Poor mental health suicide risk assessment
231 items
1 source
Failures in recognising and assessing high suicide risk due to limited training, inadequate supervision, and poor call triage.
Cross-Source Insight
Poor mental health suicide risk assessment has been flagged across 1 independent accountability source:
231 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (231) — showing 100 most recent
Micheala Finch
Concerns: Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse and not deploying escalated home-based treatment.
Pending
Mansoor Zaman
Concerns: Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the police via emergency channels.
Pending
Simon Moss
Concerns: Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk evaluation for suicidal patients due to gaps in training and policy.
Pending
Jason White
Concerns: Antipsychotic medication was abruptly ceased, and the daily monitoring plan was not followed, creating an unmanaged risk of relapse and serious deterioration in the patient's mental health.
Overdue
Warren Green
Concerns: High-risk self-harm patients could leave the acute ward without assessment or staff knowledge. The Mental Health Liaison Service lacks clear escalation criteria to consultants, leading to insufficient oversight for vulnerable patients.
Response: Mid and South Essex NHS Foundation Trust has reviewed and updated relevant policies and flowcharts to guide staff in managing high-risk self-harm patients and preventing them from leaving wards unsupervised. …
Response: EPUT defers concerns about patients leaving acute wards to MSE. For the Mental Health Liaison Service, EPUT has introduced a Consultant Psychiatrist review for all patients assessed by the MHLT …
Responded
Anthony Card
Concerns: There is no formal mechanism for police to share medium-risk mental health information with care providers, even with consent. This prevents crucial risk data from informing future assessments and potentially vital support decisions.
Response: Suffolk County Council clarifies that direct mental health provision is primarily an NHS responsibility, and they will not establish a new MASH pathway for medium risk mental health-only cases. However, …
Response: Suffolk Constabulary provides ongoing mental health training for staff, including new recruits, and is developing new vulnerability training for Autumn/Winter 2026. A multi-agency audit of NHS 111 Option 2, which …
Responded
Evan Dandou-Dambelle
Concerns: Significant changes in a mental health patient's medication are not automatically factored into decisions about their required level of contact and observation.
Response: The Trust has already communicated the learning to all consultant psychiatrists via email, emphasizing that significant medication changes must be considered when determining patient contact levels. This will be further …
Responded
Tony Duncan
Concerns: A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate discharge without medication review or escalation.
Response: The Trust has strengthened its psychiatric liaison service at King's College Hospital ED by extending hours to 24/7, introducing comprehensive training, increasing staff, and launching a new ED Low Intensity …
Responded
Charlotte Tetley
Concerns: A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance services decline calls if whereabouts are unknown, increasing risk of death.
Responded
Gareth Jackson
Concerns: Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, contrary to the safety plan. A national bed crisis also delayed transfer.
Responded
Sidi Bojang
Concerns: Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, despite significant changes in presentation, posing a risk of unsafe discharges.
Responded
Louise Crane
Concerns: A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within mental health facilities.
Responded
Louise Crane
Concerns: Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition and risk mitigation.
Responded
Patrick Viles
Concerns: A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric input, raising concerns about medication safety.
Responded
Sally Burr
Concerns: Detained mental health patients can exploit mobile internet access to research self-harm methods, as staff lack effective technical means to monitor or control usage, despite revised policies.
Responded
Andrew Connolly
Concerns: GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient risks due to absent guidance for these situations.
Responded
Oladeji Omishore
Concerns: Police dispatch failed to relay crucial mental health information to responding officers via airwaves, leading to an initial lack of consideration for the individual's mental health state during interaction.
Overdue
William Grieve
Concerns: Critical suicide risk assessments were flawed because different healthcare teams used incompatible electronic systems, preventing access to complete patient notes. Unaddressed staff training needs pose ongoing risks.
Overdue
Darren Turner
Concerns: Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to neglect, contributing to the deceased taking his own life.
Responded
Jean Pike
Concerns: Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide risk, indicating a systemic failure in communication and risk management.
Responded
Duncan Holloway
Concerns: Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also concerns about uncoordinated care between different agencies.
Responded
Hayley Beavington
Concerns: A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed to guide the junior doctor on challenging this decision, leading to premature discharge and the patient's death.
Responded
Nicholas J’Dourou
Concerns: A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient observation on wards raises concerns about insufficient monitoring.
Responded
Kim Robinson
Concerns: The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe medication access.
Responded
Shaun Hall
Concerns: The Urgent Care and Assessment Team declined a referral despite clear suicide risks, with the decision-maker remaining unidentified and no record of the rationale, posing a serious safety failure.
Responded
Matthew Brierley
Concerns: Excessive delays in police investigations prolong suicide risk for vulnerable individuals on bail. Standardised bail conditions and a lack of proactive support fail to address their elevated risk.
Responded
Thomas Kingston
Concerns: There are concerns about adequate communication of suicide risks associated with SSRI medications and the appropriateness of continuing or switching them when ineffective or causing adverse effects.
Responded
Dean Ford
Concerns: Mental health teams failed to perform holistic suicide risk formulations per NICE guidelines, with a senior clinician showing a simplistic assessment approach. Critically, risk assessments for unaccepted patients are not audited, creating a safety net gap.
Responded
Charlie Owen
Concerns: The army's vulnerability risk management process fails to ensure 'check-ins' for high-risk soldiers, and suicide prevention training for welfare officers is not mandatory. Inadequate information sharing and documentation between medical and command personnel further hinder support and risk reduction.
Responded
Nicolette McCarthy
Concerns: The NHS smoke-free policy on mental health wards may increase self-harm risk by exacerbating mental distress and forcing patients into unsupervised smoking areas, potentially leading to unnoticed disappearances and suicides.
Responded
Yemisi Cielto-Opaleye
Concerns: Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post Injection Syndrome.
Responded
Erin Tillsley
Concerns: A vulnerable child presenting to the Emergency Department after self-harm missed crucial early mental health intervention due to the failure to apply established NICE guidelines and local policy for comprehensive assessment.
Responded
Alexander Rogers
Concerns: A prevalent "cancel culture" among students, involving social ostracism without formal process, severely impacts mental health. This 'self-policing' is linked to a lack of trust in formal reporting mechanisms.
Responded
Jamie Harding
Concerns: A lack of compulsory training on the Dual Diagnosis pathway, poor communication, and an inefficient system for the Frontline Resolution Team to manage caseloads and follow up referrals led to significant care failures.
Responded
Kashim Ali
Concerns: Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.
Responded
George Kyriacos Petrou
Concerns: Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a risk that vulnerable individuals with suicidal intentions may not receive necessary observation.
Overdue
Jennifer Chalkley
Concerns: A widespread misconception among schools that £6,000 must be spent on a child's SEN before an EHCP assessment application is delaying critical early support, increasing the risk of mental health issues and suicidality.
Responded
Locket Williams
Concerns: Insufficient in-county psychiatric inpatient beds for children persist, with new units inadequate for demand or specific needs. A new suicide risk assessment system lacks clear alerts on medical records, risking clinicians missing vital information.
Responded
Oliver Davies
Concerns: Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care coordinator then improperly prioritized Oliver's case, failing to ensure timely support before going on leave.
Responded
Florence Stewart
Concerns: The system of high-level intermittent observations failed to prevent the suicide, indicating a need for fundamental review. Additionally, an oxygen bottle ran out during resuscitation efforts.
Responded
James Agius
Concerns: The Trust's mental health care had significant medical record omissions, conflicting assessments of the patient's mental state, and failed to implement new national risk assessment training.
Responded
Danny Anderson
Concerns: There was a lack of adequate risk formulation, over-reliance on patient self-reporting, and insufficient information gathering before discharge from mental health services, indicating staff lacked understanding of robust risk assessment and safety planning.
Responded
Sally Poynton
Concerns: An inaccurate discharge summary, failure to involve family in patient history-taking, and absence of a clear follow-up plan for a patient with emerging mental illness who declined treatment, created significant care gaps.
Overdue
Zarah Ravn
Concerns: A systemic failure to conduct annual mental health and medication reviews for patients with severe mental illness, alongside a lack of risk assessment and follow-up for deteriorating mental health, created significant safety risks.
Responded
Jason Pulman
Concerns: Delays in specialist gender dysphoria treatment and lack of psychiatric support were exacerbated by unclear referral mechanisms and CAMHS being unaware of new national support offers, risking patient safety.
Responded
Emmanuel Ladapo
Concerns: Mental health services showed a lack of engagement with the patient's family and psychiatrists repeatedly failed to inquire about suicidal ideation during periods of clinical deterioration, despite prior similar omissions.
Overdue
Paul Templeton
Concerns: The Trust seriously failed to recognize a patient's prolonged refusal to eat or drink as an active suicide attempt and an elevated suicide risk, indicating a systemic failure in risk assessment.
Responded
Daniela Pani
Concerns: Unimplemented safety measures at a train station, including lack of Samaritan signs and low fencing, were identified. Additionally, mental health staff lacked training on managing service users who decline critical 72-hour review meetings.
Overdue
Francis Williams
Concerns: Probation officers require better training to identify suicide risk in IPP offenders and to understand licence cancellation processes, as a failure to refer for cancellation contributed to despair and death.
Responded
Mark Kinzley
Concerns: Inappropriate care location, absence of formal capacity assessments, and a failure to refer for mental health assessments despite a history of self-harm and deteriorating mental state contributed to the death of a vulnerable adult.
Overdue
Adrian James
Concerns: The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for predicting and preventing impulsive acts of self-harm.
Responded
Jamie Pilkington
Concerns: Mental health teams repeatedly failed to complete suicide risk assessments and thoroughly explore the deceased's suicidal thoughts, research into methods, or support networks. No system changes were assured to prevent future omissions.
Responded
Roberto Bottello
Concerns: Failures in mental health service follow-up and assessment, alongside significant delays in Mental Health Act assessment at hospital, despite clear signs of acute psychosis.
Responded
Narjit Gill
Concerns: Mental health practitioners failed to remove a visible ligature from Mr Gill's home despite his expressed suicidal ideation.
Responded
Liam Turner
Concerns: It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a significant proportion of staff without current life-saving skills.
Responded
Tom Sweeting
Concerns: Poor communication between the hospital and General Practice led to a critical delay in prescribing antidepressant medication for a patient reporting suicidal thoughts.
Responded
Larry Spriggs
Concerns: Systemic failures include a lack of demonstrated cultural change in patient care, inadequate risk assessment and management, poor information sharing, and insufficient management of intermittent observations.
Responded
Denise Porter
Concerns: The Trust's failure to thoroughly interrogate a police referral and reliance on an incomplete incident summary led to a critical misassessment of suicide risk and an inadequate care plan.
Overdue
Kimberley Liu
Concerns: Unregulated websites facilitate dangerous, unchecked sales of prescription-only sedative medications, actively instructing customers to evade detection, which exploits vulnerable individuals and poses a suicide risk.
Responded
Ryan Evans
Concerns: Hospital staff failed to conduct a mental health assessment for a patient with obvious self-harm and suicidal ideation, contradicting NICE guidelines. Critical suicidal ideation was also not adequately recorded.
Responded
Amanda Hitch
Concerns: Critical suicidal intent information was missed due to thematic clinical record display and a failure to use structured risk management tools. British Transport Police's multi-agency support plan also failed to communicate railway station attendances, especially from unstaffed stations.
Overdue
Martin Willis
Concerns: The ACCT procedure was not properly implemented or supervised, including false entries and omissions. Concerns remain regarding correct observation levels and the need for an inter-agency review of mental health care provided in prison.
Responded
Paul Perrott
Concerns: Inadequate observation charting, unclear staff responsibility for checks, and a lack of historical risk analysis meant staff were unaware of the patient's critical suicide risk history.
Overdue
Alice Litman
Concerns: Mental health services lack adequate training and clarity for supporting transgender individuals, coupled with significant delays and insufficient mental healthcare provision for those awaiting gender-affirming treatment.
Responded
Mohammed Akram
Concerns: A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant risk.
Responded
Teresa Chmielek
Concerns: Critical failures in mental health referral management include missed suicide risk, inadequate MDT discussions, no patient contact, unmanaged absences, and a lack of standard operating procedures and audit for decision-making.
Responded
Igor Szalapski
Concerns: Hostel staff failed to re-contact the crisis team despite a resident's deterioration, lacked meaningful engagement, and did not perform consistent welfare checks. Inadequate self-harm training and a chaotic culture contributed to missed opportunities for intervention.
Responded
Elizabeth Watson
Concerns: Security staff monitoring a bridge for distressed individuals lack structured training from mental health professionals on identification and interaction. Delays in emergency service response further leave staff unequipped to handle vulnerable people for extended periods.
Overdue
Christopher Allum
Concerns: Initial referral processes have gaps in recording past self-harm and family information. Private healthcare providers also struggle to access NHS notes, creating information deficits that compromise risk assessments and care plans.
Responded
Jack Zarrop
Concerns: Custodial Nurse Practitioners lack adequate mental health training for complex patients and suicide risk, and agency staff in prisons receive insufficient training on the ACCT process.
Responded
Shaun Houghton
Concerns: A junior doctor allowed a high-risk patient with impulsivity and suicidal intent to self-discharge against medical advice, without consulting senior clinicians, raising concerns about the decision-making process.
Responded
Gerard Murray
Concerns: Inadequate risk assessment and management, poor monitoring of unescorted leave, lack of family involvement in care, and limited staff awareness of ligature risks compromised patient safety.
Responded
Oleg Khala
Concerns: A vulnerable patient with complex mental health needs was repeatedly discharged for community care despite suicidality and non-engagement, likely due to a shortage of care-coordinator provision and lack of consultant advice.
Responded
Kaye McCoy
Concerns: The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, suggesting these crucial guidelines are not fully integrated into practice.
Responded
Christopher Stevens
Concerns: Implementation of identified safety improvements, including a new consultant model, standardised documentation, and risk assessment protocols for patient leave, has been significantly delayed, raising concerns about ongoing risks.
Responded
Ivan Ignatov
Concerns: A detainee's mental health assessment was missed in police custody, and an act of self-harm was misjudged. Critical risk information, including first-time custody status, was not properly recorded or collated, hindering comprehensive risk assessment.
Responded
Hilary Guedalla
Concerns: Multiple communication failures meant staff were unaware of a patient's high suicide risk and allowed unescorted leave. Inadequate record-keeping, brief un-noted risk assessments, and delayed, confused responses to a missing patient compounded the risk, exacerbated by short-staffing.
Responded
Stuart Robinson
Concerns: Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners with mental health issues. This meant self-harm was not adequately addressed.
Responded
Rebecca Fisher
Concerns: GMP officers failed to recognize high-risk missing person status due to poor understanding of mental health risks, misapplication of "golden hour" guidance, and inadequate information sharing. The effectiveness of new training and tools remains unconfirmed.
Responded
Elsie Leaver
Concerns: Critical failures included not recognising the patient's extensive psychiatric history and suicidality, inadequate risk assessments, and lack of bag searches during hospital transfers, contributing to her death by overdose.
Overdue
Patrick Soames
Concerns: Multiple agencies lacked a unified system for sharing critical information about the patient's serious self-harm across different geographic areas, compounded by no national 'risk flagging' system or out-of-hours GP access.
Overdue
Aoife McAdam
Concerns: A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, leaving her with a significant, unneeded quantity that led to an overdose.
Responded
Nicola Norman
Concerns: The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, follow up on distressed callers, or routinely escalate critical concerns to clinicians or the GP.
Overdue
John Abrahams
Concerns: Recommendations from the Isotretinoin Expert Working Group for prescribing to under-18s have not been implemented over a year later, despite ongoing adverse psychiatric events, including attempted suicide.
Responded
Daniel Lee
Concerns: A lack of a key worker approach led to superficial risk assessments and professional relationships. Communication with both the armed forces and the family was inadequate, hindering effective risk sharing and support.
Responded
Harry Evans
Concerns: The university lacked mandatory mental health and suicide prevention training for staff, employed an overly reactive, email-based approach to welfare concerns, and had staff unaware of information-sharing policies. Pastoral support was also limited by a lack of direct contact protocols.
Responded
Vincenzo Lippolis
Concerns: Mental health services failed to consider Mental Health Act admission criteria, focusing instead on social stressors after suicide attempts. A recommended face-to-face assessment was replaced by a telephone call, leading to case closure.
Overdue
Emma Simkin
Concerns: Professionals are perceived to accept patients' statements at face value, failing to detect "masking" of mental illness and often ignoring family concerns, requiring policy and training review.
Responded
Donna Neill
Concerns: A known risk of the deceased taking a spouse's medication was not documented, assessed, or managed by the Trust, and this critical systemic failure was overlooked in their internal investigation.
Overdue
Lily Girton
Concerns: Community CAMHS failed to adequately monitor and prescribe medication, expedite psychiatric appointments, or properly assess and communicate risk, hindering timely care access. The care plan was not updated despite escalating hospital concerns, leaving the patient without necessary support.
Overdue
Archi Johnson
Concerns: Crucial information, especially about previous suicide attempts, was not consistently recorded or shared across different risk assessments. This prevented staff from knowing significant risks, potentially impacting care decisions and safety measures.
Responded
Anthony McLellan
Concerns: Mental health care failed to adequately consider the impact of autism on risk assessment and communication of distress, including the higher suicide prevalence for autistic individuals. Staff lacked understanding of specialist team access.
Overdue
Matthew Evans
Concerns: The GP failed to adequately assess mental health or provide proactive care, while the practice lacked robust policies for prescribing, clinical governance, and learning. Thresholds for referring to secondary mental health services were also unclear.
Responded
Sarah Clarke
Concerns: University mental health services were insufficiently robust for high-risk students, lacking national guidance implementation, proper oversight, effective NHS liaison, and adequate systems to ensure student safety after distress.
Responded
Zoe Zaremba
Concerns: Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective inter-provider communication, increasing suicide risk for autistic individuals.
Responded
Ryan Merna
Concerns: The forensic team failed to adequately probe and document disclosures regarding a perpetrator's living situation and weapon possession, hindering risk assessment and police notification.
Overdue
Jason Lennon
Concerns: Failures in mental health care involved not using an appropriate care pathway, a flawed clinical review with poor record-keeping and communication, an incomplete incident action plan, and no regulatory referral for staff failings.
Overdue
Sheila Steggles
Concerns: Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.
Responded
Benjamin Stroud
Concerns: A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing a significant risk.
Overdue
Jack Taylor
Concerns: Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.
Responded