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
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
Noleen McPharlane
Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, and a lack of input from other professionals despite poor patient rapport.
Matched on
terms: health, mental, poor
PFD report
89match
William Abel
Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse led to unsafe discharge.
Matched on
terms: assessment, health, mental
PFD report
89match
Patricia Cleghorn
The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside a failure to conduct a formal risk assessment despite repeated threats of overdose.
Matched on
terms: assessment, health, mental
PFD report
89match
Andrew Peebles
Significant failures by RMNs included inadequate documentation of mental health assessments, insufficient review of critical patient information, and a lack of follow-up on referrals. Additionally, no internal investigation was conducted 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
Jardine Williams
The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially hindering call handlers from understanding urgent risk.
Matched on
terms: health, mental, suicide
PFD report
85match
Kimberley Lindfield
Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, and inadequate record-keeping practices.
Matched on
terms: assessment, health, mental
PFD report
85match
Nicholas Sullivan
Reception staff in the Emergency Department did not use a checklist to identify mental disorder/conditions and record important background issues, there was no clear system to trigger urgent triage and safeguarding steps, and no system to safeguard the patient pending a mental health assessment.
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
Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail and unacknowledged retrospective entries, hindering effective investigation.
Matched on
terms: assessment, mental, poor
PFD report
81match
Jordan Buckton
Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.
Matched on
terms: health, mental
PFD report
81match
Jonathan Thorpe
A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
Matched on
terms: assessment, health, mental
PFD report
81match
John Thorpe
The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed to adequately consider the increased suicide risk associated with starting antidepressants in a patient with a history of attempts.
Matched on
terms: health, mental, suicide
PFD report
81match
Wanda Stachurska
Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, delaying learning opportunities.
Matched on
terms: assessment, health, mental
PFD report
81match
Simon Reynolds
Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing suicide/self-harm risk, and communicating risks were identified.
Matched on
terms: assessment, suicide
PFD report
81match
Louise Locke
Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent suicide prevention approaches.
Matched on
terms: assessment, health, mental, suicide
PFD report
81match
Rachel Morgan
The mental health ward failed to review medication despite patient concerns and did not conduct full risk assessments after self-harm incidents. There was also an over-reliance on inpatient status as a protective factor and a lack of clarity in observation policies.
Matched on
terms: assessment, health, mental
PFD report
81match
Abigail Baynham
The report notes that when Ms Baynham left hospital, there was no referral made back to the Mental Health Liaison Service which may have triggered a further assessment.
Matched on
terms: assessment, health, mental
PFD report
77match
Thomas Thurling
Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a period of mental health deterioration due to staff shortages, posed significant risks.
Matched on
terms: health, mental
PFD report
77match
Kevin Dermott
While at HMP Durham, the deceased was left in a urine soaked cell during a hypomanic episode and a psychiatric referral was never completed; inadequate mental health cover at HMP Haverigg and a lack of suitable psychiatric care facilities at HMP Kirkham contributed to a failure to recognise relapse into depression at HMP Risley.
Matched on
terms: health, mental
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
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
PFD report
73match
Thomas Whitfield
Family-reported suicide risks were not documented or acted upon by hospital staff. The absence of monitored or recorded patient telephone calls prevented verification of communications regarding risks and affected risk assessments.
Matched on
terms: assessment, suicide
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
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
Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, risking patient lives.
Matched on
terms: health, mental
PFD report
69match
Darren Arnoup
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.
Matched on
terms: health, mental
PFD report
69match
Samarjit Singh
The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and declined referrals for mothers with severe postnatal depression.
Matched on
terms: health, mental
PFD report
69match
Isobel Griffin and Jane Clark
For Jane Clark, challenging events were not handed over, the nurse in charge did not read the notes before granting leave, risk assessment was ill-informed, not discussed, and poorly documented; for Isobel Griffin, there were issues with key worker allocation, updating risk assessments, clinician reviews, medication management, and ligature points.
Matched on
terms: assessment, poor
PFD report
69match
Harold Ambrose
There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was not properly flagged in medical records.
Matched on
terms: health, mental
PFD report
69match
Joanna Bowring
Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.
Matched on
terms: assessment, suicide
PFD report
69match
Jason Vaughan
The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor patient deterioration. Practitioners may also lack awareness of increasing suicide rates in specific demographics.
Matched on
terms: assessment, suicide
PHSO casework decision
69match
P-002713 - Greater Manchester Mental Health NHS Foundation Trust
His late mother's death was due to preventable failings in her care and treatment by the mental health trust.
Matched on
terms: health, mental
Committee recommendation
68match
#47 - Third Report - Firearms licensing regulations in Scotland
We heard (for example, from Reverend Gordon Matheson) that people close to an individual may not know that they own, or are applying to own, firearms.129 This lack of knowledge may prevent family and friends from reporting concerns about an individual who is not best placed to own firearms (for example, because of poor mental health).
Matched on
terms: health, mental, poor
PFD report
65match
Danuta Corbett
The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.
Matched on
terms: assessment
PFD report
65match
Alexander Holt
Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.
Matched on
terms: assessment
PFD report
65match
Jaroslaw Rogala
Patients with addiction are at risk of suicide due to a lack of in-patient facilities for care and supervision during crises.
Matched on
terms: suicide
HSSIB recommendation
65match
Patients at risk of self-harm: continuous observation
HSSIB recommends that the Department of Health and Social Care, through the National Institute for Health and Care Research (NIHR), assesses the priority, feasibility and impact of future research into the efficacy and acceptability of continuous observation of mentally unwell adult patients. The research should take into account different care settings in which continuous observation may take place...
Matched on
terms: health, mental
IOPC learning recommendation
65match
Recommendation - Dorset Police, May 2026
The IOPC recommends that Dorset Police should develop a process to ensure that their local police system records, and national police system records, contain the same warning marker information. This recommendation has arisen as a result of a death or serious injury review in which a woman, with warning markers regarding her mental health, attempted to take her...
Matched on
terms: health, mental
PHSO casework decision
65match
P-004082 - Oxford Health NHS Foundation Trust
Dr V complained a Trust psychiatrist opened and deleted her email expressing concern for her husband before his suicide, and about the psychiatrist's demeanour at the inquest.
Matched on
terms: health, suicide