Poor mental health suicide risk assessment
Failures in recognising and assessing high suicide risk due to limited training, inadequate supervision, and poor call triage.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
100match
Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of...
Organisations can improve patient safety by listening to and communicating with patients, their families and carers, about the safety and wellbeing of people who have self-harmed and/or are expressing suicidal thoughts. It is important that this involvement starts from the point of a patient’s admission through to their discharge from inpatient mental health wards and during follow up....
Matched on
terms: assessment, health, mental, suicide
HSSIB recommendation
99match
Care delivery within community mental health teams
NHS England has written to all mental health trusts in England to highlight the importance of taking a person-centred approach to psychosocial assessments and safety planning. The communication asks trusts to move away from risk assessment tools that stratify an individual’s risk of suicide or self-harm.
Matched on
terms: assessment, health, mental, suicide
Inquiry recommendation
95match
74 - Mental health assessments to address risk
When prisoners are referred for a mental health assessment, the assessment should address the risk which they pose to staff and other inmates.
Matched on
terms: assessment, health, mental
HSSIB recommendation
95match
Provision of mental health care to patients presenting at the emergency department
It is recommended that the Royal College of Emergency Medicine, in conjunction with the Royal College of Psychiatrists, develops and disseminates national guidance for emergency department practitioners to standardise the initial assessment of a person presenting following a mental health emergency.
Matched on
terms: assessment, health, mental
Committee recommendation
90match
#36 - Eighth Report - Children and young people’s mental health
We are deeply concerned about the increasing numbers of children and young people who experience self-harm and suicide and the quality of care they are able to access. Much more needs to be done to tackle suicide and self-harm amongst children and young people. In particular, given the link between self-harm in children and young people and later...
Matched on
terms: health, mental, suicide
PFD report
89match
Andrew Peebles
The coroner raised concerns about the Registered Mental Health Nurse's (RMN) inadequate documentation, assessment of delusional symptoms, and failure to record or act on a referral regarding the deceased's mental health. There was also no Trust internal investigation into the death.
Matched on
terms: assessment, health, mental
PPO recommendation
86match
The Head of Healthcare
The Head of Healthcare should ensure that reception staff make an urgent mental health referral when a prisoner presents as hopeless or expresses thoughts of suicide or self-harm.
Matched on
terms: health, mental, suicide
PFD report
85match
Finnulla Martin
The coroner identified unclear protocols for mental health patients brought voluntarily by police, resulting in inadequate information sharing between agencies and incomplete risk assessments. Concerns were also noted regarding poor record-keeping and insufficient urgency in escalating patient information.
Matched on
terms: assessment, health, mental, poor
PFD report
85match
Wanda Stachurska
The quality of mental health risk assessments was noted as diminished due to staff unawareness of policies and the routine use of untrained interpreters without guidance. The coroner also identified that a Serious Incident Review was not undertaken, delaying learning opportunities.
Matched on
terms: assessment, health, mental
PFD report
85match
William Abel
A Mental Health Act assessment was not conducted when Mr. Abel expressed suicidal intention, and there was inadequate communication with his family about his mental health relapse and the expectation for his safe keeping.
Matched on
terms: assessment, health, mental
PFD report
85match
Louise Locke
The coroner identified concerns regarding a premature discharge from the Community Mental Health Service without adequate risk assessment or support, and the lack of a system to collate information from other agencies. The report also highlights the absence of a consistent multi-agency approach to high-risk individuals and suicide prevention across all areas served by Southern Health.
Matched on
terms: assessment, health, mental, suicide
PFD report
85match
Patricia Cleghorn
The coroner noted a lack of acute mental health inpatient beds, which meant vulnerable individuals received community care with limited resources. There was also no formal risk assessment concerning the deceased's access to medication despite her repeated statements about ending her life by overdose.
Matched on
terms: assessment, health, mental
IOPC learning recommendation
84match
Recommendation - Nottinghamshire Police, March 2022
The IOPC recommends that Nottinghamshire Police review their policy/guidance for high risk cases in relation to safeguarding and suicide risk assessments, to ensure that these are conducted at the 'known trigger points' of an investigation. This follows a case where police were called to attend to a report of a male found at his home address having taken...
Matched on
terms: assessment, health, mental, suicide
PFD report
81match
Delwyn Preece
Repeated instances of patients being granted ward leave without documented mental state examination or risk assessment were noted. Additionally, medical records featured poor documentation, including unflagged retrospective entries, which impacted subsequent investigations.
Matched on
terms: assessment, mental, poor
PFD report
81match
Kevin Dermott
The report highlights inadequate mental health care, incomplete care planning, and significant communication deficits during multiple prison transfers, which led to a failure to recognise a relapse in the deceased's condition and properly observe ACCT procedures.
Matched on
terms: health, mental
PFD report
81match
Abigail Baynham
The coroner noted no referral was made back to the Mental Health Liaison Service when Ms Baynham left hospital, which could have led to a further assessment of her mental state and risk of self-harm.
Matched on
terms: assessment, health, mental
CJINI report
78match
Not a Marginal Issue: Mental health and the criminal justice system in Northern Ireland
Matched on
terms: health, mental
PFD report
77match
Tallulah Wilson
Healthcare professionals lacked a good understanding of young people's evolving internet use and its impact on their wellbeing, highlighting a need for improved training and risk assessment refinement regarding digital lives.
Matched on
terms: assessment, health
PFD report
77match
Simon Reynolds
The coroner identified a lack of documented risk assessment upon service user admission to Mason Unit, and insufficient guidance and training for staff on setting observation levels, assessing and managing suicide/self-harm risk, and communicating that risk.
Matched on
terms: assessment, suicide
CQC action
77match
Rotherham General Hospital
The trust must ensure that all patients presenting with a mental health condition have all appropriate risk assessments completed.
Matched on
terms: assessment, health, mental
CQC action
77match
Pilgrim Hospital
The trust should ensure patients at risk of self harm or suicide are cared for in a safe environment meeting standards recommended by the Psychiatric Liaison Accreditation network (PLAN) and mental health risk assessments and care plans are completed for all patients at risk.
Matched on
terms: assessment, health, mental, suicide
CQC action
77match
Ellesmere Port Hospital
The trust must ensure that patients identified with a mental health condition are cared for in a safe ligature free environment and have appropriate risk assessments completed.
Matched on
terms: assessment, health, mental
CQC action
77match
St Benedict's Hospice
The service must ensure that children and young people with a mental health condition are risk assessed for their mental health needs, self-harm or suicide and are cared for in a safe environment that has been appropriately risk assessed.
Matched on
terms: health, mental, suicide
CQC action
77match
Royal Bolton Hospital
The trust should ensure that mental health risk assessments including environmental assessments are thoroughly completed.
Matched on
terms: assessment, health, mental
CQC action
77match
Durham Diagnostics and Treatment Centre
The service must ensure that children and young people with a mental health condition are risk assessed for their mental health needs, self-harm or suicide and are cared for in a safe environment that has been appropriately risk assessed.
Matched on
terms: health, mental, suicide
IOPC learning recommendation
77match
Recommendations - Nottinghamshire Police, February 2026
The IOPC recommends that Nottinghamshire Police should review and amend policy documents ‘PS260 – Suicide Prevention and Risk Management of Suspects’ and ‘PD485 – Dealing with Indecent Images of Children and Extreme pornography’ to include suspects who are under investigation (including those visited at home) or those that have attended a voluntary interview at a police station. This...
Matched on
terms: assessment, health, mental, suicide
IOPC learning recommendation
77match
National recommendations - College of Policing, July 2024
The IOPC recommends that the College of Policing review and update its guidance on Suicide and Bereavement Response as part of its ongoing work to review APP on mental health. This review should: - Ensure that any national strategies and academic work signposted in APP remain relevant and do not conflict with the current policing position on mental...
Matched on
terms: health, mental, suicide
Article 2 learning point
77match
CR — HMP Swansea - LP Healthcare 1
A range of information including that from assessment during custody and from court proceedings should be considered along with the presenting risk factors when undertaking an initial assessment of an individual’s risk of suicide/self-harm and the opening of a potential ACCT.
Matched on
terms: assessment, health, suicide
PHSO casework decision
76match
P-004470 - Surrey and Borders Partnership NHS Foundation Trust
Mr C alleged failures in his sister's mental health treatment, including inappropriate medication, inadequate risk assessments, and non-adherence to guidance, contributing to her suicide.
Matched on
terms: assessment, health, mental, suicide
CJINI report
74match
Mental Health and the criminal justice system in Northern Ireland
Matched on
terms: health, mental
PFD report
73match
Alexander Holt
The coroner noted insufficient challenge to Mr Holt's minimised suicidal intent and poor information flow, notably staff being unaware of his recent self-harm attempt. This led to inadequate risk assessment and disrupted care continuity.
Matched on
terms: assessment, poor
PFD report
73match
Isobel Griffin and Jane Clark
Concerns include inadequate information handover, staff not reading patient notes before making critical decisions, and poor or outdated risk assessment documentation. The coroner also noted delayed patient reviews and the presence of non-ligature-proof doors.
Matched on
terms: assessment, poor
PFD report
73match
Jake Robinson
Disjointed care was noted due to insufficient follow-up on a GP's medication recommendation and Phoenix Futures' inability to prescribe. An unexplained rescheduling of a mental health appointment also occurred despite the patient's self-harm risk.
Matched on
terms: health, mental
PFD report
73match
Nicholas Sullivan
The coroner noted the absence of a checklist for emergency department staff to identify mental health issues and trigger urgent triage. Concerns also included no clear system for patient safeguarding or escalation, and insufficient inter-trust protocols.
Matched on
terms: health, mental
Committee recommendation
72match
#8 - Fifty-Second Report - Key challenges facing the Ministry of Justice
HMPPS’ data shows that during 2020, there were 67 self-inflicted deaths in custody, and 58,879 self-harm incidents in the 12 months to September 2020. We heard from HMPPS that while these levels are high, they are showing signs of declining. The situation remains particularly alarming for female prisoners.8 We welcomed HMPPS’ work to set up a taskforce to...
Matched on
terms: health, mental
CQC action
72match
The York Hospital
The service should ensure ED staff complete all sections of risk assessments for patients who show signs of mental ill health. They should consider revising this documentation’s length to improve staff compliance.
Matched on
terms: assessment, health, mental
CQC action
72match
Royal Preston Hospital
The trust must ensure that risk assessments are fully completed for patients attending with mental health needs and mitigating actions to limit identified risks are implemented.
Matched on
terms: assessment, health, mental
IOPC learning recommendation
72match
Recommendation - Northumbria Police, March 2022
The IOPC recommends that Northumbria Police update their policy/guidance in relation to conducting suicide risk assessments. These should be conducted in person, wherever possible, and any other method used needs to be recorded along with the rationale for the use of that method. This follows a case where a male was alleged to have sexually abused two family...
Matched on
terms: assessment, health, mental, suicide
IMB recommendation
72match
Swaleside (2024)
The Board remains concerned regarding the mental health of prisoners who have suffered long-term lockdown. This is evidenced by the number of opened Assessment, Care in Custody and Teamwork (ACCT) documents, self-harm cases and violent incidents. The first indications from the recent improvement in regime are positive. However, the necessity for increased psychology and psychiatric services still needs...
Matched on
terms: assessment, health, mental
Scottish FAI
72match
Dr Sara Lilian Macrae
(i) When staff in a secure mental health ward are presented with evidence that a patient has vocalised suicidal ideation and demonstrated means to complete suicide by presentation of a ligature, urgent action to search that patient’s room and person for any other potential ligatures ought to be taken. In addition, consideration should be given to placing the...
Matched on
terms: health, mental, suicide
IMB recommendation
72match
Swaleside (2022)
The Board has concerns regarding the mental health of prisoners who have suffered long-term lockdown as evidenced by the high number of assessment, care in custody and teamwork (ACCTs) cases, self-harm cases and general violent incidents. The necessity for increased psychology and psychiatric services should be assessed.
Matched on
terms: assessment, health, mental
PFD report
69match
Robert Day
The coroner noted a lack of national guidance for frontline emergency services concerning complex, time-critical mental health situations. Non-specialist staff require clearer direction on appropriate actions when Mental Health Act provisions are not readily applicable.
Matched on
terms: health, mental
PFD report
69match
Jonathan Thorpe
During GP consultations for a patient with depression and a history of self-harm, the coroner noted no reference to Mental Health Services, nor was advice sought regarding previous involvement or need for further input.
Matched on
terms: health, mental
PFD report
69match
Darren Arnoup
The coroner raised concerns regarding the process for managing an individual's mental health risks, including suicidal ideation, after specific details had been communicated to their GP practice.
Matched on
terms: health, mental
PFD report
69match
Samarjit Singh
There was no Specialist Community Perinatal Mental Health Service in Wirral, resulting in sub-optimal treatment. Additionally, the Liverpool City Region lacked a Mother and Baby in-patient Unit, leading to many distant referrals being declined.
Matched on
terms: health, mental
PFD report
69match
John Thorpe
The coroner noted concerns regarding the deceased's self-referral to mental health services instead of a direct referral, a lack of recorded follow-up, and that the patient's history and British National Formulary advice on anti-depressants were not adequately considered.
Matched on
terms: health, mental
PFD report
69match
Noleen McPharlane
The coroner identified that the clinical specialist did not directly ask the patient about suicidal thoughts or illicit medication use. There was also no exploration of therapeutic benefit from an alternative healthcare professional despite poor rapport and shortened sessions.
Matched on
terms: health, poor
PFD report
69match
Kimberley Lindfield
The coroner raises concerns about the lack of an auditing process for the new mental health referral system, as well as the absence of clear written policies for increased patient observations and for clinical reviews responding to new risks. The report also notes the importance of reminding staff about record-keeping responsibilities and conducting periodic audits.
Matched on
terms: health, mental
PFD report
69match
Harold Ambrose
The coroner noted that information regarding firearms license holders was not consistently flagged on medical records and that there is no requirement for medical professionals to notify police of a license holder's deteriorating mental health.
Matched on
terms: health, mental
PFD report
69match
Joanna Bowring
The patient and carer left an initial assessment without a clear understanding of the service or a care plan. Carers were not routinely included in risk assessments, their views were not actively sought, and they were not advised about behaviours indicating an increased risk of suicide.
Matched on
terms: assessment, suicide