PFD report

Stephen Martin ADAMS · Prevention of Future Deaths report

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Issued 30 Nov 2015•Worcestershire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Failure to record suicide risk assessment in risk assessment documents
    Part of recurring concern: Unreliable recording of safety-critical mental health informationPart of recurring concern: Unreliable recording of suicide-risk information
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to record suicide risk assessment in risk assessment documents

Wider context from the report

“(1) It emerged during the inquest that the Risk Assessment document completed by the Mental Health Liaison Team worker was not complete in as much as the box indicating the assessment of suicide risk had not been completed. The witness indicated that many workers do not complete this box and the assessment of risk is to be extrapolated from the actions taken by the worker. No where on the document is the assessment of risk to be found. ”

Is this part of a recurring concern?

Yes — Unreliable recording of safety-critical mental health information; Unreliable recording of suicide-risk information.

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026