reported 29 Jan 2016•Latest report 8 Aug 2025
What this concern includes
Includes failures in explicitly identified suicide-prevention systems, strategies, guidance or service arrangements where implementation, consistency across service areas, policy integration or operational practice is insufficient to provide reliable prevention and support.
Not included
- Excludes suicide-prevention controls dedicated to a narrower named hazard or setting, such as prison ACCT, suicide-prevention signage, railway stations, bridges or multi-storey car parks, where that narrower concern supplies the more specific boundary.
- Excludes isolated suicide or self-harm incidents or outcomes without an identified deficiency in a suicide-prevention system or its implementation.
- Excludes generic staff training, communication, staffing or mental-health service deficiencies unless they are explicitly tied to implementing or operating suicide-prevention arrangements.
- Excludes broader mental-health treatment, crisis-support or safeguarding failures where suicide prevention is not the identified unsafe condition.
- Reports
- 8
- Individual concerns
- 9
- Date range
- 2016–2025
- Stated actions
- 13
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 provide crisis text services across all ICBs
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.2
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Action
Request all Integrated Care Boards to establish integrated crisis text services.
Stated by NHS England -
Action
Request regular progress reports on national integrated crisis text service delivery.
Stated by Department of Health and Social Care
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Concerns raised2
Failure of suicide prevention contact services to accommodate people with hearing difficulties or other disabilities
Failure of suicide prevention contact numbers to provide continuous access to someone able to speak with callers
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
Recruit staff to improve Sussex Mental Health Line capacity.
Stated by Sussex Partnership NHS Foundation Trust -
Action
Change Sussex Mental Health Line working patterns to improve call accessibility.
Stated by Sussex Partnership NHS Foundation Trust -
Action
Improve Sussex Mental Health Line productivity to address demand and unanswered calls.
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
A range of accessible community and crisis options, rather than improved helplines alone, is considered sufficient to provide local support 24/7.
Stated by Sussex Partnership NHS Foundation Trust
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Concerns raised1
Failure to fully incorporate suicide-prevention guidelines into policy and practice
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.
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 identify and address suicide risk for Veterans
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.5
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Action
Maintain a Trustwide Lead for Suicide Prevention responsible for strategy, training, clinical practice and learning.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Complete the three-year Suicide Strategy review with specific consideration of veteran suicide risk and implications for clinical practice.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Update essential suicide awareness and response training to reflect enhanced risk among veterans.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Action
Reflect veteran suicide-prevention learning at the annual Trust suicide-prevention conference, with veteran-service information available.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Disseminate the Veterans and Suicide Prevention Champions Network presentation Trustwide through communications and the intranet.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised1
Lack of a clear and timely timeline for Suicide Prevention Group data analysis and strategy development
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.
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
Establish a dedicated subgroup to investigate Defence information-sharing processes, explore solutions and report findings.
Stated by Army -
Action
Develop a Defence Suicide Prevention Plan, including agreeing a leadership roadmap and producing an initial draft.
Stated by Army
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Concerns raised1
Failure to implement national guidance to reduce student suicide
This report raised 11 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 with the Surrey Suicide Prevention Partnership on university suicide-safety policy, guidance, staff training and student mental health support.
Stated by University of Surrey
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 University had a suicide safety policy and had adopted the national recommendations, except for a planned round-table event.
Stated by University of Surrey
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Concerns raised1
Failure of suicide risk guidance to include irrational behaviour indicative of psychosis
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.
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 provide a consistent suicide prevention approach across service areas
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.
Data last updated 7 September 2026