Poor mental health suicide risk assessment
Failures in recognising and assessing high suicide risk due to limited training, inadequate supervision, and poor call triage.
Source spread
Where this theme appears
This theme appears across 19 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
223 PFD reports
13 committee recs
18 HSSIB recs
16 CQC actions
6 PPO recs
10 IOPC recs
119 IMB recs
7 IMB reports
3 Scottish FAIs
5 Article 2 learning points
200 DHR recs
16 PHSO decisions
10 LGO/SPSO decisions
2 CJINI reports
2 CQC enforcement actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(2)
77 — Measures for mentally disordered prisoners on wings
Recommendation: The measures which should be taken to minimise the risk which a mentally disordered prisoner on ordinary location poses to staff and other inmates includes: • not placing such a prisoner in a shared cell • if such a prisoner …
Unknown
74 — Mental health assessments to address risk
Recommendation: When prisoners are referred for a mental health assessment, the assessment should address the risk which they pose to staff and other inmates.
Unknown
Prevention of Future Deaths reports(223)— showing 50 strongest matches
Delwyn Preece
Concerns: 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.
Response (Rotherham Doncaster South Humber NHS Foundation Trust): • The Trust revised its patient leave policy to mandate pre-leave mental state and risk assessments, post-leave reviews, and detailed recording for all leave periods. • The Trust reinforced strict … (AI summary)
Responded
Robert Day
Concerns: 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.
Response (Kent and Medway Mental Health NHS Trust): • The Trust stated it undertook a multidisciplinary case conference and introduced a daily 'Did Not Attend' huddle to address professional curiosity concerns. • The Collaborative Risk Assessment and Management … (AI summary)
Response (DHSC Department for Womens Health and Mental Health): • The government has committed to a consultation to explore powers available to professionals in mental health crises, including sections 135 and 136 of the Mental Health Act. • Mental … (AI summary)
Response (Home Office): • The Home Office outlined the provisions of the Mental Capacity Act 2005 concerning an individual's capacity to make decisions and the circumstances for intervention. • The response referred to … (AI summary)
Responded
Jardine Williams
Concerns: The coroner noted that the NHS England 999 call pathway did not include a question to assess the immediacy of a stated plan to take one's own life, which may have affected the call handler's understanding of the case.
Response (NHS England): • NHS England confirmed that the NHS Pathways triage system includes a question, 'do you feel you are going to do that now?', to assess the immediacy of a potential … (AI summary)
Response (Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust): • Cumbria Health held a learning event meeting with North West Ambulance Service (NWAS) in March 2026 and agreed to continue close working, sharing significant adverse incidents, and holding regular … (AI summary)
Responded
Jordan Buckton
Concerns: Concerns were raised regarding inadequate information sharing within the prison about a person's history of self-harm and the lack of follow-up care, including a PHQ9 assessment, after antidepressant medication was prescribed.
Overdue
John Walker
Concerns: The risk care plan for Mr Walker was insufficient in scope and depth and was not revisited or revised. There was no clear rationale provided for decreasing observation levels, despite the patient expressing suicidal thoughts.
Response (Sussex Partnership NHS Foundation Trust): • The Trust revised risk care planning documents and confirmed regular audits are completed to ensure adequate standards. • A Nurse Consultant provided training to staff on documenting the rationale … (AI summary)
Responded
Jill Sinson
Concerns: The coroner noted insufficient regular monitoring by the GP and a Staff Nurse's assessment that lacked appropriate referral and review of medical records. Unsupervised monthly prescriptions of significant medication were also issued without due consideration of the deceased's self-harm history.
Overdue
Mark Stephen Smith
Concerns: The coroner identified a need for guidance on the interpretation of 'where possible' in policy OPO6O for intentional overdose calls. It was suggested a supervisor should be consulted before ending such calls when the person is alone.
Overdue
Roshan Abbas Ladak-Ebrahim
Concerns: The coroner identified a need for clearer guidance on assessing self-harm risk and ensuring patient safety, including clarification on not leaving at-risk patients alone and confidentiality. Concerns also related to doctors consulting with patients before and after prescribing medication with an increased self-harm risk.
Response (Department of Health): • The Department of Health confirmed it had worked with Royal Colleges and professional organisations to agree and publish a consensus statement on information sharing to prevent suicide. • The … (AI summary)
Responded
Jonathan Thorpe
Concerns: 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.
Overdue
Michael O’Sullivan
Concerns: The DWP assessing doctor did not take into account the views of Mr O'Sullivan's treating doctors. Additionally, the non-medically qualified ultimate decision maker did not request or review any reports from these medical professionals.
Response (Department for Work and Pensions): • The Department for Work and Pensions stated it would issue a reminder to staff regarding guidance on requesting further medical evidence for claimants reporting suicidal ideation. • The Department … (AI summary)
Responded
Tallulah Wilson
Concerns: 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.
Response (Department of Health): • The Policy Research Programme is funding a study by the University of Bristol, Samaritans, and Papyrus to explore internet use in relation to suicidal behaviour, with findings due in … (AI summary)
Responded
Danuta Corbett
Concerns: The coroner identified gaps in the documentation and application of the leave policy for informal patients, particularly regarding risk assessments and decisions for escorted leave. Critical patient information, including risks associated with her home, was not handed over to the escort.
Response (Sussex Partnership NHS Trust): • The consultant psychiatrist stated she now carefully reviews notes taken during ward reviews. • The Trust reinforced with staff the requirement to complete retrospective notes in specific circumstances. • … (AI summary)
Responded
Darren Arnoup
Concerns: 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.
Response: • The medical centre conducted a detailed review of events and commissioned an external medical records review, committing to implement its recommendations. • The medical centre amended its procedures to … (AI summary)
Overdue
Gary Richards
Concerns: Psychiatric staff did not properly assess the patient's risk of self-harm or communicate vulnerabilities, and there were failures in follow-up due to unreliable communication. Previous recommendations regarding risk assessment and follow-up had not been completed eighteen months later.
Response (South London Maudsley NHS Trust): • Staff were reminded to ensure risk assessments are documented in the correct location on the electronic patient record system. • The Trust secured funding to pilot a mental health … (AI summary)
Responded
Samarjit Singh
Concerns: 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.
Response (Wirral Clinical Commissioning Group): • An additional perinatal mental health midwife post was approved and filled, increasing the number of such midwives to two. • The new specification for IAPT services includes a requirement … (AI summary)
Response (Department of Health): • NHS England developed a specification for specialised perinatal services, including Mother and Baby Units. • The Department of Health copied the correspondence to the Chief Nursing Officer for England … (AI summary)
Overdue
John Thorpe
Concerns: 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.
Overdue
Noleen McPharlane
Concerns: 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.
Response (Camden & Islington NHS Trust): • An internal investigation into the serious untoward incident has been completed, and recommendations have been made. • Additional supervision and support have been organised and are in place for … (AI summary)
Responded
Kimberley Lindfield
Concerns: 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.
Response (Manchester Mental Health NHS): • The Trust stated that induction training for junior medical staff incorporates advice on assessing patients regardless of medical fitness. • Revised Urgent Care Standard Operating Procedures are being finalised … (AI summary)
Response (Department of Health): • The Department of Health reviewed and revised the Mental Health Act 1983 Code of Practice, which came into effect on 1st April 2015 and includes advice on enhanced observation. … (AI summary)
Responded
Tanya Page
Concerns: The coroner noted a lack of communication between hospital wards regarding a patient's disclosure of a self-harm attempt, which appeared to be influenced by a concern about perceived blame between staff.
Overdue
Alexander Holt
Concerns: 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.
Overdue
Isobel Griffin and Jane Clark
Concerns: 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.
Overdue
Colin Tyson
Concerns: The coroner noted concerns regarding GPs' interpretation of patient confidentiality, which prevented family members from sharing pertinent information about vulnerable individuals at risk.
Response (NHS England): • NHS England, in collaboration with NHS Wakefield Clinical Commissioning Group, developed an advice sheet for GP practices on responding to third-party concerns or information requests about patients. • This … (AI summary)
Responded
Harold Ambrose
Concerns: 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.
Overdue
Finnulla Martin
Concerns: 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.
Overdue
Wanda Stachurska
Concerns: 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.
Response (Surrey and Borders Partnership NHS Trust): • The Trust ensured a shortcut to relevant policies was available on Psychiatric Liaison staff computers and made the translation services policy mandatory reading. • A local protocol was mandated … (AI summary)
Responded
Mark Daniels
Concerns: The crisis team failed to adhere to Mr Daniels' visit plan or document non-compliance, and had communication issues. Concerns were also raised about delays in crisis house referrals and insufficient consideration of hospital admission despite high-risk factors.
Response (Camden and Islington NHS Trust): • The Trust stated that a comprehensive action plan had been put in place. • The Trust confirmed that measures had been implemented across all Crisis Teams and Crisis Houses. … (AI summary)
Responded
Simon Reynolds
Concerns: 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.
Overdue
Thomas Thurling
Concerns: The coroner identified inadequate monitoring of a change in medication, a lack of review or alternative care coordinator during an extended absence, and staffing shortages within the Trust.
Response (Norfolk and Suffolk NHS Trust): • The Trust stated it would share the issue of medication monitoring with leads in Pharmacy and Triangle of Care, and with clinical teams to cascade learning. • The Trust … (AI summary)
Responded
William Abel
Concerns: 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.
Response (Leicester Partnership NHS Trust): • The nurse concerned is undergoing a programme of reflective practice. • The protocol for Mental Health Act assessments by the Triage Car service is being revised, and changes have … (AI summary)
Responded
Emma Bray
Concerns: The coroner identified a lack of clear guidelines for patient assessment, obtaining medical history, and appropriate referral from the Intake team. Further concerns included insufficient patient monitoring and follow-up, and the failure to record or act upon crucial information provided by family members.
Response (North East London NHS Foundation Trust): • The Trust developed an action plan in response to the coroner's recommendations and findings. • The plan includes objectives to improve the quality of assessment and treatment plans, communication … (AI summary)
Responded
Jake Robinson
Concerns: 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.
Response (Bodmin Road Health Centre): • The practice stated that the coroner's comment regarding unprovided evidence was erroneous, clarifying that documentation had been sent previously. • Jake's death was recorded as a Significant Event and … (AI summary)
Response (Greater Manchester West NHS Mental Heath Foundation Trust): • Trafford Aim reviewed its administration process for letters and faxes, implementing a more streamlined system. • Staff were reminded of the established protocol for service users under 25 requiring … (AI summary)
Response (GMCA): • Greater Manchester West Mental Health Foundation Trust implemented systems to capture and act upon received correspondence and undertook a serious incident review. • Bodmin Road Health Centre took steps … (AI summary)
Responded
Julie Rose
Concerns: The Trust's protocol for patients unable to be contacted lacks clear stipulations for when police welfare checks are mandatory. A shift co-ordinator was also not conversant with the protocol, raising questions about its reinforcement within the team.
Response (Kent and Medway NHS Trust): • The Trust reviewed and amended its 'Unable to Make Contact' Protocol, which is now in use and subject to a three-month pilot. • A new 'Acute Service Line Welfare … (AI summary)
Responded
Joanna Bowring
Concerns: 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.
Response (Joanna Bowring): • An Initial Action Plan Proforma is now required after every assessment to provide service users and their carers with written outcomes and next steps. • The Trust re-launched its … (AI summary)
Responded
Louise Locke
Concerns: 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.
Response (Southern Health NHS Foundation Trust): • Clinical Service Directors will formulate a standard plan to ensure patients requesting second opinions are not prematurely discharged. • The Standard Operating Procedure for patients attending Emergency Departments for … (AI summary)
Responded
Stewart Akins
Concerns: The coroner identified inadequate information sharing regarding an individual's repeatedly stated intentions to end his own life between the custody record, the investigating officer, and the Crown Prosecution Service. This led to a significant under-reporting of suicide/self-harm risk during bail consideration.
Response (S Akins): • West Mercia Police conducted a full review into Mr Akins' detention. • West Mercia Police revised its practice to ensure all Prisoner Escort Forms are signed as accurate by … (AI summary)
Responded
Jason Vaughan
Concerns: Insufficient detail in IAPT electronic records for medication and a risk assessment tool unable to reflect patient deterioration were identified. Additionally, there was a lack of practitioner recognition of increasing suicides in middle-aged males and socio-economic factors.
Response (Rotherham Doncaster and South Humber NHS Trust): • The Trust is procuring a new electronic patient record system, with implementation expected within 18-24 months. • The Trust's IAPT Teams participated in workshops discussing findings from the National … (AI summary)
Responded
Danielle Robinson
Concerns: The coroner notes the Therapeutic Engagement and Observation Policy is not being rigorously followed by staff, leading to missed opportunities for escalating observation levels. A review of the policy is needed to implement automatic escalation to higher observation levels or one-to-one engagement after a serious event.
Response: • The Therapeutic Engagement and Observation Policy was reviewed and updated to include automatic escalation of observations following serious self-harm attempts. • An audit process for monitoring compliance will be … (AI summary)
Responded
Kevin Dermott
Concerns: 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.
Response (NHS England): • NHS England developed national service specifications for mental health services in prisons in December 2013, outlining an integrated stepped care model. • The Health & Justice Indicators of Performance … (AI summary)
Response (HM Prison and Probation Service): • Management checks on the Assessment; Care in Custody and Teamwork (ACCT) process are being increased, including daily checks by Offender Supervisors and weekly checks by Custodial Managers. • A … (AI summary)
Response (Department of Health): • The Department of Health ensured that colleagues at the National Offender Management Service (NOMS) received a copy of the report and requested a direct response. • The Government announced … (AI summary)
Responded
Patricia Cleghorn
Concerns: 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.
Response (NHS England): • NHS England committed to ensuring all areas have high-quality, 24/7 Crisis Resolution Home Treatment Teams by 2020/21, supported by over £400 million investment. • NHS England is developing an … (AI summary)
Response (Department of Health): • The Government has stated its expectation for NHS England to make rapid progress in delivering accessible, responsive, and high-quality crisis services, as outlined in its 2015-16 Mandate. • The … (AI summary)
Response (Birmingham and Solihull NHS Trust): • The Trust implemented a new standard policy for patients awaiting inpatient beds, which includes daily reviews, updated risk assessments, and crisis plans. • A formal practice alert was issued … (AI summary)
Response (CQC): • The CQC requested and received the Trust’s Root Cause Analysis report into the death, subsequently requiring further information from the Trust regarding medication management and staff training. • The … (AI summary)
Responded
Nathan Lowe
Concerns: The coroner raised concerns regarding whether more active efforts should have been made to contact the patient between 10th March and 12th May, considering his illness and non-compliance with follow-up.
Response (Nathan Lowe): • The Trust conducted a serious incident investigation, which identified areas for improved practice and missed opportunities for more assertive follow-up post-discharge. • An action plan was implemented to address … (AI summary)
Responded
Nicholas Sullivan
Concerns: 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.
Overdue
Edward Mallen
Concerns: The coroner noted concerns that a GP prescribed medication based on advice from a non-prescribing nurse, resulting in the patient not receiving crucial information about potential increased suicidality or crisis support. There was also a reported lack of awareness among GPs regarding the duty psychiatrist service.
Overdue
Demi Williams
Concerns: The coroner identified that specific risks described by Ms Williams regarding taking her own life were not considered during general risk assessments. The Trust's investigation also does not reflect this issue, potentially missing learning opportunities.
Overdue
Jaroslaw Rogala
Concerns: The coroner noted a lack of in-patient facilities to admit patients with addiction for care and supervision when in crisis, raising concerns about the risk of suicide in such circumstances.
Responded
Janet Millar
Concerns: The coroner noted a potential training deficit in supporting patients withdrawing from nicotine addiction, particularly for suicidal patients within the hospital's non-smoking policy.
Overdue
Jack Portland
Concerns: The practical implementation of Section 17 leave, particularly concerning the mandatory provision of 'Records of Grant' copies to patients and an additional party, was identified as a concern.
Response (HM Prison and Probation Service): • The prison implemented extensive training, new procedures, and quality checks for ACCT management. • A new database system was introduced for managing complex discharge cases, with plans for a … (AI summary)
Response (Oxford Health NHS Trust): • The Trust implemented a new standard operating procedure for managing patient leave, clarifying responsibilities and simplifying documentation. • Responsibilities for ensuring patient return from leave and informing the shift … (AI summary)
Responded
Rachel Morgan
Concerns: Concerns were raised regarding the absence of a medication review process and a failure to conduct full risk assessments following incidents that indicated risk. The coroner also noted issues with multi-disciplinary review of observations and clarity within the observation policy.
Overdue
Andrew Peebles
Concerns: 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.
Overdue
Abigail Baynham
Concerns: 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.
Overdue
Thomas Whitfield
Concerns: The coroner noted a lack of documented records regarding family concerns about suicide risk communicated to hospital staff, particularly concerning telephone conversations. There were also no current systems for monitoring or recording such calls to verify their content.
Overdue
Select committee recommendations(13)
#41 —
Recommendation: We have heard evidence about the inadequate provision of mental health support and care in social care settings, which can be one of the contributing causes for self-inflicted injuries and deaths. The government must tackle this as a matter of …
Response status not verified
#94 —
Recommendation: Rebecca Robson, from Womenâs Community Matters, explained that âa lot of the mental health difficulties we see are the result of experiences of domestic and sexual abuse in childhood, and then ongoing domestic abuseâ. She went on to explain that …
Response attribution not verified
#93 —
Recommendation: Representatives from two such womenâs centres told us about the specific needs of women in the criminal justice system. Niki Scordi, the then CEO of Advance, told us about high rates of âself-harm, depression and suicideâ. She added that some …
Response attribution not verified
#8 —
Recommendation: 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. …
Response attribution not verified
#36 —
Recommendation: 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 …
Response attribution not verified
#7 —
Recommendation: The Ministry and HMPPS have a duty of care to those in prisons. We have reported in the past that improving the mental health of prisoners is a difficult and complex task, and that it is essential to reducing reoffending …
Response attribution not verified
#2 —
Recommendation: The pandemic has significantly impacted the wellbeing and life chances of prisoners, making it critical that the Ministry and HMPPS accelerate their work to improve the mental health of prisoners. The need for restrictive regimes to maintain social distancing in …
Response attribution not verified
#47 —
Recommendation: 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 …
Response attribution not verified
#18 —
Recommendation: We recommend that the Ministry of Justice and Welsh Government redesign the Female Offending Blueprint for Wales to take account of the policy changes since it was published in 2019, drawing on the recommendations contained within the Women’s Justice Board’s …
Response status not verified
#17 —
Recommendation: The number of Welsh women receiving custodial sentences in Wales is rising, as is the number of those offenders receiving short sentences. This is despite longstanding and ever-increasing evidence that prison—and short sentences—pose particular harm to women and do little …
Response status not verified
#21 —
Recommendation: The Government must introduce a dedicated, trauma-informed health pathway for all those affected by historical forced adoption. This should include improved access to specialist psychological support for birth mothers and adult adoptees, national clinical guidance recognising the heightened prevalence of …
Response attribution not verified
#27 — Provide clear action plan to develop understanding of gambling's relationship with suicide risk
Recommendation: We welcome that the Government’s suicide prevention strategy for England recognises the role harmful gambling can play in suicide risk. In its response to this report, the Government should provide us with a clear action plan on what it and …
Response attribution not verified
#64 —
Recommendation: We recommend that the current renewal period of five years remain in place for the time being. However, we recommend that the renewal period should be kept under review, particularly if an alternative, workable method of mental health monitoring and …
Response attribution not verified
HSSIB safety recommendations(18)
Potential under-recognised risk of harm from the use of propranolol
The Practice has developed a new depression scoring and screening tool to build on the existing good practice followed during Emma’s case, and ensures this approach is adopted consistently in future patient consultations.
Safety Action
Potential under-recognised risk of harm from the use of propranolol
Safety action by NHS England/NHS Improvement In March 2019, NHS England wrote to ambulance trusts in England regarding the management of cases where patients have self-harmed and are at risk of suicide. This included specific reference to patients who may …
Safety Action
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 …
Safety Recommendation
Provision of mental health care to patients presenting at the emergency department
It is recommended that the National Institute for Health and Care Excellence review and amend guidance for the management of self- harm in the emergency department.
Safety Recommendation
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 …
Safety Action
Patients at risk of self-harm: continuous observation
Is there a mechanism for regular communication and review of a patient’s risk of self-harm and need for observation?
Learning Prompt
Patients at risk of self-harm: continuous observation
Is there a shared approach to, and understanding of, how to respond if the patient were to self-harm?
Learning Prompt
Patients at risk of self-harm: continuous observation
Is there a shared approach to supervision and support for all staff involved in caring for patients who may self-harm in hospital?
Learning Prompt
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 …
Safety Recommendation
Creating conditions for learning from deaths and near misses in inpatient and community mental health …
Organisations can improve patient safety by ensuring that a person centred approach to biopsychosocial assessment should be offered for all patients who have contact with mental health services, when a patient has an episode of self-harm or suicidal thinking, every …
Safety Observation
Creating conditions for learning from deaths and near misses in inpatient and community mental health …
Organisations can improve patient safety by taking a person-centred approach to biopsychosocial assessments and safety planning and stop asking for evidence of risk assessment tools that stratify an individual’s risk of suicide or self-harm as high, medium, or low risk.
Safety Observation
Potential under-recognised risk of harm from the use of propranolol
The Ambulance Trust has amended its call handling policy to offer more discretion to call handlers as to when they can choose to stay on the phone with a first party caller who has taken an overdose. Propranolol re-coding
Safety Action
Care delivery within community mental health teams
HSIB recommends that NHS England works with appropriate stakeholders, including experts with appropriate experience, to create guidance on culture change. A quality improvement programme should also be developed to support practitioners in undertaking psychosocial assessments that are in line with …
Safety Recommendation
Patients at risk of self-harm: continuous observation
Is there a shared understanding of the different roles and responsibilities of mental and physical healthcare staff in caring for a patient, including checking their personal belongings for items that could be used to self-harm. Are the different roles and …
Learning Prompt
Creating conditions for learning from deaths and near misses in inpatient and community mental health …
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 …
Safety Observation
Patients at risk of self-harm: continuous observation
Is there a mechanism to allow for shared learning and reflection between care providers involved in caring for patients at risk of self-harm?
Learning Prompt
Patients at risk of self-harm: continuous observation
Is there a process to ensure staff undertaking continuous observation who are new to an acute hospital ward are introduced to staff and the environment, including rest facilities and access to relevant patient records?
Learning Prompt
Patients at risk of self-harm: continuous observation
HSSIB recommends that NHS England, working with relevant stakeholders, produces national guidance for staff undertaking continuous observation of mentally unwell adult patients, along with a training and competency framework to provide staff with the necessary skills for this intervention in …
Safety Recommendation
CQC inspection actions(16)
Worthing Hospital
The trust must ensure that all patients on medical wards receive regular risk assessments upon admission and throughout their stay and take all reasonable steps to mitigate any identified risks. This includes mouth care, skin and nutritional assessments as well …
Must Do
Royal Hallamshire Hospital
The trust must have effective systems to ensure staff assess and manage the risks to service users in relation to their mental health.
Must Do
Rotherham General Hospital
The trust must ensure staff implement appropriate risk management plans for all patients presenting with mental health conditions.
Must Do
Rotherham General Hospital
The trust must ensure that all patients presenting with a mental health condition have all appropriate risk assessments completed.
Must Do
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 …
Should Do
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.
Must Do
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.
Must Do
Royal Bolton Hospital
The trust should ensure that mental health risk assessments including environmental assessments are thoroughly completed.
Should Do
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.
Must Do
Birmingham Children's Hospital
The trust should ensure staff fully implement trust policies and procedures when undertaking enhanced supervision of patients at risk of self-harm.
Should Do
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.
Should Do
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.
Must Do
Pilgrim Hospital
The trust should ensure that falls and mental health risk assessments and transfer documentation are in place for patients when they are required and that completion risk assessments and transfer documentation are audited.
Should Do
Cumberland Infirmary
The trust must ensure that all mental health patients had appropriate and timely risk assessments completed. Regulation 13(1)(2)(3)(4)(d).
Must Do
Chorley and South Ribble 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.
Must Do
Charlton House Medical Centre
Arrangements for monitoring and review of patients experiencing poor mental health (including people with dementia) continued to place patients at risk of harm.
Must Do
PPO death in custody recommendations(6)
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.
The Head of Healthcare
The Head of Healthcare should review the procedures in place for assessing the mental health needs of prisoners who have requested mental health support.
The Head of Healthcare
The Head of Healthcare should review the GP medication review waiting times and if a patient has had a number of incidents of self-harm, triage of their needs is undertaken, and an urgent medication review is facilitated.
The Governor
The Governor should ensure that managers imposing punishments of cellular confinement fully consider the likely impact on the health and welfare of the prisoner, including referring the prisoner to the mental health team, where appropriate.
The Head of Healthcare
The Head of Healthcare should ensure that those who are on a waiting list for therapy have access to mental health support in the interim if there is a risk of suicide and self-harm.
The Head of Healthcare
The Head of Healthcare should review the arrangements in place for carrying out assessments of mental health needs to ensure that these are consistent with NICE guidelines.
IOPC learning recommendations(10)
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 …
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 …
National recommendations - College of Policing, July 2024
The IOPC recommends the College of Policing and the National Police Chiefs’ Council (NPCC) work together to produce clear guidance on preservation of life at the scene of a hanging where death has not been confirmed. This should include guidance …
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 …
Recommendation - Derbyshire Constabulary, April 2026
The IOPC recommends that Derbyshire Constabulary should review and update its operational guidance and officer training on responding to suicide-related incidents to ensure officers clearly understand the legal powers available to them to remove items that pose an immediate risk …
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 …
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 …
Recommendation - Avon and Somerset Police, February 2023
The IOPC recommends that Avon and Somerset Constabulary should introduce specific training to equip officers with the appropriate skills to deal with instances of suicide. This follows an IOPC review of a local investigation by Avon and Somerset Constabulary’s professional …
Police response for welfare concerns - Sussex Police, November 2021
The IOPC recommends that Sussex Police provides specific guidance or training to contact officers on how to elicit information during a 999 or 101 call from people who have attempted suicide. This follows an IOPC investigation where it was identified …
National recommendation - The College of Policing, June 2021
The IOPC recommends that the College of Policing explores potential opportunities to support forces in managing the risk posed by perpetrators of domestic abuse (to either victims, others or themselves) who express credible suicidal threats or ideation. When completing a …
IMB annual reports(7)
Eastwood Park (2025)
HMP Eastwood Park, a women's closed local prison, maintained a population of 351 against an operational capacity of 395. The report highlights ongoing challenges with an extremely high rate of self-harm (4,479 incidents) and 235 assaults on staff, although no deaths in custody occurred for the second consecutive year. Significant concerns include the detention of mentally unwell women awaiting hospital transfers, persistent staffing shortages exacerbated by vetting delays, and a restrictive regime for the general population due to the management of segregated prisoners.
PRISON
Key concerns
Wakefield (2025)
HMP Wakefield is a high-security prison for men, reporting an operational capacity of 744 and a population of 793. The Board noted significant improvements in staff recruitment and key worker sessions, as well as the delivery of healthcare and a varied education curriculum. However, it raises serious concerns regarding prisoner safety, including drone incursions and increased violence. Longstanding issues with delays in mental health transfers to hospitals, inadequate physical infrastructure, and insufficient purposeful activity opportunities for prisoners remain critical areas for development.
PRISON
Key concerns
New Hall (2025)
HMP/YOI New Hall operates as a closed prison for women, holding 313 prisoners against an operational capacity of 376. The report highlights several positive developments, including effective reception processes, successful key worker implementation, and improved chaplaincy services. However, significant concerns remain regarding inadequate mental health provision and lengthy transfer delays for acutely unwell prisoners, a 50% increase in healthcare complaints, and ongoing issues with regime limitations and prison maintenance.
PRISON
Key concerns
North East Midlands, Yorkshire & Humber STHF (2025)
The IMB report for North East Midlands, Yorkshire & Humber STHFs highlights generally positive staff-detainee interactions and a relaxed atmosphere at Swinderby RSTHF, but raises significant concerns across the wider STHF estate. Key issues include inadequate risk identification processes, the inhumane policy of confiscating medication, and the unsuitability of several holding facilities. The Board's ability to monitor effectively is severely hampered by restricted access to records and persistent unresponsiveness from the Home Office regarding critical concerns, including medical confidentiality breaches and emergency response failures.
PRISON
Key concerns
Maidstone (2023)
HMP Maidstone, a Category C foreign national prison with a population of 603, is generally safe but faces significant challenges. Persistent delays in the Home Office immigration system cause profound uncertainty and prolonged detention for prisoners, exacerbating mental health issues. The prison struggles with severe staffing shortages across healthcare, education, and regime provision, alongside an acute lack of quality purposeful activity places. Additionally, communication barriers due to inadequate translation of official documents and the dilapidated condition of the Victorian estate remain key concerns.
PRISON
Key concerns
Bronzefield (2023)
HMP/YOI Bronzefield is a privately run local prison for female remand and sentenced prisoners, with an average population of 471 and Certified Normal Accommodation of 542. The reporting year saw concerns over staffing shortages impacting regime, increased healthcare complaints following a contract change, and a significant number of prisoners released without safe accommodation. Positive developments included the implementation of PPO recommendations, a new Employment Hub, and re-established gardening team.
PRISON
Key concerns
Gatwick IRC (2024)
Gatwick IRC experienced a volatile year ending March 2024, marked by high levels of violence, self-harm, and one death in custody. The Board expresses significant concerns over inadequate safeguards for vulnerable detainees, long detention periods, and systemic failures in healthcare, particularly around Rules 34 and 35. Detainees also face issues with interpretation services, excessive handcuffing, and an inhumane regime with long lock-up times and increased segregation.
IRC
Key concerns
IMB individual recommendations(119)— showing 50 strongest matches
Lancaster Farms (2020)
Urgent consideration of the increasing number of incidents of self-harm by prisoners, and the very large numbers of self-harm incidents associated with a small number of individuals facing mental health difficulties, is required (see paragraph 4.9).
Ministry of Justice
In Progress
Hewell (2020)
The Board is keen to see evidence of a concerted focus on addressing prisoners’ mental health needs. We wish to see improved outcomes for those accessing these services and interventions. The Board would wish to see evidence of a reduced incidence of self-harm.
Governor / Director
In Progress
Gatwick IRC/RSTHF (2022)
Ensure that relevant healthcare clinical staff, GPs and psychologists and psychiatrists are fully educated in the application of Rules 35(1) and 35(2) (section 4.4.2).
NHS / Healthcare Provider
Gatwick IRC/RSTHF (2022)
Building on the recommended review of AAR, ACDT and Rule 35, define and promulgate procedures and guidance to ensure cases of men “likely to be injuriously affected by continued detention” (Rule 35(1)) or who are suspected “of having suicidal intentions” (Rule 35(2)) are properly identified and assessed (section 4.4.2).
Home Office
Portland (2023)
Key work is crucial to the early identification of deteriorating mental health. If an individual has mental health issues it can adversely affect their ability to engage with learning and training. It therefore makes sense to prioritise key work over training and learning opportunities rather than being seen as an “add-on” with the option to drop it if staffing is …
Governor / Director
Lancaster Farms (2023)
To further improve the strategies available to the prison to manage and reduce the number of incidents of self-harm, particularly among the small number of prisoners who frequently self-harm and could be assessed as demonstrating severe mental health difficulties.
HMPPS
Implemented
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 to be …
HMPPS
In Progress
Leeds (2024)
Is the Minister satisfied that all necessary resources are being delivered to significantly reduce self-inflicted deaths?
Other
In Progress
Bronzefield (2024)
The Board remains concerned about the number of prisoners coming into the prison, having been identified as acutely mentally unwell (including some prolific self-harmers), either requiring section under the Mental Health Act or admission to a secure hospital. How does the Prison Service plan to provide support to manage these prisoners, who cannot be easily moved to secure psychiatric hospitals …
HMPPS
In Progress
Lancaster Farms (2022)
To further improve the strategies available to the prison to manage and reduce the number of incidents of self-harm, particularly among the small number of prisoners who frequently self-harm and could be assessed as demonstrating severe mental health difficulties.
Other
In Progress
Lancaster Farms (2020)
Similarly, access to telephone calls to the Samaritans at night has been absent for much of the year, and a solution should be implemented with urgency (see paragraph 4.4).
Governor / Director
Implemented
Lancaster Farms (2020)
Immediate action is required to reverse the decline in the number of trained Listeners to just two, as prisoners have not had sufficient access to this important form of support (see paragraph 4.4).
Governor / Director
In Progress
Foston Hall (2020)
The high level of self-harm (see paragraph 4.2.5) and the variable standard of assessment, care in custody and teamwork (ACCT) documents (see paragraph 4.2.6).
Governor / Director
Noted
Drake Hall (2020)
The Board is interested in how the prison will mitigate the long-term impact of the pandemic on some prisoners’ mental health.
Governor / Director
Thameside (2021)
The Board has considerable concerns at the longer-term impact on the mental and physical health and wellbeing, and potentially the future behaviours, of prisoners who have endured prolonged periods of confinement and lack of socialisation.
Ministry of Justice
In Progress
Lewes (2021)
The IMB urges the Governor to take steps to reduce the number of men on an assessment, care in custody and teamwork (ACCT) plan and on constant watch in the care and separation (CSU) unit.
Governor / Director
Gartree (2021)
Will the Governor continue to ensure that monitoring and quality assurance checks of all ACCT and CSIP documents are carried out by a dedicated custodial manager, and that all post-closure reviews and documentation are of the required standard?
Governor / Director
Bullingdon (2021)
There are some prisoners in Bullingdon whose state of mental health is such that the prison is not equipped to cope with them; it is very likely that they need to be sent to secure psychiatric institutions. Some of these prisoners have spent far longer in the SSCU than 42 days, after which continued segregation has to be reported to …
HMPPS
Bullingdon (2021)
There are some prisoners in Bullingdon whose state of mental health is such that the prison is not equipped to cope with them; it is very likely that they need to be sent to secure psychiatric institutions instead. Some of these prisoners have spent far longer in the SSCU than 42 days, after which continued segregation has to be reported …
Ministry of Justice
In Progress
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.
HMPPS
In Progress
Bedford (2022)
We have made several suggestions in relation to suicide and self-harm. This includes considering whether the number of meetings to review these individual’s care could be streamlined to improve the quality and consistency of decision-making.
Governor / Director
Bedford (2022)
The layout of the ACCT form does not facilitate care coordinators to summarise the prisoner’s story to bring together a description of triggers, coping strategies and other relevant factors into an individual ‘formulation’. We believe this remains a fundamental flaw in the ACCT process.
HMPPS
Styal (2023)
Reduced staffing levels have had a significant impact on the operational activities in the prison, impacting on safety and mental health. The prison staffing budget, with an ineffective rate of 20%, appears insufficient to cover all duties. Will there be any review of staffing budgets in the coming year?
HMPPS
Styal (2023)
The prison continues to be challenged by the need to manage many prisoners with severe and enduring mental health problems and complex needs. Nationally, there is still a pressing need for more specialist facilities that can be easily accessed, particularly psychiatric units. When will the findings made by the National Women’s Prisons Health and Social Care Review be available?
Ministry of Justice
Peterborough (women) (2023)
Can the Minister take action to prevent prisons being deemed a place of safety for women with serious mental health issues?
Ministry of Justice
Peterborough (women) (2023)
Can the Minister work with the Department of Health and Social Care to ensure women with serious mental health issues in the criminal justice system are directed to an appropriate pathway?
Ministry of Justice
Parc (2023)
Despite efforts by management and staff at Parc to support those prisoners serving an Imprisonment for Public Protection (IPP) sentence, not knowing when they will be released is a cause of anxiety impacting on the mental health of those affected. We urge the Government to put in place a process where IPP prisoners’ sentences are reviewed, and a single sentence …
Ministry of Justice
In Progress
Durham (2023)
How will you ensure there are sufficient trained ‘Listeners’ in, and distributed across, the prison, and that they are given access to prisoners requesting support? (4.2.13)
Governor / Director
Dovegate (2023)
There are still a number of IPP prisoners at HMP Dovegate and one of the deaths in custody was immediately prior to the IPP prisoner’s sentence hearing. A clear strategy on how IPP prisoner can progress to release is much needed.
Ministry of Justice
Bedford (2023)
We hope that the prison will take note of the findings of our mental health survey and see what improvements can be made.
Governor / Director
Wetherby (2024)
The IMB recommends that the YCS reconsiders the appropriateness of the ACCT format.
HMPPS
Parc (2024)
Despite efforts by management and staff at Parc to support those prisoners serving an Imprisonment for Public Protection (IPP) sentence, not knowing when they will be released is a cause of anxiety impacting on the mental health of those affected. We urge the Government to put in place a process where IPP IPP prisoners’ sentences are reviewed, and a single …
Other
In Progress
North East Midlands, Yorkshire & Humber STHF (2024)
The Board recommends the examination and review of the low number of Rule 32/35 risk to health and risk of suicide cases, in order to check that the low number of cases is not indicative of the process failing to be used as it should be to identify those facing a deterioration of their health in detention and those at …
Home Office
Lewes (2024)
Given the increase in incidents of prisoner-on-prisoner violence and self-harm, the Board asks for extra steps to encourage good behaviour and to improve the management of ACCTs.
Governor / Director
Leeds (2024)
Certain Prisons and Probation Ombudsman (PPO) reports highlight concerns that staff are not always following correct procedure, particularly in relation to ACCT prisoners. Is the Governor monitoring that this is being actively addressed?
Governor / Director
In Progress
Exeter (2024)
Given the high proportion of prisoners with mental ill health, will the Prison Service ensure the delivery of standalone mental health training for all officers?
HMPPS
Implemented
Cardiff (2024)
The Board suggests the newly introduced practice of triaging only those individuals who ask to see mental health during their reception or secondary health screening process be kept under review to ensure other prisoners are not inadvertently overlooked.
NHS / Healthcare Provider
In Progress
Wandsworth (2025)
The number of ACCTs opened increased by over 20% during the reporting period, reflecting the severity of the mental health crisis and inadequacy of support. How is the Prison Service addressing this major issue?
HMPPS
In Progress
Stoke Heath (2025)
Unfortunately, deaths and cases of serious self-harm have significantly increased. Is there more opportunity for staff to actively engage with prisoners who are at risk to help reduce self-harm?
Governor / Director
In Progress
Nottingham (2025)
How will the Governor continue to address the issue of self-harm and maintain the recent reduction in numbers?
Governor / Director
Norwich (2025)
The Board still has concerns about ACCT documents. What action will the Governor take to ensure further improvements in the management of the ACCT process and completion of documents by staff?
Governor / Director
Coldingley (2025)
The Minister should propose actions to alleviate the destabilising effects of population churn on the resettlement and training estate, which include more men at risk of self-harm and arriving on ACCTs, men coming to a category C when not ready, many without sentence plans, poorer behaviour, more adjudications, more men arriving with health needs the prison is ill-equipped to care …
Ministry of Justice
In Progress
Bronzefield (2025)
How does the Prison Service plan to provide support to manage prisoners who are acutely mentally unwell (including some prolific self-harmers) who require being sectioned under the Mental Health Act or admission to a secure hospital, but cannot be easily moved due to a shortage of beds (6.3)?
HMPPS
In Progress
Altcourse (2025)
When will the statutory 28-day time limit for the transfer to hospital of prisoners requiring in-patient mental health treatment come into effect?
Ministry of Justice
In Progress
Brinsford (2025)
The Board is of the view there remains a problem in relocating prisoners with mental health problems to more suitable mental health facilities. All transfers to a secure mental health facility from HMP Brinsford continued to exceed the 28-day stipulated time frame. Will the Minister take steps to ensure that sufficient secure hospital places are available?
Ministry of Justice
In Progress
Risley (2020)
There have been instances of untimely attendance by healthcare staff to prisoners on ACCT documents following self-harm incidents. How does the prison intend to ensure that all incidents of self-harm are attended to promptly?
Governor / Director
Norwich (2020)
provision of a 24-hour safer custody hotline that is ‘a well-advertised and reliable means of speaking to a member of staff – such as a duty governor or orderly officer – where there is an imminent risk’ (Robert Buckland, 25/02/2020, IAP Keeping Safe Conference). This statement from the Minister implies that the system at Norwich, whereby the hotline is operated …
Governor / Director
Norwich (2020)
swift provision of a Listener or a Samaritans telephone for those prisoners in need of immediate support
Governor / Director
Isle of Wight (2020)
In 2020 there have been a number of remand prisoners requiring immediate admission to inpatient healthcare facilities in the prison and urgent referral to secure units. Are there any actions planned with HM Courts and Tribunals Service to provide appropriate psychiatric assessment in the court setting, to ensure prisoners who are significantly mentally unwell are diverted to psychiatric hospital rather …
Ministry of Justice
In Progress
Isle of Wight (2020)
Again the issue of prisoners experiencing significant mental health issues has been overlooked. The HMIP recommendation to Her Majesty’s Prison and Probation Service (HMPPS) to ensure that mentally ill prisoners are transferred to appropriate facilities, in line with national guidance, was rejected. What plans are in place to ensure that mentally ill prisoners are managed in line with HMIP recommendations …
Ministry of Justice
In Progress
Health investigations(87)
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec p.
That where a detained patient has recently harmed themselves or others, or an injunction is in force, their current mental state must always be assessed and recorded by a qualified nurse before they are permitted any leave in accordance with their consultant‘s general authorisation.
midlands
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 2
All front-line primary care staff, including GPs, Practice Nurses and Receptionists, should receive risk assessment training, tailored to individual need. Training for GPs and nurses should include: violence and mental illness, assessment of suicide risk, the effects of drugs and alcohol on risk, and relevant provisions of the Mental Health …
london
Independent investigation: William Moss, Newquay (2007) — Rec 7
The Cornwall and Isles of Scilly Multi-agency Safeguarding Adults Policy is reviewed and audited to consider the interface for: young People who are leaving the care system and on a care order; young people with a diagnosed serious mental illness; people who present with self harm.
south_west
Independent investigation: Sharon Stokes, Exmouth (2007) — Rec 3.7.3.1.
The Devon Partnership NHS Trust Clinical Risk policy should be reviewed. It should be brought more in line with the principles outlines in “Best Practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services” (Department …
south_west
Independent investigation: Paul Taylor, Jarrow (2019) — Rec 7
Care coordinators must initiate a discussion with the Consultant Psychiatrist to assess whether a formal medication review is required when there is a crisis and serious risk of harm to self.
north_east_yorkshire
Independent investigation: Michael Martin, Almondsbury, (1999) — Rec 3
Mr Martin should have been able to express his fears for his own safety to mental health services and expect a helpful response. Mental health services should alert relatives and carers to the risks arising from mental illness.
south_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.34
There should be further training for all Social Services staff especially those dealing with looked-after adolescents in risk assessment which should include child protection/vulnerability issues, deliberate self-harm and suicidality, violence assessment and substance misuse assessment and management.
north_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.32
There should be further training for all CAMHS staff in risk assessment which should include child protection/vulnerability issues, deliberate self-harm and suicidality, violence assessment and substance misuse assessment and management.
north_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.9a
It is recommended that the Deliberate Self Harm (DSH) assessment protocol is revised to give greater weight to issues of substance misuse and of potential risk to others and from others as well as the risk to self, ensuring that these points are documented.
north_west
Independent investigation: Brian Marsh, Swindon (2007) — Rec 19
That the Trust consider the need to develop Trust procedural guidance on the following (if this has not been done since the completion of this report): Suicide and serious self-harm Clinical risk management and the CMHT’s responsibilities with regards to actual or suspected domestic violence Medication non-compliance
south_west
Independent investigation: Anthony Harrison, Andover (1998) — Rec 12
Mental health service providers and accident and emergency departments should develop guidelines for the referral and assessment by a mental health professional of people who self-harm.
south_east
Independent investigation into the care and treatment provided to Ms … — Rec Recommendation 5
To-date the Trust has rolled out new risk assessment and suicide prevention training for CRHTT staff. This programme should be audited within six months of the publication of this report to ensure effectiveness and take up.
Ms X and her son who died in September 2014. Ms X had received care from Berkshire Healthcare NHS Foundation Trust
south_east
An independent inquiry into the care and treatment of Ms … — Rec 3
We recommend that OHFT put in place a process that ensures a consistent pattern of practice that enables appropriate and adequate assessment of patients’ mental health whether or not they are detained under the Mental Health Act. This should include a clear process for determining the responsible clinician and for …
south_east
An independent inquiry into the care and treatment of Ms … — Rec 1
The mental health division to agree a consistent pattern of practice in relation to adequate assessment of patients detained on Section 2 of the Mental Health Act, including good practice in engaging with patients; exploring background information including collateral history, all old notes and third party risk information and consider …
south_east
Independent investigation into the care and treatment of Mr T — Rec 2
The Trust’s Rehabilitation and Recovery Division should implement measures to provide assurance that risk assessments meet the necessary quality standards. In particular, all risk assessments should flag known relapse signs and proven risk management strategies
Mr T who committed a homicide in May 2014. Mr T was in receipt of services from Camden and Islington NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr F: … — Rec 4
Mental health services’ risk assessments and support plans should be identifying and considering a patient’s current housing situation. Where a patient is experiencing housing issues, this should be identified as both a significant risk factor and one that requires support.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Accepted
Independent investigation into NHS mental health care of ‘X’ — Rec 2
The Trust has taken a range of significant steps to improve the way that training about risk is undertaken (including risk of suicide in association with physical problems such as chronic pain or physical disability). However, the Trust should now ensure that the delivery of, and effectiveness of, risk simulation …
east_of_england
Accepted
An independent investigation into the care and treatment of Ms … — Rec 7
Care coordinators must initiate a discussion with the Consultant Psychiatrist to assess whether a formal medication review is required when there is a crisis and serious risk of harm to self.
north_east_yorkshire
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.3.2
The Division should insist that a formal written risk assessment and risk management plan, including a crisis management plan, is in place, before submitting a recommendation for conditional discharge to the First Minister. It should ensure that the symptoms and signs of the individual’s mental disorder are addressed in such …
scotland
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.2.4
The Social Work Department should review the written clinical information that it requires to carry out its supervisory functions and ensure that this is contained within the individual’s case file. In the view of the Inquiry, this should include a formal risk assessment and risk management plan, including a crisis …
scotland
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 10
The case of DN has highlighted a number of training issues which are pertinent today. There is a need to address: (cid:2) risk assessment and management training across the whole Mental Health Trust (cid:2) the particular problems associated with substance misuse in conjunction with mental illness, which in some cases …
london
Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009) — Rec 3.13
Aneurin Bevan Health Board and Caerphilly County Borough Council must assure themselves that risk management is embedded in the culture of all mental health services, ensuring that: (cid:131) all staff recognise that accurate risk assessment relies fundamentally on high quality history-taking and review of all previous information (including risk assessments)96; …
wales
Independent investigation into the care and treatment of Mr X — Rec 9
The Gallions Reach Health Centre should adopt a formal risk assessment process when making clinical decisions about patients with severe and enduring mental illness. This should be supported by secondary care (clinical expertise and care pathway support) and CCG input (peformance management).
X This is the independent investigation report into the care and treatment of Mr X who committed a homicide in 2013. Mr X was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr X — Rec 1
Clinicians should make every effort to draw together the psychosocial circumstances and diagnoses of all service users. Whenever possible a full psychiatric history should be taken and used to construct a comprehensive diagnostic formulation. This should be recorded in full in the service user’s clinical record and used to inform …
X This is the independent investigation report into the care and treatment of Mr X who committed a homicide in 2013. Mr X was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 3
The use of rating scales to assess psychotic symptoms would improve the assessment of mental state and assist in decisions about compliance.
north_west
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 51
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in risk assessment and risk management.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 34
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff involved in the care of patients receive appropriate training in risk assessment and risk management.
midlands
Independent investigation: Tracey Baker, Chard (2015) — Rec 13
Somerset Partnership NHS Foundation Trust should introduce either their community risk assessment tool in their IAPT service or developing a IAPT risk assessment tool that includes: • the identification and assessment of all potential current risks, including the patient’s risk to self and others; • documentation of all historical risks …
south_west
Independent investigation: Suryakant Patel, Harlington, London (2006) — Rec 4
This investigation highlighted two issues which need to be addressed in client-focused risk assessment training delivered in all mental health trusts and in documented risk assessments. The first is the concept of ‘risk vulnerability’, a concept that was not well understood by all members of the MHSU’s care team. Furthermore …
north_east_yorkshire
Independent investigation: Martin Ellicot, Walthamstow (2006) — Rec 1
A consistent approach to clinical risk assessment should be developed across London (NB the London Mental Health Trust CEO Group is preparing a two year improvement programme in this area).
london
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 20
South and East Belfast Trust should review the assessment models used by CRT and FCC IAT in cases where a parent with dependent children has attempted suicide or made a serious threat of self-harm.
northern_ireland
Independent investigation: Keziah Flux Edmonds, East Cowes, IoW (2016) — Rec 2
Isle of Wight NHS Trust IAPT service must either develop a bespoke IAPT service risk assessment or utilise the community mental health risk assessment tool. The IAPT risk assessment must include the identification and assessment of : • All potential risk, including the patient’s risk to self and others • …
south_east
Independent investigation: Jordan Cooper, Washington (2011) — Rec 2
Risk assessments undertaken by NTW’s mental health inpatient and community services must ensure that historical and current risks are being consistently documented and appropriately assessed.
north_east_yorkshire
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R25
The trust should ensure a broad view of a patient’s past history forms part of any risk assessment and that there should not be undue reliance on whether the person has been violent or has self-harmed as a predictor of risk.
london
Independent investigation: Joanne Butler, East Shilton, Leics (2006) — Rec R9
The trust considers how best to deal with patients who disengage from services and who might be a risk to themselves and others who may not be detained under the Mental Health Act (B).
midlands
Independent investigation: Chloe Fahey, Manchester (2003) — Rec N.1
It is recommended that at every admission to hospital as an inpatient, a doctor must record in writing a full Maudsley model history and mental state examination as soon as possible and present it to the responsible medical officer (RMO) .
north_west
Independent investigation: Emily Jones, Bolton (2020) — Rec R1
The trust should review its risk policy to ensure that static risks are identified, and realistically assessed, and unnecessary weight is not given to dynamic factors.
north_west
Independent investigation: Anthony Wakeford, Effingham (2010) — Rec 7
A review to be carried out to assess clinical staff understanding and management of both alcohol misuse and self harm behaviour and management.
south_east
Independent investigation: Adel Makar, Westcliff on Sea (2006) — Rec 7
The assessment should not only examine risks to others, but also the risk to the service user, including risk of self harm, self neglect and social exclusion and isolation.
east_of_england
*Mental health homicide investigation legacy report into the care and … — Rec 7
A review to be carried out to assess clinical staff understanding and management of both alcohol misuse and self harm behaviour and management.
south_east
Independent investigation into the care and treatment of Mr Z: … — Rec 1
That in all cases where multiple factors are identified which may be contributing to a person’s mental health problems a diagnostic formulation must be prepared and reviewed in subsequent clinical contacts. This will be subject to review as a part of the ongoing medical appraisal and patient review process.
Manchester Mental Health and Social Care NHS Trust
north_west
Independent investigation into the care and treatment of Mr C … — Rec Recommendation Six
It is recommended that:- Within both Trusts the Quality Assurance Programme is revised to ensure that Teams assessing and caring for psychiatric patients are producing Care Plans that reflect a comprehensive understanding of the current psychiatric, social, family circumstances and risk characteristics of the individual they are treating. These audits …
Camden and Islington NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of Mr … — Rec 2
The Trust must provide clear guidance to staff on the identification and management of patients who are not engaging with mental health services, this must include how engagement will be monitored and reviewed.
Mr H. At the time of the incident Mr H was receiving care from Lancashire and South Cumbria NHS Foundation Trust
north_west
An independent investigation into the care and treatment of Mr … — Rec 2
Crisis plans. Service user crisis plans should include planning for the service user’s safety and the safety of others in the event of the service user’s mental health deteriorating.
Somerset NHS Foundation Trust
south_west
An independent investigation into the care and treatment of David: … — Rec 4
All patients should have a risk assessment which addresses triggers and relapse indicators and includes assessment and management plans if there is an escalation in risk.
David. At the time of his death David was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust
north_west
An independent investigation into the care and treatment of Darren … — Rec 2
Isle of Wight NHS Trust IAPT service must either develop a bespoke IAPT service risk assessment or utilise the community mental health risk assessment tool. The IAPT risk assessment must include the identification and assessment of : • All potential risk, including the patient’s risk to self and others • …
Isle of Wight NHS Trust
south_east
An independent investigation into the care and treatment of a … — Rec 7b
Formal mental state assessments should follow a standard approach and cover expectations surrounding adequate questioning.
south_east
An independent investigation into the care and treatment of a … — Rec 2
The Trust must ensure that clarity is provided to the early intervention team about the process for seeking a second opinion and/or formal consultation with another clinician or team (in particular the forensic team) when a patient has not responded to treatment for a prolonged period of time and where …
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
Independent investigation into the care and treatment of DO — Rec 9
The Trust is required to implement a suicide awareness training programme for its staff which addresses the following elements of care: a) the need to create and preserve hope; b) assist people to work through suicide towards achievable recovery and growth goals; c) integrate suicide care into recovery care. It …
DO who committed a homicide in 2013. DO was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of patient … — Rec 6
At the time of the incident the CMHT did not have a risk stratification system to indicate which patients were at higher risk of deterioration or were at risk of harm to themselves or others. A system which could have supported the team to convey essential information about dynamic risk …
north_east_yorkshire
Scottish Fatal Accident Inquiries(3)
Fraser John O'Donnell
It is for those reasons that any comments I have made in connection with matters of connectivity, communication and accountability are in the form of observations which I hope those charged with the management of the services will look at in light of the circumstances of Fraser’s death. For the avoidance of doubt the terms of the protocol, should be …
Mar 2012
Niamh Frances Bysouth/Lafferty and Terrie Faye Oliver also known as Georgia May Rowe
When young people such as Niamh attend Accident and Emergency departments of hospitals in Scotland presenting with histories suggesting serious self-harm, or suggestive of a suicide attempt there must be value in having a psychiatric/psychological assessment carried out as near to the time of presentation as possible. At present, that option is not available automatically. Consideration should be given to …
Apr 2012
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 patient on …
Dec 2024
Health
4 recs
Article 2 learning points(5)
— LP 4
We recommend that people presenting with multiple complex symptoms, in particular in the context of a serious episode of self-harm, should have a full diagnostic psychiatric and suicide/self-harm risk assessment, highlighting triggers for self-harm and likely high risk times, with contingency planning.
HMPPS
Accepted
— 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.
Healthcare Provider
— LP 7
As part of the mental health assessment post-reception, all prisoners should have an assessment of their risk to self and others. If they are thought to be a self-harm risk, either at this assessment or at a later stage in the prison term, then a full risk assessment should be …
HMP Altcourse and HMPPS
Accepted
— LP Healthcare 3
The opening of an ACCT and a summary of key issues and actions from ACCT reviews should be documented in the clinical record to ensure that this information is easily accessible to members of the healthcare team. In addition, the ACCT flag function should be used to ensure that all …
Healthcare Provider
— LP 3
We recommend that men in prison for the first time should be distinguished as a category of prisoners requiring extra vigilance and support for the first two to four weeks in custody and that HMPPS and the Governor of Chelmsford consider setting this out in policy guidance.
HMPPS
Rejected
Independent reviews(13)
Acheson Report — Rec 34
We RECOMMEND policies which reduce the excess mortality from accidents and suicide in young men (see also: recommendation 24). Specifically:
Health & Social Care
Acheson Report — Rec 24
We RECOMMEND measures to prevent suicide among young people, especially among young men and seriously mentally ill people.
Health & Social Care
Litchfield WCA Review Year 4 — Rec 30
Mental Health training for Decision Makers should include dealing on the telephone with distressed people, interpreting warning signs of potential self-harm and signposting to appropriate sources of help
Employment & Work
Mental Health Taskforce 2016 — Rec 57
NHS Improvement and NHS England, with support from PHE, should identify what steps services should take to ensure that all deaths by suicide across NHS-funded mental health settings, including out-of-area placements, are learned from, to prevent repeat events. This should build on insights through learning from never events, serious incident …
Health & Social Care
Corston Report — Rec 43
The management and care of self-harming women should be led by the NHS, either in an NHS resource or shared multi-disciplinary care in prison.
Justice & Legal
Wessely Review — Rec 139
There should be a common framework for assessment of risk across criminal courts, clinicians and the Justice Secretary. The assessment needs to be regularly reviewed (at least annually and before every Tribunal hearing). Every patient should have written in to the Care and Treatment Plan what their risk levels are.
Health & Social Care
Accepted
Darzi Review — Rec 12
The picture on quality of care is mixed. For the most part, once people are in the system, they receive high quality care. But there are some important areas of concerns, such as maternity care, where there have been a succession of scandals and inquiries. There have been improvements in …
Health & Social Care
Litchfield WCA Review Year 4 — Rec 36
Maintain the arrangement whereby a Mental Function Champion is available to Decision Makers via the advice line.
Employment & Work
Litchfield WCA Review Year 4 — Rec 28
The Department strengthen its requirements for HCPs working on the contract to have suitable and sufficient previous experience of dealing with people with mental health problems so that they can contextualise their findings at assessment.
Employment & Work
Mental Health Taskforce 2016 — Rec 3
The Department of Health, PHE and NHS England should support all local areas to have multi-agency suicide prevention plans in place by 2017, reviewed annually thereafter and supported by new investment.
Health & Social Care
Shaw Detention Review — Rec 21
Recommendation 21: I recommend that the Home Office immediately consider an alternative to the current rule 35 mechanism.
Immigration
Harris Review: Deaths in Custody — Rec 23
All staff working in prisons who have contact with prisoners, including prison officers, contracted staff, and in-reach workers must receive regular mandatory training to enable them to recognise and deal with vulnerabilities, particularly mental health needs, and also in relation to the Safety and Vulnerability, Risk Assessment and Support (SAVRAS) …
Justice & Legal
Corston Report — Rec 37
Sentencers must be able to access timely psychiatric reports and fail to remand in custody/sentence if not available.
Justice & Legal
PHSO casework decisions(16)
P-002004 — Sheffield Health and Social Care NHS Foundation Trust
Mr O complained the Trust failed to treat his suicidal thoughts appropriately, delayed admission for three months, and provided inadequate care and complaint responses.
NHS in England
May 2023
P-002532 — Sussex Partnership NHS Foundation Trust
Mr R complained the Trust failed to recognize his deteriorating mental health, delaying referrals and support for various conditions, and not informing his school about suicidal ideation. He sought acknowledgement and payment.
NHS in England
Apr 2024
P-003678 — Tees, Esk and Wear Valleys NHS Foundation Trust
Miss U complained about the Trust's inadequate risk management, unsafe transition, and poor communication regarding her daughter's care, which she believed caused her death.
NHS in England
Jul 2025
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.
NHS in England
Sep 2025
P-004151 — Norfolk and Suffolk NHS Foundation Trust
The Trust allegedly failed to communicate with Ms B's family, ignored distress, poorly managed records and suicide risk, misdiagnosed EUPD, and changed medication without consulting prior plans.
NHS in England
Partly Upheld
Oct 2025
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.
NHS in England
Partly Upheld
Dec 2025
P-004514 — A practice in the Gateshead area
Mrs G complained the Practice failed to reissue her morphine medication at the correct dosage and a receptionist prevented her from discussing suicidal feelings, leading to withdrawal symptoms and hospital admission.
NHS in England
Dec 2025
P-001995 — Leeds and York Partnership NHS Foundation Trust
Miss O complained Trust staff failed their duty of care by releasing her when mentally unwell, not supporting her after suicide attempts, and being unavailable, causing significant harm.
NHS in England
May 2023
P-002790 — Derbyshire Healthcare NHS Foundation Trust
Mrs A complained the Trust failed to recognise her son's autism and vulnerability, provide follow-up care after suicide attempts, and notify the family, contributing to his death.
NHS in England
Jul 2024
P-003565 — Oxleas NHS Foundation Trust
Mr R complained about inappropriate stopping of medications without detox in prison, delays in new prescriptions, and inadequate management of his physical pain and mental health.
NHS in England
Not Upheld
Dec 2024
P-003585 — Nottinghamshire Healthcare NHS Foundation Trust
Mrs R complained Nottinghamshire Healthcare NHS Foundation Trust failed to provide effective mental health support to her father, Mr Y, leading to his accidental death, by discharging him while suicidal and mismanaging appointments.
NHS in England
Upheld
Jun 2025
P-004573 — A practice in the Norwich area
The Practice failed to provide enough mental health support for her husband, negatively impacting both their health and causing discrimination.
NHS in England
Jan 2026
P-001256 — A medical practice in the Gloucestershire area
Mrs V complained a medical practice and Trust failed to act on her brother's abdominal/urinary symptoms and provided inappropriate treatment for seizures, possibly contributing to his death.
NHS in England
Partly Upheld
Aug 2021
P-002332 — Nottinghamshire Healthcare NHS Foundation Trust
The Trust failed to plan for his brother's care, ensure medication, and contact him before his death, leading to fatal clozapine poisoning.
NHS in England
Sep 2023
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.
NHS in England
Jun 2024
P-003277 — Tees, Esk and Wear Valleys NHS Foundation Trust
Mrs C complained the Trust did not adequately support her son's declining mental health, which led to his rapid decline and ultimately, his suicide.
NHS in England
Jan 2025
LGO / SPSO decisions(10)
NIPSO-202005122 — Belfast Health and Social Care Trust
The Belfast Trust should have given a new mother better mental health support to help her cope with the premature birth of her twins.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Oct 2025
21-010-465 — Rotherham Metropolitan Borough Council
Summary: Mr Y complains about the Council’s delay in providing the support his family needed when the Council received a referral about his daughter’s emotional wellbeing and self-harming behaviours. The Council apologised and accepted it could have acted sooner to provide support for the family. In addition to the apology …
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2022
18-006-752b — South West Yorkshire Partnership NHS Foundation Trust (18 …
Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they …
LGO (Local Government & …
Health
Upheld
Jul 2022
18-006-752a — South West Yorkshire Partnership NHS Foundation Trust (18 …
Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they …
LGO (Local Government & …
Health
Upheld
Jul 2022
22-002-090d — Coquet Medical Group (22 002 090d)
Summary: We found fault in the way a Council, Mental Health Trust and GP Practice supported a vulnerable man in the community for over two years. Each of the organisations has accepted its failings and the impact of them and has taken steps to prevent recurrences, so we have not …
LGO (Local Government & …
Health
Not Upheld
Dec 2022
22-002-090a — North East Ambulance Service NHS Foundation Trust (22 …
Summary: We found fault in the way a Council, Mental Health Trust and GP Practice supported a vulnerable man in the community for over two years. Each of the organisations has accepted its failings and the impact of them and has taken steps to prevent recurrences, so we have not …
LGO (Local Government & …
Health
Not Upheld
Dec 2022
24-008-253b — NHS Cornwall and Isles of Scilly ICB (24 …
Summary: We will not investigate Ms B’s complaint about her son’s mental health care and support in 2019 and 2020 prior to his death. Her complaint to us was made outside our 12-month time limit and it would have been reasonable to complain to us sooner.
LGO (Local Government & …
Health
Oct 2024
25-005-077b — NHS North West London ICB (25 005 077b)
We find fault by West London NHS Trust and London Borough of Hammersmith and Fulham in terms of their delivery of aftercare services to which Mr X was entitled under section 117 of the Mental Health Act 1983. This fault caused Mr X uncertainty and distress. The Trust and Council …
LGO (Local Government & …
Health
Not Upheld
Feb 2026
25-005-077a — West London NHS Trust Headquarters (25 005 077a)
We find fault by West London NHS Trust and London Borough of Hammersmith and Fulham in terms of their delivery of aftercare services to which Mr X was entitled under section 117 of the Mental Health Act 1983. This fault caused Mr X uncertainty and distress. The Trust and Council …
LGO (Local Government & …
Health
Upheld
Feb 2026
21-018-706 — Hampshire County Council
Summary: Mr X complained that the Council failed to carry out a proper risk assessment when it changed his daughter, D’s, care plan and stopped his visits in response to the COVID-19 pandemic. He said this resulted in D’s suicide attempt. We find that there was fault in the Council’s …
LGO (Local Government & …
Education
Upheld
Dec 2022
Domestic Homicide Reviews(200)— showing 50 strongest matches
Doncaster — recommendation 2
Training for primary care staff to raise awareness of suicide risk in domestic abuse and the importance of routine enquiry when a patient presents with indicators of domestic abuse.
Doncaster Clinical Commissioning Group
West Lancashire — recommendation 7
WLCSP to share this learning opportunity with the Lancashire Domestic Abuse Board and request they consider the findings of the Home Office Report with the aim of developing an assessment process that identifies any risk of victim suicide, i.e., where coercion and control (and according to the evidence – non-fatal …
West Lancashire Community Safety Partnership
West Lancashire — recommendation 6
WLCSP to encourage all agencies that have formed part of this Panel to ensure a process is in place to identify domestic abuse victim suicides and ensure they are considered for a DHR
Lancashire Constabulary | West Lancashire Community …
Lancashire Constabulary
West Lancashire — recommendation 5
To share this (action 4) learning opportunity with the pan-Lancashire DHR Task and Finish Group, in order to encourage services to consider the possible links between 'suicidal ideation' and Domestic Abuse as part of the intelligence gathering process to identify “victim suicides” who should be considered for the DHR process. …
West Lancashire Community Safety Partnership
Manchester — recommendation Bridges 1
All Bridges referrals that disclose low mood/ suicidal ideation will be referred to the Jigsaw Support Wellbeing Navigator team for support and signposting.
Bridges Domestic Abuse Support Services
Manchester — recommendation 2
That the Manchester CSP share the learning from this DHR with the Greater Manchester Bereavement Service; That the Manchester CSP share the learning from this DHR with the National Suicide Prevention Group in Wales and with the Mental Health Division within the BCUHB; That the Manchester CSP supports the recommendations …
Manchester Community Safety Partnership | Greater …
Gloucester — recommendation 7
Probation services to ensure that Offender Managers are aware of the importance of exploring disclosures of mental health issues and that they are proactive in making contact with mental health services to provide further information and support, if required.
BGSW CRC
Kent — recommendation 4
The MARAC process should consider the risk of victim suicide following domestic abuse alongside the risk of homicide, where risk factors which indicate coercive controlling abuse, harassment and attempts to separate are present.
Kent and Medway MARAC steering group
Kent — recommendation 3a
To highlight to the Government the huge gap regarding the link between suicide and domestic abuse.
Domestic Abuse Commissioner’s Office.
Kent — recommendation 2
To write to the National Suicide Prevention team in the Department of Health to make them aware about the growing number of deaths by suicide that are happening very close to court cases relating to domestic abuse.
Domestic Abuse Commissioner’s Office
Swindon — recommendation 11
When a GP Practice member has discussions with a patient around their ability to cope with thoughts of self-harm this needs to be fully documented. It should include all the patient comments on how they are feeling and managing their feelings, rather than being summed up in a single phrase …
Swindon GP Practices | Swindon ICB
NHS Bath and North …
West Berkshire — recommendation 9
Staff should receive training in identifying suicidal ideation that is based on an evidence-based model and includes covert signs and managing ambivalence within telephone contact.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Haringey — recommendation National 1
That any individual reporting suicidal thoughts within an NHS environment be routinely questioned about partners or those close to them to assess the risk to those individuals, in the light of the findings of this review and record and respond to that risk appropriately, if necessary informing the police or …
NHS
NHS
Kingston upon Thames — recommendation 4
Mental health assessments for suicidal actions or ideation should include whether there is a risk of domestic abuse
South West London and St George’s …
South West London and …
Bristol — recommendation 2
As part of the consideration of the DHR process, greater flexibility could be given to Community Safety Partnerships to only review those suicides where Domestic Abuse appears to have been a significant and primary influence on the decision of the person to take their own life.
Home Office
Home Office
Bristol — recommendation 1
The Home Office reviews both the title of Domestic Homicide Reviews and the content of its Guidance document in the context of deaths occurring from suicide.
Home Office
Home Office
Kent — recommendation 7
The Kent and Medway Suicide Prevention Programme to consider and highlight culturally specific issues relating to suicidal behaviour within different religious and ethnically diverse communities (including the Sikh community).
KCC – Public Health Team
Leeds — recommendation LCCG2
Clinicians in Primary Care assessing mental health presentations are advised to routinely assess and record: risk to self, risk to others, perceived risk from others
Leeds Clinical Commissioning Group
Stafford — recommendation 20.4
For Staffordshire Women’s Aid to work with partners in exploring ways of better identifying signs of suicide and working together to respond to these risks.
Staffordshire Women’s Aid
Chorley and South Ribble — recommendation 2.3
The Lancashire Care Foundation NHS Trust (LCFT – now known as the Lancashire and South Cumbria NHS Foundation NHS Trust) should provide assurance to the Community Safety Partnership that clinical guidance in relation to the management of self-harm and suicide is followed in primary and secondary care.
Lancashire Care Foundation NHS Trust
Kent — recommendation 6
Suicide prevention team to link in with (AAFDA) to join the conversation regarding unexplained deaths.
KCC Suicide prevention team
Somerset — recommendation 7.2.3
Remind GP practices to ensure a request for counselling is accompanied by a review of mental health and any risks e.g., of self-harm.
NHS Somerset ICB
NHS Somerset ICB
Somerset — recommendation 1
Increasing awareness among professionals on the links between and impacts of mental health, self-harm and/or suicidal ideation, with domestic abuse.
Safer Somerset Partnership
Rochdale — recommendation 10.1
That the Rochdale Safer Communities Partnership (SCP) is assured that a process is in place to identify “domestic abuse victim suicides”; That the Rochdale Safer Communities Partnership (SCP) share the learning from this DHR with the Greater Manchester Bereavement Service; That the Rochdale Safer Communities Partnership (SCP) supports the recommendations …
Rochdale Safer Communities Partnership (SCP)
Nottingham — recommendation 4
Nottingham Community Safety Partnership and their partner agencies to ensure that current training includes the Suicide Timeline (to include the additional risk indicators based upon protected characteristics for example, ASD and LGBT).
Nottingham Community Safety Partnership
Somerset — recommendation 1
Domestic abuse routine enquiry within mental health contacts Awareness raising regarding DA routine enquiry (DARE) for clients/carers presenting with suicidal ideation.
Somerset NHS Foundation Trust
Taunton and Somerset NHS …
Norfolk — recommendation 6
When services become aware during assessments that a person has habitually used cannabis from their early teens and they develop early onset psychosis symptoms, this should be factored into risk assessments. This is essential in cases of poly-substance misuse co-morbidity to ensure assessments are robust in assessing risk to others …
Local Authorities | NHS Trusts | …
Local Authorities
Telford and Wrekin — recommendation 8
Safer Telford and Wrekin to ensure that a suicide prevention specialist sits on all future Domestic Abuse Related Death Reviews involving suicide in their area
Safer Telford and Wrekin
Telford and Wrekin — recommendation 3
Telford and Wrekin Suicide Prevention Action Group, coordinated by the Public Health Team, to ensure that domestic abuse perpetrators, as well as domestic abuse victims, feature within their suicide prevention strategy.
Telford and Wrekin Suicide Prevention Action …
Leicester — recommendation National - 3
The Home Office to commission research into the links between mental health, domestic abuse and suicide and the experiences of marginalised communities. The methodology chosen should allow for the experiences of those from different cultures to be separated out. Upon completion, guidance for professionals should be developed and widely distributed.
Home Office
Home Office
Leicester — recommendation WALL - 1
Review of Suicide Protocol after each suicide or at least annually.
Women’s Aid Leicestershire Ltd (WALL)
Lincoln — recommendation 6
The group that leads for the Lincolnshire Suicide Prevention Strategy, should ensure it incorporates within the strategy the link between domestic abuse and suicide. The Safer Lincolnshire Partnership should promote the refreshed Suicide Prevention Strategy to ensure it is understood within all agencies and professionals.
Lincolnshire Suicide Prevention Strategy Lead Group …
Lincoln — recommendation 2
With the new DHR threshold including DA Homicides linked to suicide, Edan have embedded suicide and risk as a key element to risk assessments throughout support.
Lincolnshire Domestic Abuse Specialist Service (formally …
Somerset — recommendation 2
The Safer Somerset Partnership to write to the Home Office with the findings of this DHR suggesting that they undertake further research into cases of suicide with a reported history of domestic abuse where the perpetrators are male, in order to develop a profile of potentially vulnerable men.
Safer Somerset Community Safety Partnership
Sheffield — recommendation 2
Sheffield CCG to encourage GPs to assess the risk of harm to others from those who have disclosed self-harm thoughts.
Sheffield Clinical Commissioning Group
Sheffield Clinical Commissioning Group
Hartlepool — recommendation 10
TEWV to review their risk assessment arrangements to ensure it captures new information and intelligence.
TEWV
Tees, Esk and Wear …
Hartlepool — recommendation 4
TEWV to ensure all frontline staff attend Domestic Abuse training focussing on staff always considering potential vulnerabilities of other members of the household when undertaking assessments of a patient’s mental health and associated risks encouraging the adoption of a think family approach..
TEWV
Tees, Esk and Wear …
Norfolk — recommendation IMR_NNUH_1
Where a patient expresses feelings of low mood or makes comments consistent with not wishing to live any longer, professional curiosity should be used to explore the rationale and home circumstances which may be influencing these thoughts, and a referral to the Mental Health Liaison Team (MHLT) considered.
Norfolk & Norwich University Hospital NHS …
Norfolk and Norwich University …
Buckinghamshire — recommendation Oxfordshire CCG Reco
OCCG and Primary Care Safeguarding Leads to share with the Suicide and Self-Harm Strategy Group the issues found in relation to non-engagement, and request support in developing some guidance around communication options in situations where a patient chooses not to engage.
Oxfordshire ICB | Primary Care Safeguarding …
NHS Buckinghamshire, Oxfordshire and …
Nottingham — recommendation 20.5.2
That training will be reviewed to increase the understanding of the risk of suicide and the impact of poor mental-health for domestic abuse survivors.
Nottingham City Council Adult Services
Nottingham City Council
Nottingham — recommendation 20.1.2
The Public Health Suicide Prevention Group should consider whether something should be put in place similar to the MARAC regarding the impact of domestic abuse on suicide.
Nottingham City Council Public Health
Lincoln — recommendation 2iii
The Suicide Prevention Steering Group should consider implementing a process to review all or at least a proportion of suicides similar to the process already in place for reviewing childhood deaths. This will enable agencies to share and learn lessons with the intention of preventing future suicides, in particular those …
Suicide Prevention Steering Group
Solihull — recommendation 5
That West Midlands Ambulance Service should review the SADPERSON risk assessment tool currently used by responders to predict future suicide or repetition of self-harm, in the light of current NICE guidance giving specific consideration to the fact that it should not be relied upon for this purpose. The service should …
West Midlands Ambulance Service
West Midlands Ambulance Service …
Solihull — recommendation 1a
That West Midlands Police and Hertfordshire Constabulary and commissioners of police custody health services relevant to these two Police areas should, in consultation with mental health services, consider the effectiveness of their mental health screening processes upon detention in light of the circumstances of this case. They should provide assurances …
West Midlands Police | Hertfordshire Constabulary …
West Midlands Police
Somerset — recommendation 17.2.2
Risk screen and information to be completed in relation to all MHA assessments to include recording current suicide risk. This would be achieved by monitoring this practice through supervision and caseload management.
Somerset Partnership NHS Foundation Trust
Somerset Partnership NHS Foundation …
Tower Hamlets — source paragraph 154
The internal learning identified from the local General Practice IMR is to consider using words like ‘paranoid’ only in the paranoid delusional sense and remember to record suicidality if the patient is depressed. Record presence/absence of thought disorder and hallucinations if recording paranoid ideation and review taking a forensic history. …
Local General Practice
North Lincolnshire — recommendation 8.13
Follow up screening for IDVAs when depression or suicidal thoughts are disclosed should be considered.
It’s My Right
Dorset — recommendation 1
That Dorset Community Safety Partnership make use of this review as a case study to inform single and multi-agency training with a particular emphasis on understanding factors which increase the risk of homicide including threats of suicide by the perpetrator and attempts by the victim to end the relationship and …
Dorset Community Safety Partnership
Exeter — recommendation R4
Review how well Devon Partnership Trust policies and procedures on contact with families fit with the national consensus statement on information sharing and suicide prevention.
Devon Partnership Trust
Devon Partnership NHS Trust
Exeter — recommendation R1
Ensure that support staff from a range of statutory and community settings have the skills to identify when someone is considering suicide, have the confidence to ask, the knowledge to effectively signpost and ability to share concerns with other agencies involved in the person’s care.
Safer Devon Partnership | Exeter Community …
CJINI inspection reports(2)
CQC enforcement actions(2)
Warning Notice: Devon Partnership NHS Trust
The Care Quality Commission (CQC) told Devon Partnership NHS Trust it must make urgent improvements on Delderfield ward and complete its ligature minimisation work across its acute wards and psychiatric intensive care units. This directive followed an inspection in June …
Aug 2020
Criminal Prosecution: University Hospitals Sussex NHS Foundation Trust
The trust was fined after a young person absconded from a ward in March 2022, was found within hospital grounds having ligatured, and died shortly afterwards. Sentenced at Brighton Magistrates' Court with £25,405 costs.
Nov 2025
£200000