Poor mental health suicide risk assessment
Failures in recognising and assessing high suicide risk due to limited training, inadequate supervision, and poor call triage.
423 items
11 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
90match
#36 - Eighth Report - Children and young people’s mental health
We are deeply concerned about the increasing numbers of children and young people who experience self-harm and suicide and the quality of care they are able to access. Much more needs to be done to tackle suicide and self-harm amongst children and young people. In particular, given the link between self-harm in children and young people and later...
Matched on
terms: health, mental, suicide
PFD report
89match
Noleen McPharlane
Inadequate mental health care included a failure to directly assess suicidal ideation or illicit drug use, short sessions, and a lack of input from other professionals despite poor patient rapport.
Matched on
terms: health, mental, poor
PFD report
89match
William Abel
Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse led to unsafe discharge.
Matched on
terms: assessment, health, mental
PFD report
89match
Patricia Cleghorn
The unavailability of acute mental health beds led to a vulnerable patient being cared for in the community with limited resources, alongside a failure to conduct a formal risk assessment despite repeated threats of overdose.
Matched on
terms: assessment, health, mental
PPO recommendation
86match
The Head of Healthcare
The Head of Healthcare should ensure that reception staff make an urgent mental health referral when a prisoner presents as hopeless or expresses thoughts of suicide or self-harm.
Matched on
terms: health, mental, suicide
PFD report
85match
Jardine Williams
The 999 call pathway for mental health crises lacks a specific question to assess the immediacy of a stated suicide plan, potentially hindering call handlers from understanding urgent risk.
Matched on
terms: health, mental, suicide
PFD report
85match
Kimberley Lindfield
Deficiencies include a lack of audit for mental health assessment referrals, absence of clear protocols for patient observation and clinical review changes, and inadequate record-keeping practices.
Matched on
terms: assessment, health, mental
PFD report
85match
Nicholas Sullivan
Reception staff in the Emergency Department did not use a checklist to identify mental disorder/conditions and record important background issues, there was no clear system to trigger urgent triage and safeguarding steps, and no system to safeguard the patient pending a mental health assessment.
Matched on
terms: assessment, health, mental
IOPC learning recommendation
84match
Recommendation - Nottinghamshire Police, March 2022
The IOPC recommends that Nottinghamshire Police review their policy/guidance for high risk cases in relation to safeguarding and suicide risk assessments, to ensure that these are conducted at the 'known trigger points' of an investigation. This follows a case where police were called to attend to a report of a male found at his home address having taken...
Matched on
terms: assessment, health, mental, suicide
PFD report
81match
Delwyn Preece
Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail and unacknowledged retrospective entries, hindering effective investigation.
Matched on
terms: assessment, mental, poor
PFD report
81match
Jordan Buckton
Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.
Matched on
terms: health, mental
PFD report
81match
Jonathan Thorpe
A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
Matched on
terms: assessment, health, mental
PFD report
81match
John Thorpe
The deceased was inappropriately asked to self-refer to mental health services, and crucial follow-up was absent. Doctors failed to adequately consider the increased suicide risk associated with starting antidepressants in a patient with a history of attempts.
Matched on
terms: health, mental, suicide
PFD report
81match
Wanda Stachurska
Mental health risk assessments were diminished by untrained interpreters and staff unaware of policies. Furthermore, a serious incident review was not undertaken, delaying learning opportunities.
Matched on
terms: assessment, health, mental
PFD report
81match
Simon Reynolds
Lack of documented risk assessments on admission, inadequate record-keeping, and insufficient staff training on setting observation levels, assessing suicide/self-harm risk, and communicating risks were identified.
Matched on
terms: assessment, suicide
PFD report
81match
Louise Locke
Premature discharge from mental health services occurred without adequate risk assessment or support, compounded by a lack of systems to collate multi-agency information and inconsistent suicide prevention approaches.
Matched on
terms: assessment, health, mental, suicide
PFD report
77match
Thomas Thurling
Inadequate monitoring of medication changes, including lack of awareness and delayed reviews, coupled with the absence of a Care Co-ordinator during a period of mental health deterioration due to staff shortages, posed significant risks.
Matched on
terms: health, mental
PFD report
77match
Kevin Dermott
While at HMP Durham, the deceased was left in a urine soaked cell during a hypomanic episode and a psychiatric referral was never completed; inadequate mental health cover at HMP Haverigg and a lack of suitable psychiatric care facilities at HMP Kirkham contributed to a failure to recognise relapse into depression at HMP Risley.
Matched on
terms: health, mental
IOPC learning recommendation
77match
National recommendations - College of Policing, July 2024
The IOPC recommends that the College of Policing review and update its guidance on Suicide and Bereavement Response as part of its ongoing work to review APP on mental health. This review should: This follows two IOPC investigations where officers attended separate incidents where members of the public had taken their own lives by hanging. The IOPC has...
Matched on
terms: health, mental, suicide
Article 2 learning point
77match
CR — HMP Swansea - LP Healthcare 1
A range of information including that from assessment during custody and from court proceedings should be considered along with the presenting risk factors when undertaking an initial assessment of an individual’s risk of suicide/self-harm and the opening of a potential ACCT.
Matched on
terms: assessment, health, suicide
Committee recommendation
72match
#8 - Fifty-Second Report - Key challenges facing the Ministry of Justice
HMPPS’ data shows that during 2020, there were 67 self-inflicted deaths in custody, and 58,879 self-harm incidents in the 12 months to September 2020. We heard from HMPPS that while these levels are high, they are showing signs of declining. The situation remains particularly alarming for female prisoners.8 We welcomed HMPPS’ work to set up a taskforce to...
Matched on
terms: health, mental
IOPC learning recommendation
72match
Recommendation - Northumbria Police, March 2022
The IOPC recommends that Northumbria Police update their policy/guidance in relation to conducting suicide risk assessments. These should be conducted in person, wherever possible, and any other method used needs to be recorded along with the rationale for the use of that method. This follows a case where a male was alleged to have sexually abused two family...
Matched on
terms: assessment, health, mental, suicide
IMB recommendation
72match
Swaleside (2024)
The Board remains concerned regarding the mental health of prisoners who have suffered long-term lockdown. This is evidenced by the number of opened Assessment, Care in Custody and Teamwork (ACCT) documents, self-harm cases and violent incidents. The first indications from the recent improvement in regime are positive. However, the necessity for increased psychology and psychiatric services still needs...
Matched on
terms: assessment, health, mental
Scottish FAI
72match
Dr Sara Lilian Macrae
(i) When staff in a secure mental health ward are presented with evidence that a patient has vocalised suicidal ideation and demonstrated means to complete suicide by presentation of a ligature, urgent action to search that patient's room and person for any other potential ligatures ought to be taken. In addition, consideration should be given to placing the...
Matched on
terms: health, mental, suicide
IMB recommendation
72match
Swaleside (2022)
The Board has concerns regarding the mental health of prisoners who have suffered long-term lockdown as evidenced by the high number of assessment, care in custody and teamwork (ACCTs) cases, self-harm cases and general violent incidents. The necessity for increased psychology and psychiatric services should be assessed.
Matched on
terms: assessment, health, mental
PHSO casework decision
72match
P-004151 - Norfolk and Suffolk NHS Foundation Trust
Mrs Y complains about the mental health care provided to her late daughter Ms B, by the Norfolk and Suffolk NHS Foundation Trust. Specifically, she complains about a lack of communication, poor risk management and record keeping, poor care plan management, an incorrect diagnosis, and unwarranted medication changes.
Matched on
terms: health, mental, poor
PFD report
69match
Robert Day
Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, risking patient lives.
Matched on
terms: health, mental
PFD report
69match
Janet Blackman
Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated care delivery for both physical and mental health.
Matched on
terms: health, mental
PFD report
69match
Darren Arnoup
Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.
Matched on
terms: health, mental
PFD report
69match
Samarjit Singh
The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and declined referrals for mothers with severe postnatal depression.
Matched on
terms: health, mental
PFD report
69match
Isobel Griffin and Jane Clark
For Jane Clark, challenging events were not handed over, the nurse in charge did not read the notes before granting leave, risk assessment was ill-informed, not discussed, and poorly documented; for Isobel Griffin, there were issues with key worker allocation, updating risk assessments, clinician reviews, medication management, and ligature points.
Matched on
terms: assessment, poor
PFD report
69match
Harold Ambrose
There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was not properly flagged in medical records.
Matched on
terms: health, mental
PFD report
69match
Charlotte Bevan and Zaani Malbrouck
There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
Matched on
terms: health, mental
PFD report
69match
Joanna Bowring
Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.
Matched on
terms: assessment, suicide
PFD report
69match
Jason Vaughan
The IAPT electronic patient record system has insufficient narrative detail, and its risk assessment tool cannot track minor patient deterioration. Practitioners may also lack awareness of increasing suicide rates in specific demographics.
Matched on
terms: assessment, suicide
PHSO casework decision
69match
P-002713 - Greater Manchester Mental Health NHS Foundation Trust
Mr A complains about his mother’s care and treatment in 2022 and says her death had been due to failings in her care.
Matched on
terms: health, mental
Committee recommendation
68match
#47 - Third Report - Firearms licensing regulations in Scotland
We heard (for example, from Reverend Gordon Matheson) that people close to an individual may not know that they own, or are applying to own, firearms.129 This lack of knowledge may prevent family and friends from reporting concerns about an individual who is not best placed to own firearms (for example, because of poor mental health).
Matched on
terms: health, mental, poor
PFD report
65match
Danuta Corbett
The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.
Matched on
terms: assessment
PFD report
65match
Alexander Holt
Failures included not challenging minimised suicidal intent, providing intended treatment, ensuring continuity of care, and maintaining information flow, leading to inadequate risk assessment and a broken referral process.
Matched on
terms: assessment
PFD report
65match
Rohid Shergill
Lack of clear protocols for NGT feeding parental competence, poor information sharing between trusts, and inadequate training for staff on pH testing and syringe hygiene compromised care for a child in the community.
Matched on
terms: poor
PHSO casework decision
65match
P-002004 - Sheffield Health and Social Care NHS Foundation Trust
Mr O complains the Trust failed to take his health seriously after the police made a referral reporting concerns of suicide. He also complains the Trust did not handle his complaint properly and it took too long to reply to him.
Matched on
terms: health, suicide
IMB recommendation
64match
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...
Matched on
terms: health, mental
IMB recommendation
64match
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...
Matched on
terms: health, mental
Article 2 learning point
64match
Mr Quartz — HMP Doncaster - 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.
Matched on
terms: assessment, suicide
Committee recommendation
64match
#2 - Fifty-Second Report - Key challenges facing the Ministry of Justice
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 prisons during the pandemic has exacerbated the existing mental health challenges that prisoners face. In 2019–20, the incidents...
Matched on
terms: health, mental
IMB annual report
64match
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...
Matched on
terms: health, mental
IMB annual report
64match
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...
Matched on
terms: health, mental
IMB recommendation
64match
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?
Matched on
terms: health, mental
CQC action
63match
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.
Matched on
terms: health, mental, poor
IMB recommendation
63match
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...
Matched on
terms: assessment, health, mental