Recurring concern

Unreliable response to suicidal communications by text

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First reported 12 Nov 2020•Latest report 8 Aug 2025

Definition

What this concern includes

Includes failures in dedicated processes for receiving, assessing, escalating and responding to text messages indicating suicidal thoughts or immediate suicide risk, including expedited police or emergency action, direct contact, location and welfare arrangements, crisis-text-service procedures, local pathway coordination and handover to responsible services.

Not included

Excludes general suicide-prevention, mental-health access or crisis-response deficiencies where text-based suicidal communication is not the material unsafe condition.
Excludes generic text-message, telephone, CAD or communication failures without an expressed suicidal-thought or immediate suicide-risk context.
Excludes failures in treatment or follow-up after an appropriate response to the suicidal text has been reliably initiated.
Excludes failures involving ordinary non-safety-related service-user messaging or appointment communication.

Reports: 2
Individual concerns: 4
Date range: 2020–2025
Stated actions: 4

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

Home Office1

Metropolitan Police Service1

NHS England1

NHS Greater Manchester Integrated Care Board1

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.

8 Aug2025
Manchester North
Concerns raised3
1. Unavailability of arrangements for locating people at immediate risk across all charity crisis text services
2. Lack of standard policies and procedures for responding to immediate suicide risk
3. Failure of charity crisis text services to link with local NHS Trusts and pathways
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement a phased, locally delivered crisis-text service integrated with the Greater Manchester 111 mental-health crisis line.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
2. Action
  Review the interface between the crisis-text service and Greater Manchester Police during service scoping and mobilisation.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
3. Action
  Request all Integrated Care Boards to establish integrated crisis text services.
  Stated by NHS EnglandStated completed
Respondent positions 3
1. Position
  The non-NHS charity’s service delivery and clinical governance arrangements fall outside the respondent’s ability to comment on.
  Stated by NHS EnglandOutside remit
1. Position
  NHSE and its provider should address the crisis text service's interface with Greater Manchester Police through their commissioning arrangements.
  Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibility
2. Position
  Independent charitable organisations providing crisis text services are outside Government and NHS control.
  Stated by Department of Health and Social CareOutside remit
AI-generated summary

Jessica Lynda Smithson · 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

Jessica Lynda Smithson, aged 27, died by suicide after contacting a crisis text mental health service following an alleged serious sexual assault. The service did not contact the Metropolitan Police despite messages indicating an immediate risk to her life. The report identified concerns about inconsistent procedures among charity crisis text services and the absence of a commissioned crisis text mental health service in Greater Manchester.

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
Unavailability of arrangements for locating people at immediate risk across all charity crisis text services
Wider context from the report
“(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide. The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life. Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities. In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services. ”
Source location
Jessica Lynda Smithson · Prevention of Future Deaths report
Page 2 · 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
Lack of standard policies and procedures for responding to immediate suicide risk
Wider context from the report
“(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide. The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life. Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities. In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services. ”
Source location
Jessica Lynda Smithson · Prevention of Future Deaths report
Page 2 · 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 of charity crisis text services to link with local NHS Trusts and pathways
Wider context from the report
“(b) At present this gap in a health-related service is being filled by charity organisations who have different policies and processes regarding actions to be taken if a person is at immediate risk of suicide. The charities are not under the Department of Health so there is no standard policy or procedure for them to follow if there is a real and immediate risk to a service user’s life. Hence there is a lack of consistency as to the support an individual can receive when there is an immediate risk to their life, for example whilst the charity involved in this case have an agreement with the Metropolitan Police Service to help locate someone whose whereabouts are unknown, this is not the case for all charities. In addition, as they are not linked into local NHS Trusts, they have limited ability to understand local mental health NHS pathways or to offer a more co-ordinated response where someone is already under local mental health services. ”
Source location
Jessica Lynda Smithson · 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
Implement a phased, locally delivered crisis-text service integrated with the Greater Manchester 111 mental-health crisis line.

Verbatim wording from the response
“NHS GM alongside the mental health trusts have considered options for the provision of crisis text services and are currently considering our preferred model through our Greater Manchester Mental Health Clinical Effectiveness Group (CEG) as our established clinical governance route. Our preferred model is for a text service to be incorporated into the Greater Manchester 111 Mental Health crisis line service so that texts are handled by Greater Manchester Mental Health First Responders based within the team.”

Source location
Response from Greater Manchester Integrated Care
Page 2 · response
Published 13 August 2025
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 the interface between the crisis-text service and Greater Manchester Police during service scoping and mobilisation.

Verbatim wording from the response
“For additional information, NHS GM has commissioned SHOUT (Shout is a free, confidential, 24/7 text messaging service for anyone who is struggling to cope) previously and took the decision to discontinue after one year in 2020/21 based on an evaluation by Health Innovation Manchester and negative service user feedback online. This was also done in the context that the universal offer commissioned by NHSE was in place so at this time NHS Greater Manchester does not currently commission a text crisis service. In this instance, Jessica accessed SHOUT, commissioned by NHSE. The interface between SHOUT and Greater Manchester Police should be considered within any commissioning arrangements between NHSE and the provider.”

Source location
Response from Greater Manchester Integrated Care
Page 2 · response
Published 13 August 2025
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
Request all Integrated Care Boards to establish integrated crisis text services.

Verbatim wording from the response
“Anyone in England can access age-appropriate crisis support by calling NHS111 and selecting the ‘mental health option’, with services commissioned and designed to deliver consistent triage, risk assessment and, where necessary, rapid face-to-face assessments. To further enhance accessibility, NHS England has requested that all ICBs put in place integrated crisis text services and ICBs have now submitted their plans, with delivery expected across all areas by Spring 2026.”

Source location
Response from NHS England
Page 1 · response
Published 13 August 2025
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 non-NHS charity’s service delivery and clinical governance arrangements fall outside the respondent’s ability to comment on.

Verbatim wording from the response
“We would suggest the Coroner’s Office approaches the charity directly for further information about the support provided, if required. As this is a non-NHS provider, we are unable to comment on their service delivery arrangements or clinical governance processes.”

Source location
Response from NHS England
Page 1 · response
Published 13 August 2025
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
NHSE and its provider should address the crisis text service's interface with Greater Manchester Police through their commissioning arrangements.

Verbatim wording from the response
“For additional information, NHS GM has commissioned SHOUT (Shout is a free, confidential, 24/7 text messaging service for anyone who is struggling to cope) previously and took the decision to discontinue after one year in 2020/21 based on an evaluation by Health Innovation Manchester and negative service user feedback online. This was also done in the context that the universal offer commissioned by NHSE was in place so at this time NHS Greater Manchester does not currently commission a text crisis service. In this instance, Jessica accessed SHOUT, commissioned by NHSE. The interface between SHOUT and Greater Manchester Police should be considered within any commissioning arrangements between NHSE and the provider.”

Source location
Response from Greater Manchester Integrated Care
Page 2 · response
Published 13 August 2025
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 charitable organisations providing crisis text services are outside Government and NHS control.

Verbatim wording from the response
“I hope you will understand that charitable organisations providing crisis text services are independent of both Government and the NHS.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 13 August 2025
Open published response
12 Nov2020
East London
Concerns raised1
1. Failure to provide an adequately expedited and direct response to suicidal thoughts communicated by text
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Require SOIT and investigating officers to notify supervisors of concerning victim contact, agree and document a response, and make immediate telephone contact.
  Stated by Metropolitan Police ServiceStated completed
AI-generated summary

Imane Bouasbia · 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

Imane Bouasbia was sexually assaulted on 1 January 2020 and subsequently expressed suicidal thoughts to police. On 3 January 2020, she stepped in front of a moving Central Line tube train at Newbury Park Station and was killed instantly. The principal concerns were failures to communicate her suicidal thoughts, complete a self-harm or suicide risk assessment, and respond adequately to her text message indicating suicidal thoughts.

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 an adequately expedited and direct response to suicidal thoughts communicated by text
Wider context from the report
“c. The police reaction to Ms Bouasbia’s text message at of 3rd January 2020 indicating suicidal thoughts was limited to a non-expedited instruction on a CAD action. The only response to Ms Bouasbia was a further text message rather than a telephone call. ”
Source location
Imane Bouasbia · 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
Require SOIT and investigating officers to notify supervisors of concerning victim contact, agree and document a response, and make immediate telephone contact.

Verbatim wording from the response
“Upon reflection, the SOIT officer accepts that she should have contacted Ms Bouasbia by telephone to speak directly with her. On 21st December 2020, the MPS addressed this by e-mailing all SOIT officers and Public Protection Department managers with the instruction that SOIT and investigating officers must inform a supervising officer if they receive any contact from a victim that causes them concern. A course of action must be agreed and documented on the CRIS report or CAD message and immediate contact made with the victim by telephone. In addition, SOIT officers must ensure their work mobile telephone recorded answer message provides alternative contact numbers should the SOIT officer be off duty or uncontactable and the caller needs reassurance.”

Source location
2020-0234-Response-from-MPS-Redacted.pdf
Page 4 · response
Published 23 December 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Unavailability of arrangements for locating people at immediate risk across all charity crisis text services

Lack of standard policies and procedures for responding to immediate suicide risk

Failure of charity crisis text services to link with local NHS Trusts and pathways

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to provide an adequately expedited and direct response to suicidal thoughts communicated by text

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

Actions described in response 3

Respondent positions 3

Actions described in response 1