“The assessment of Sam's risk of self-harm was recorded by his care-coordinator in a Wales…”

The coroner’s concerns

(1) The assessment of Sam's risk of self-harm was recorded by his care-coordinator in a Wales Applied Risk Research Network (WARRN) assessment tool in March 2019. This form of assessment was adopted by the Integrated Mental Health Services (Powys County Council & Powys Teaching Health Board) in Powys. I also received evidence that it is used throughout Wales by similar services. (2) The evidence I received indicated that the WARRN assessment documentation/tool could be routinely accessed, updated & revised by the Integrated Team. It was a fluid document for the purpose of recording information as to the current assessment of risk(s) of self-harm & how that risk(s) was to be mitigated. Whilst I received evidence that in practice, such risk assessments were being undertaken with Sam, the WARRN documentation did not necessarily reflect that, nor was it optimally viewable in terms of clearly recording fluctuating presentations & any accompanying re-assessment of risk. (3) It appeared to me that the format/layout of the WARRN tool, its accessibility, & in particular, its ability to provide a user with clear & easily viewable information as to how Sam's risk of self-harm had fluctuated/altered/changed in the months preceding his death, could lead to important information/assessments being lost to a new/infrequent user. This, for example, might be a new care co-ordinator (as in Sam's case), Crisis Team/Community Nurse, or clinician not previously involved with Sam. (4) Given the variety of services involved in Sam's care, this central document, addressing & recording fluctuating risk appeared to me to be a crucial document in the recording of current risk (my emphasis). The ability of those charged with Sam's care to view those fluctuations might be hampered by the current presentation of/access to such information. That could lead to an underestimation of the current risk & sub-optimal mitigating measures being put in place. (5) The WARRN assessment tool might also benefit from a greater degree of interaction between it & the user. For example, it was clear, on the evidence that Social Worker's, Mental Health Nurses & Clinicians were all busy addressing the needs (& assessing risk) of a wide number & variety of patients. Prompting (my emphasis) the user to consider & record referrals for, for example, to advocacy services & for capacity assessments might optimise the benefits of the tool & reduce the risk of such opportunities being missed/un-recorded. Such then leading to the potential absence of key information for new/infrequent users when assessing risks of self-harm It may well be helpful (given the Integrated Services approach to Mental Health Services in Powys) if I were to receive one jointly prepared response from both organisations to whom this Report has been sent. 2

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2022-0163

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0