Risk of suicide in mental health care
Midlands Partnership NHS Foundation Trust received 3 coroners' reports about this hazard between 21 Dec 2018 and 19 Mar 2025.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 7 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Risk assessment and progress notes. a) The electronic records were hard for a lay person to follow or understand”
Original on judiciary.uk ↗ Midlands Partnership NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“Following discussions within the teams involved, I ani now in a position to respond to your specific concerns, where by you. stated you heard at the inquest during the course of the evidence: 1. Delay in IAPT Counselling After turned 18 she moved to Adult Mental Health Services. She had parallel contact with her GP surgery in Shortly before 18th birthday according to the MPFT Clinical Review I (page 9 of 33), was referred to Improving Access to Psychological Therapies (IAPT) . by'the Access Team for”
Stated timescale: 14th November 2017
- 5 years 2 months later
Raised again · 1st time
Jamie Pilkington↗
22 Feb 2024 · Andrew Barkley · Staffordshire and Stoke on Trent
Closely relatedConfidence 0.85 · higha different coroner“During a Mental Health triage with the the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.”
Original on judiciary.uk ↗ Repeated from the earlier report:RiskAssessment
Midlands Partnership NHS Foundation Trust responded, stating 6 specific actions.Response (PDF) ↗
“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide”
Stated timescale: December 2023
“When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide”
Stated timescale: December 2023
4 more stated actions in the Promises tab.
- 1 year 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system.”
Original on judiciary.uk ↗ Midlands Partnership NHS Foundation Trust responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Midlands Partnership NHS Foundation Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2018 → 2024Jamie Pilkington5 years 2 months after 2018-0405 · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with the completion and use of risk assessments in mental health care. The earlier report stresses that risk assessments must be updated and read alongside progress notes, while the later report describes repeated failures to complete suicide risk assessments.
2018-0405 · 21 Dec 2018
“Risk assessment and progress notes. a) The electronic records were hard for a lay person to follow or understand”
Original on judiciary.uk ↗ Jamie Pilkington · 22 Feb 2024
“During a Mental Health triage with the the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.”
Original on judiciary.uk ↗ 2024 → 2025William Grieve1 year 1 month after Jamie Pilkington · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with suicide risk assessments – the earlier report cites failures to complete assessments, while the later report notes assessments were done incorrectly due to lack of shared information and insufficient staff training.
Jamie Pilkington · 22 Feb 2024
“During a Mental Health triage with the the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide.”
Original on judiciary.uk ↗ William Grieve · 19 Mar 2025
“Both assessments, were incorrect, and took account of incorrect information because neither team had access to the others computer system.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“An exploration of risk would entail a conversation around factors such as risk to self, risk to others or self- neglect. If during that conversation any risks are identified these would be explored in further detail to include intent, severity, access to resources and following this a robust safety plan formulated collaboratively between professional, the service user and carer (if”
Stated action · timescale: 14th November 2017
“Following discussions within the teams involved, I ani now in a position to respond to your specific concerns, where by you. stated you heard at the inquest during the course of the evidence: 1. Delay in IAPT Counselling After turned 18 she moved to Adult Mental Health Services. She had parallel contact with her GP surgery in Shortly before 18th birthday according to the MPFT Clinical Review I (page 9 of 33), was referred to Improving Access to Psychological Therapies (IAPT) . by'the Access Team for”
Stated action · timescale: December 2023
“During a Mental Health triage with the Mental Health and Social Inclusion Hub on 8th February 2023 there was a failure to complete the Risk Assessment in relation to his risk of suicide”
Stated action · timescale: December 2023
“When referred to and assessed by the Integrated Mental health Team on 3rd March 2023 again there was a failure to complete a Risk Assessment as to his risk of suicide”
Stated action · timescale: December 2023
“An exploration of risk would entail a conversation around factors such as risk to self, risk to others or self- neglect. If during that conversation any risks are identified these would be explored in further detail to include intent, severity, access to resources and following this a robust safety plan formulated collaboratively between professional, the service user and carer (if”
What happened next: No evidence found either way
The trust's patient safety plan outlines a process for discussing risk factors and developing safety plans collaboratively, but no specific timeline for implementation is provided in the document.
“Patient safety incident response plan Summary This plan describes how the trust will respond to patient safety incidents, in accordance with the Patient Safety Incident Response Framework (PSIRF) and national reporting requirements.”
No evidence found does not mean the action did not happen.
Stated action · timescale: Ongoing
“The Overcoming Challenging Times plan is collaborative in nature, designed to enable the service user to identify changes in behaviours, risk and thought processes and empowers them to engage in activities that have previously proven effective in supporting them to manage their emotions and related risks”
Stated action · timescale: Ongoing
“Family and carer engagement; ensuring that families and carers are included in safety planning”
Stated action · timescale: Ongoing
“Monitoring; engagement in real time suicide surveillance, patient safety incident review and learning from deaths process”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Midlands Partnership NHS Foundation Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2018 → 2024 | 0.73 | 0.02 | Closely related · 0.85 | different |
| 2024 → 2025 | 0.78 | 0.06 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Midlands Partnership NHS Foundation Trust
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.