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
Source spread
Where this theme appears
Poor mental health suicide risk assessment has been flagged across 11 independent accountability sources:
243 PFD reports
8 committee recs
1 CQC action
6 PPO recs
7 IOPC recs
7 IMB reports
119 IMB recs
1 Scottish FAI
5 Article 2 learning points
16 PHSO decisions
10 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
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.
PFD Reports (243) — showing 50 strongest matches
Lee Adams
Concerns: GPs need greater awareness of propranolol's high toxicity at small doses, its lack of antidote, and the need to proactively inquire about patients' gambling habits.
Overdue
Delwyn Preece
Concerns: 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.
Response (Rotherham Doncaster South Humber NHS Foundation Trust): • The Trust’s patient leave policy (including Section 17 leave for detained patients, and also applicable to informal patients) has been revised to clarify and strengthen documentation requirements around leave. …
Responded
Robert Day
Concerns: 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.
Overdue
Jardine Williams
Concerns: 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.
Overdue
Jordan Buckton
Concerns: 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.
Overdue
John Walker
Concerns: Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.
Response (Sussex Partnership NHS Foundation Trust): The Trust has revised the documents clinicians are asked to complete to ensure they are less repetitive and better support succinct recording of relevant issues and the fences throughout Langley …
Responded
Jill Sinson
Concerns: The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records or consultant advice.
Overdue
Mark Stephen Smith
Concerns: Guidance is needed for emergency services on when to remain on the line with a person who has taken an intentional overdose and is alone.
Overdue
Roshan Abbas Ladak-Ebrahim
Concerns: Inadequate guidance on assessing self-harm risk, confusion regarding safeguarding responsibilities, and insufficient patient consultation when prescribing high-risk medication contributed to safety concerns.
Response (Department of Health): The Department of Health acknowledges concerns about assessing self-harm risk and providing safety advice, referencing existing government action plans, NICE guidance, and GMC guidance on confidentiality and information sharing.
Responded
Jonathan Thorpe
Concerns: 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.
Overdue
Michael O’Sullivan
Concerns: The DWP assessment process for fitness to work failed to incorporate vital medical information from the patient's treating GP, psychiatrist, and clinical psychologist, leading to decisions without comprehensive medical input.
Response (Department for Work and Pensions): DWP acknowledges concerns and will issue a reminder to staff about guidance related to suicidal ideation. They also state that they will continue to monitor their policies around assessment of …
Responded
Tallulah Wilson
Concerns: Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric or medical inductions.
Response (Department of Health): The Department of Health highlights a Policy Research Programme investing in projects exploring the internet's role in suicidal behaviour and identifies priorities for prevention. It also mentions that the Royal …
Responded
Michael Tarratt
Concerns: There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions for an opiate-dependent patient.
Response (Leicestershire Partnership NHS Trust): An urgent memo was sent to the Drug & Alcohol team regarding GP communication standards (minimum every 3 months). Standard GP letter templates have been reviewed to ensure detailed updates …
Responded
Danuta Corbett
Concerns: 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.
Response (Sussex Partnership NHS Trust): The consultant psychiatrist now carefully reviews notes taken during ward review. The Trust has reinforced with staff that should extraordinary circumstances arise again, a retrospective note must be completed, and …
Responded
Roger Duggan
Concerns: An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his unnoticed departure.
Response (Royal Devon Exeter NHS Trust): The staff nurse involved in the incident was reminded of the importance of contemporaneous record keeping. The Trust is using its Care Quality Assessment Tool (CQAT) to ensure that documentation …
Response (South Western Ambulance Service NHS Foundation Trust): Following an investigation, the Trust upgraded its version of 'NHS Pathways' to version 6.5.1, including a dedicated Mental Health Pathway, and trained staff on its use; a Mental Health Group …
Responded
Janet Blackman
Concerns: 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.
Overdue
Darren Arnoup
Concerns: 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.
Response: The medical centre will develop clear lines of communication with NCH&C staff, alert GPs to referrals related to mental health or substance misuse, and ensure GPs fully document any areas …
Overdue
Gary Richards
Concerns: Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous incident report.
Response (South London Maudsley NHS Trust): The Trust has secured funding for a mental health specific homeless project, linked to an existing scheme across hospitals. There is now an expectation that discharge summaries will be sent …
Responded
Samarjit Singh
Concerns: 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.
Response (Wirral Clinical Commissioning Group): NHS Wirral CCG established a working group to review the perinatal mental health pathway. They are revising the Liaison Psychiatry service specification to include dedicated consultant psychiatrist time and requiring …
Response (Department of Health): The Department of Health acknowledges the coroner's concerns regarding perinatal mental health services in the Wirral and Liverpool. They state that commissioning of local services is the responsibility of Clinical …
Overdue
Ashley Ponsonby
Concerns: Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led to inappropriate management and monitoring of a deteriorating patient.
Response (Greater Manchester Police): • Greater Manchester Police agrees that a mental disorder does not absolve individuals of the criminal consequences of their actions. • It is often appropriate and necessary for legal proceedings …
Responded
John Thorpe
Concerns: 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.
Overdue
Noleen McPharlane
Concerns: 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.
Response (Camden & Islington NHS Trust): The Trust updated its clinical risk assessment and management policy in September 2014. All clinical staff will be instructed to discuss methods of self-harm with service users and care plans …
Responded
Kimberley Lindfield
Concerns: 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.
Response (Manchester Mental Health NHS): Manchester Mental Health and Social Care Trust (MMHSCT) has agreed to provide UHSM with advice in respect of their development of a self-harm policy and guidance. Regular liaison meetings will …
Response (Department of Health): The Department of Health acknowledges the concerns raised and outlines several existing initiatives related to mental health and self-harm prevention, including national indicators, research funding, and the Mental Health Action …
Responded
Tanya Page
Concerns: Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.
Overdue
Alexander Holt
Concerns: 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.
Overdue
Isobel Griffin and Jane Clark
Concerns: 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.
Overdue
Colin Tyson
Concerns: Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at risk of suicide.
Response (NHS England): NHS England, working with NHS Wakefield CCG, has developed an advice sheet for GP practices on responding to third-party concerns about patients, which will be shared across Wakefield and Yorkshire …
Responded
Harold Ambrose
Concerns: 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.
Overdue
Finnulla Martin
Concerns: The psychiatry liaison team at Whittington Hospital appeared unclear on protocols for receiving information from police officers bringing patients in voluntarily, and did not adequately explore suicide risk or obtain collateral history; also, the police call handler did not record critical information.
Overdue
Wanda Stachurska
Concerns: 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.
Response (Surrey and Borders Partnership NHS Trust): The Trust has worked with East Surrey Hospital to ensure a shortcut to SASH policies is loaded onto Psychiatric Liaison staff computers, and has mandated that two staff members undertake …
Responded
Mark Daniels
Concerns: The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.
Response (Camden and Islington NHS Trust): Camden and Islington NHS Foundation Trust have put in place a comprehensive action plan to address the concerns raised regarding failures by the Crisis team, with measures implemented across all …
Responded
Simon Reynolds
Concerns: 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.
Overdue
Thomas Thurling
Concerns: 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.
Response (Norfolk and Suffolk NHS Trust): The Trust is sharing the issue of monitoring medication changes with a range of leads, including Pharmacy and those leading Triangle of Care; clinical services have been directed to consider …
Responded
William Abel
Concerns: 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.
Response (Leicester Partnership NHS Trust): The Trust conducted a serious incident investigation and shared the results with the deceased's father. The Triage Car service manager and team manager reviewed decisions made on the night, and …
Responded
Charlotte Bevan and Zaani Malbrouck
Concerns: 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.
Response: A consultant perinatal psychiatrist has been tasked to review individual pathway arrangements against NICE guidelines, aiming to agree and implement a Trust-wide pathway. The Trust also plans to prepare and …
Responded
Emma Bray
Concerns: The report identifies failures to obtain a proper medication history, refer the deceased to a psychiatrist, follow up with the deceased, and share family concerns with the team; also, the report mentions the absence of guidelines for assessment and referral processes.
Response (North East London NHS Foundation Trust): NELFT developed an action plan with five broad objectives addressing concerns about assessment, communication with carers, procedures, record keeping, and risk assessment.
Responded
Jake Robinson
Concerns: The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Response (Bodmin Road Health Centre): Bodmin Road Health Centre provided context and clarified their actions regarding the patient's care, and noted a past apology to the patient's mother. They reflected on whether further information sharing …
Response (Greater Manchester West NHS Mental Heath Foundation Trust): Trafford Aim has implemented a more streamlined process for receiving letters and faxes. CMHT staff have been reminded to consider alternative ways to carry out assessments and engage service users, …
Response (GMCA): GMCA stated that Greater Manchester West Mental Health Foundation Trust implemented systems to capture and act upon letters or faxes received. They also set up a Dual Diagnosis Steering Group.
Responded
Julie Rose
Concerns: The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff demonstrated inadequate understanding of its procedures.
Overdue
Joanna Bowring
Concerns: 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.
Response (Joanna Bowring): The Trust re-launched its carers protocol in February 2016, which includes identifying possible "red flags" and behaviours carers may look out for. An audit of care plans and risk assessments …
Responded
Louise Locke
Concerns: 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.
Response (Southern Health NHS Foundation Trust): The Adult Mental Health Management Team has assigned an action to Clinical Service Directors to formulate a standard plan to ensure that patients requesting second opinions have access to these …
Responded
Adam Rice
Concerns: There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, and a lack of understanding of welfare check protocols.
Response (Adam Rice): West Yorkshire Police has implemented measures to ensure vulnerable persons who come into contact with the Police receive the best possible care, including a full training programme for Custody Staff …
Overdue
Stewart Akins
Concerns: Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' Court, leading to bail being granted without full awareness of the high self-harm risk.
Response (S Akins): West Mercia Police revised its practice so all Prisoner Escort Forms are signed as accurate by the custody sergeant, who has overall responsibility for ensuring risks are correctly documented and …
Responded
Jason Vaughan
Concerns: 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.
Response (Rotherham Doncaster and South Humber NHS Trust): The Trust will reiterate the importance of recording all relevant data on the IAPT system through internal communications. The Trust is also part of a national 'Sign up to Safety' …
Responded
Danielle Robinson
Concerns: Staff are not rigorously following the Therapeutic Engagement and Observation Policy, leading to missed opportunities for escalating patient observation levels during critical risk periods.
Response: The University Health Board has reviewed and updated its Therapeutic Engagement and Observation Policy to include the automatic escalation of observations following a serious attempt of self-harm until a full …
Responded
Kevin Dermott
Concerns: 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.
Response (NHS England): NHS England is working with other organisations to address the lack of secure psychiatric beds. Updated guidelines for transferring prisoners to secure mental health hospitals are due for final consultation …
Response (HM Prison and Probation Service): HMP Risley has increased the level and depth of management checks on ACCT documents, will issue a Governor's Order clarifying staff responsibilities, and has informed staff to contact the Safer …
Response (Department of Health): The Department of Health acknowledges the concerns, highlights its commitment to working with NOMS and NHS England, and notes that NHS England and NOMS will be responding separately.
Responded
Patricia Cleghorn
Concerns: 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.
Response (Department of Health): The Department of Health acknowledges the concerns raised, refers to the government's mandate for accessible and high-quality crisis services, and notes that the availability of mental health beds is a …
Response (NHS England): NHS England highlights the establishment of an adult mental health programme taking a whole system approach and reiterates the national ambition of reducing suicides, with Clinical Commissioning Groups expected to …
Response (Birmingham and Solihull NHS Trust): The Senior Nurse for Professional Standards issued a formal practice alert regarding risk assessments, and a Clinical Risk Management Group has been established. The Head of Pharmacy will review the …
Response (CQC): The CQC is requiring the Trust to clarify the role of non-registered staff in the crisis team. The CQC will formally review the actions put in place by the Trust …
Responded
Nathan Lowe
Concerns: Consideration should be given to whether more could have been done to contact the patient, given the nature of his illness and his non-compliance with follow up.
Responded
Nicholas Sullivan
Concerns: 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.
Overdue
Edward Mallen
Concerns: A GP prescribed medication based on advice from a non-prescribing nurse without adequately informing the patient about critical side effects or support contacts. GPs also lacked awareness of available psychiatrist consultation.
Overdue
Rohid Shergill
Concerns: 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.
Overdue
Committee Recommendations (8)
#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. …
Gov response: 2: PAC conclusion: 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. 2: PAC …
Not Addressed
#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 …
Gov response: We accept this recommendation in part. The Government is accelerating the role out of MHSTs. We agree that education settings can have an important role in prevention and early intervention. MHSTs, where established, are a …
Not Addressed
#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 …
Gov response: 2: PAC conclusion: 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. 2: PAC …
Not Addressed
#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 …
Gov response: agree with the conclusion that DHSC and NHS Digital took too long to identify all clinically extremely vulnerable people. Given the data available at the time, and the novelty of shielding policy, NHS Digital, DHSC, …
Under Consideration
#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 …
Gov response: You will see that we are seeking views in the accompanying consultation paper on the recommendations made in respect of interviewing partners and household members of those certificate holders or applicants with a record of …
Under Consideration
#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 Pending
#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 …
Gov response: We recognise that harmful gambling can wreck lives, impact families and communities, and even lead to suicide in extreme cases. The package of measures outlined in the gambling white paper will significantly increase protections with …
Accepted
#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 …
Gov response: The UK Government has noted the Committee’s recommendation that the current renewal period of five years remain in place but that it should be kept under review. As you will see, we are seeking views …
Under Consideration
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 (7)
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: This follows two IOPC investigations where officers …
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 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
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
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
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
Leeds (2024)
Is the Minister satisfied that all necessary resources are being delivered to significantly reduce self-inflicted deaths?
Other
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Stoke Heath (2025)
The Board recommends that the Governor explores more opportunities for staff to actively engage with prisoners who are at risk to help reduce self-harm, given the significant increase in deaths and serious self-harm cases.
Governor / Director
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
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
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
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
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
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
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
PHSO Casework Decisions (16)
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.
NHS in England
May 2023
P-002532 — Sussex Partnership NHS Foundation Trust
Mr R complains the Trust failed to recognise his deteriorating mental health. He says the Trust did not prescribe him testosterone, delayed his referral for CBT treatment and his autism screening referral, it did not make his care providers or school know about his risk of suicidal ideation, it did …
NHS in England
Apr 2024
P-003678 — Tees, Esk and Wear Valleys NHS Foundation Trust
Miss U complains that her daughter Miss R’s death was preventable and resulted from inadequate risk management, unsafe transition, poor communication, and repeated service failures between 10–12 January 2024.
NHS in England
Jul 2025
P-004082 — Oxford Health NHS Foundation Trust
Dr V complains a Trust psychiatrist opened and deleted an email she sent in July 2022, in which she expressed concern about her husband's behaviour and made a plea for help. Dr V also complains about the psychiatrist’s appearance and demeanour at the Inquest.
NHS in England
Sep 2025
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.
NHS in England
Partly Upheld
Oct 2025
P-004470 — Surrey and Borders Partnership NHS Foundation Trust
Mr C complained about the treatment the Trust gave his sister in 2020 with regard to inappropriate medication, inadequate risk assessments, and failure to follow relevant guidance on GAD. He says failures contributed to her decision to take her own life.
NHS in England
Partly Upheld
Dec 2025
P-004514 — A practice in the Gateshead area
Mrs G complains in April 2024, a medical practice in the Gateshead area did not reissue her medication at the previously agreed prescribed dosage, and its receptionist did not allow her to explain she felt suicidal or speak with the practice manager.
NHS in England
Dec 2025
P-001995 — Leeds and York Partnership NHS Foundation Trust
Miss O complains the Trust failed to keep her safe when she had attempted to take her own life.
NHS in England
May 2023
P-002790 — Derbyshire Healthcare NHS Foundation Trust
Mrs A complains the Trust failed to recognise her son had a diagnosis of autism or that he was a vulnerable adult with a history of depression and self-harm. She says it did not take this seriously or into account when giving care and treatment and failed to give follow …
NHS in England
Jul 2024
P-003565 — Oxleas NHS Foundation Trust
Mr R complains about the care and treatment he received from two prisons. Mr R says he did not receive appropriate pain management or care in relation to his mental health.
NHS in England
Not Upheld
Dec 2024
P-003585 — Nottinghamshire Healthcare NHS Foundation Trust
Mrs R complains that in the months leading up to her father’s death in May 2022, the Trust discharged him despite him saying he was suicidal. She complains it did not allocate face to face appointments, it cancelled scheduled appointments and did not liaise with other services to ensure his …
NHS in England
Upheld
Jun 2025
P-004573 — A practice in the Norwich area
Mrs H complains about a GP Practice in Norwich that failed to support her husband Mr H mental health needs.
NHS in England
Jan 2026
P-001256 — A medical practice in the Gloucestershire area
Mrs V complained about the care the Practice and Trust provided to her brother, Mr V, for symptoms and illnesses she believes may have contributed to his sudden death. Mrs V believes her brother's autism and mental health needs were not adequately addressed.
NHS in England
Partly Upheld
Aug 2021
P-002332 — Nottinghamshire Healthcare NHS Foundation Trust
Mr A complains the Trust failed to put a plan in place for his brother when it was clear his parents could not care for him, failed to make sure his brother was taking his medication correctly and made no effort to contact his brother shortly before his death.
NHS in England
Sep 2023
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.
NHS in England
Jun 2024
P-003277 — Tees, Esk and Wear Valleys NHS Foundation Trust
Mrs C complains her son’s declining health was not well supported between October and November 2022.
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)
LGO (Local Government & …
Health
Not Upheld
25-005-077a — West London NHS Trust Headquarters (25 005 077a)
LGO (Local Government & …
Health
Upheld
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