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Unreliable police-custody risk assessment processes 6 22 12 Aug 2024 Inadequate deprivation of liberty safeguarding for people lacking capacity 11 20 10 Jul 2025 Unsafe remote clinical consultations for assessment and advice 8 13 6 Aug 2025 Inadequate management of smoking-related fire risks in vulnerable people 6 10 3 Oct 2024 Failure to conduct timely, appropriate clinical assessments 25 37 17 Feb 2026 Failure to make required contact with approved family and support contacts 2 6 30 Jun 2023 Unreliable assessment of suicide and self-harm risk 77 72 27 May 2026 Unreliable alcohol detoxification care and support 9 15 9 Dec 2020 Inadequate railway-station controls to prevent and detect suicide attempts 2 4 28 Mar 2024 Failure to provide timely suitable onward care placements for patients ready for hospital discharge 28 23 18 Jun 2026 Unreliable nurse-to-doctor escalation in primary care 3 3 19 Oct 2023 Unclear healthcare and police responsibilities for safety-critical action 9 38 7 Apr 2025 Unreliable clinical review and authorisation of discharge decisions 20 29 11 Jan 2026 Unreliable referral urgency categorisation and prioritisation 12 23 17 Apr 2025 Failure to provide patient-centred care and decisions 12 20 14 Jan 2026 Inadequate safety controls for helium canisters 3 2 20 Mar 2015 Failure to ensure people are placed in care settings suitable for their needs 19 27 10 Oct 2025 Failure to reliably obtain and verify SOAD approval for psychiatric treatment 2 2 18 Nov 2024 Insufficient acute hospital capacity for patients requiring admission 8 14 3 Nov 2025 Unreliable Haven at Millview service arrangements 2 3 27 Apr 2026 Inadequate suicide-prevention signage at public locations 4 4 13 Jan 2020 Unreliable joint emergency-service attendance at risk-marked properties 2 5 24 Nov 2020 Unsafe self-discharge decision-making 3 2 25 Sep 2023 Failure to reliably escalate patient safety concerns to primary care 9 16 4 Nov 2024 Failure to investigate concerning presentations beyond initial appearance and self-report 19 33 30 Mar 2026