Recurring concern

Unreliable operation of Suicide Vulnerability Risk Assessment processes

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First reported 4 Mar 2014•Latest report 29 Nov 2024

Definition

What this concern includes

Includes failures in the named Suicide Vulnerability Risk Assessment or VRM process, including training and refresher training, understanding of its purpose, implementation of post-assessment measures, risk-reduction actions and related competence assurance.

Not included

  • Excludes generic suicide-risk assessment, self-harm prevention or prison ACCT concerns where the Suicide Vulnerability Risk Assessment or VRM process is not identified.
  • Excludes generic staff training, supervision or communication deficiencies unless they directly impair operation of the VRM process.
  • Excludes failures in downstream care or protective action after VRM measures have been reliably assessed and implemented, unless the VRM process itself is deficient.
  • Excludes unrelated risk-assessment systems, hazards and beneficiary groups without an explicit connection to the same VRM or Suicide Vulnerability Risk Assessment process.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
4

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.

Ministry of Defence3
Nottinghamshire Healthcare NHS Foundation Trust1
Recipient name withheld1

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. Berkshire

    AI-generated summary

    Charlie Anthony OWEN · 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

    Charlie Anthony Owen was found deceased in his room at Combermere Barracks on 11 September 2023, after previously making and aborting two attempts to end his life in the context of relationship breakdown. The inquest identified concerns about inadequate sharing of risk-management information, insufficient consideration of welfare checks and protective factors on his return to barracks, and gaps in Army training and Vulnerability Risk Management processes.

    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

    Insufficient focus in VRM training on reducing risk and preventing suicide

    Wider context from the report

    “I heard evidence regarding the VRM process training. I am concerned that there is insufficient focus in that training on the actual aim including reducing risk and preventing suicide. A better understanding of risks and the purpose of VRM seems likely to assist those tasked with running it. ”

    Source location

    Charlie Anthony OWEN · 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

    Establish a working group to review all aspects of mental-health and wellbeing training, including suicide prevention, risk understanding and Vulnerability Risk Management.

    Verbatim wording from the response

    “Suicide prevention training is already mandatory for Army Welfare Officers. I am sorry that this did not come through clearly at the inquest. This is clearly a point of concern and therefore, a working group is being established to fully review all aspects of the training for mental health and wellbeing. I expect the recommendations to be published by April 25 to inform an update to training policy in the following quarter. Your comments concerning a greater focus upon suicide prevention; understanding risk, and the purpose of VRM, will be included within this review.”

    Source location

    Response from Ministry of Defence
    Page 1 · response
    Published 6 December 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

    Publish recommendations from the mental-health and wellbeing training review.

    Verbatim wording from the response

    “Suicide prevention training is already mandatory for Army Welfare Officers. I am sorry that this did not come through clearly at the inquest. This is clearly a point of concern and therefore, a working group is being established to fully review all aspects of the training for mental health and wellbeing. I expect the recommendations to be published by April 25 to inform an update to training policy in the following quarter. Your comments concerning a greater focus upon suicide prevention; understanding risk, and the purpose of VRM, will be included within this review.”

    Source location

    Response from Ministry of Defence
    Page 1 · response
    Published 6 December 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

    Update training policy using the published recommendations.

    Verbatim wording from the response

    “Suicide prevention training is already mandatory for Army Welfare Officers. I am sorry that this did not come through clearly at the inquest. This is clearly a point of concern and therefore, a working group is being established to fully review all aspects of the training for mental health and wellbeing. I expect the recommendations to be published by April 25 to inform an update to training policy in the following quarter. Your comments concerning a greater focus upon suicide prevention; understanding risk, and the purpose of VRM, will be included within this review.”

    Source location

    Response from Ministry of Defence
    Page 1 · response
    Published 6 December 2024

    Open published response

  2. Derby and Derbyshire

    AI-generated summary

    Jonathan “Jonny” Philip Cole [JC] · 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

    Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s 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

    Insufficient DCMH clinician influence in vulnerability risk management for suicidal soldiers

    Wider context from the report

    “2. I have a concern that the Vulnerability Risk Management Process [Suicide Vulnerability Risk Management as was] is Unit led and that DCMH clinicians do not have a greater role in influencing the Army’s vulnerability risk management (VRM) process for suicidal soldiers. ”

    Source location

    Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report
    Page 6 · 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

    Operate VRMIS with clinician and supporting-professional access to care action plans, subject to consent, within a multidisciplinary vulnerability-risk-management process.

    Verbatim wording from the response

    “The Vulnerability Risk Management (VRM) process was completely overhauled in 2014 and again in 2020. The major change in 2014 was the introduction of a Management Information System (Vulnerability Risk Management Information System (VRMIS)) as a Unit’s Vulnerability Risk Management Register, moving away completely from the previous paper-based system.”

    Source location

    Response from Ministry of Defence
    Page 5 · response
    Published 12 June 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

    The VRM process requires medical involvement, including attendance at risk conferences and reviews, so clinicians are not excluded from managing suicidal vulnerability.

    Verbatim wording from the response

    “Since its creation and roll-out in 2014/2015 the VRMIS specifically allows for clinicians, and other third parties who are supporting an individual, such as pastoral and welfare services, to be given read-only access to the Care Action Plan¹¹ (subject to the individual’s explicit consent). The system and process were updated and aligned to follow a multi-disciplinary approach.”

    Source location

    Response from Ministry of Defence
    Page 5 · response
    Published 12 June 2023

    Open published response

  3. Wiltshire and Swindon

    AI-generated summary

    Anne-Marie Katherine Element · 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

    Anne-Marie Katherine Element, a corporal, died by suicide outside her accommodation at Kiwi Barracks in Wiltshire on or around 9 October 2011. The inquest identified contributing matters including the lingering mental effects of an alleged rape, workplace bullying, work-related despair, and the effects of a relationship break-up. Concerns included inadequate guidance for responding to an alleged rape by one soldier against another and insufficient training and follow-up training for implementing Suicide Vulnerability Risk Assessments.

    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

    Insufficient training and follow-up training for staff implementing Suicide Vulnerability Risk Assessment measures

    Wider context from the report

    “2. The evidence at the Inquest suggested that those responsible for the implementation of measures to be put in place following a Suicide Vulnerability Risk Assessment had insufficient training in the system with no evidence of regular follow-up training. This is in marked contrast with the prison system where those responsible for managing at risk prisoners have specific targeted training with regular updates. The evidence at the Inquest suggested that instruction on the subject of suicide and vulnerability risk assessment formed little more than a lecture. ”

    Source location

    Anne-Marie Katherine Element · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026