Design flaws enabling suicide
105 items
1 source
Environmental design flaws (e.g., car park barriers) that allow surprisingly easy access to means of suicide, coupled with poor visibility of support signage.
Cross-Source Insight
Design flaws enabling suicide has been flagged across 1 independent accountability source:
105 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (105) — showing 100 most recent
Brody O’Brien
Concerns: An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.
Pending
Saranveer Sihota
Concerns: The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with suicidal thoughts, with multiple similar incidents reported.
Response: The council immediately closed the top floor of the car park using temporary fencing and completed permanent enhanced suicide prevention measures in March 2024, including full-height, heavy-duty gates and fencing …
Responded
Ricky Monahan
Concerns: An unprotected fire escape allowed easy roof access from a rehabilitation unit due to inadequate railings, without an environmental risk assessment. There are no guidelines for fire escape protections in such settings.
Response: NHS England states that appropriate national guidance regarding patient safety and risk assessment in mental health settings already exists, implying the issue was with local implementation of environmental risk assessments …
Response: The Environmental Risk Assessment has been updated to include the fire escape, and the Trust has installed new metal fence panels and an eight-foot-high gate on the ground floor and …
Response: The CQC outlines its existing regulatory duties under Regulation 12 regarding safe care and treatment, and explains its inspection processes, but states the issue of national guidelines for fire escape …
Responded
Jody Robb
Concerns: Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person on the tracks despite multiple trains passing, hindering intervention.
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
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
Pellumb Olaj
Concerns: The council failed to consider a patient's history of paranoid schizophrenia and past suicide attempts by jumping from high places when housing him on the sixth floor.
Responded
Matthew O’Reilly
Concerns: Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Responded
Samuel Dickenson
Concerns: Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Responded
Andrew Brown
Concerns: Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Responded
William Armstrong
Concerns: Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Overdue
Kelly Walsh
Concerns: Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Overdue
Chantelle Williams
Concerns: Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Responded
Mathew Price
Concerns: Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Responded
Shaun Bass
Concerns: Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Responded
Jacqueline Potter
Concerns: Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit Wi-Fi lacks filters, allowing vulnerable patients access to self-harm websites, increasing suicide risk.
Responded
Alexander Cardoza
Concerns: Despite previous deaths, barriers at a specific location remain surmountable due to design flaws and insufficient operational security, including a lack of CCTV, posing an ongoing risk of falls.
Pending
Isaiah Olugosi
Concerns: A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.
Responded
Peter Jones
Concerns: Police station design flaws, including flat-topped telephone hoods and inadequate public reception area oversight, contributed to the death, highlighting safety equipment and monitoring failures.
Responded
Alexander Thomas
Concerns: A pedestrian walkway beneath the M56 motorway provides easy, unguarded access to the eastbound carriageway's hard shoulder via a ramp and fixed ladder, unlike the securely fenced westbound side.
Responded
Alexandra Roberts
Concerns: The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount would have been preferred to reduce risk.
Responded
Morgan Betchley
Concerns: The mental health Trust lacked policy or guidance for assessing suicide risks posed by fixtures and fittings supplied to acute mental health patients.
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
Glenn Jacques and Ben Whiteman and Callum Clark
Concerns: The railway station, a known location for suicides, met the 'hotspot' criteria with three incidents in 12 months, despite previous categorisation suggesting otherwise.
Overdue
Terrence Taylor
Concerns: Window restrictor guidance and British Standards for care homes are inadequate, focusing only on accidental falls, not deliberate attempts to defeat them. Care home operators are unaware these standards may not provide sufficient security.
Responded
Laura Gawthorpe
Concerns: Safety measures, including fencing and barriers, were only partially implemented at the car park, leaving areas where the parapet wall remained easily climbable.
Responded
Chanyang Li
Concerns: Student accommodation windows lacked adequate restrictors, enabling a fatal fall from a sixth-story, highlighting a failure to address the known risk of students falling from windows.
Responded
William Erskine
Concerns: Current building regulations do not mandate fixed window restrictors in high-rise residential buildings, including existing ones, allowing windows to open fully and posing a significant fall risk.
Overdue
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
Jason Brown
Concerns: Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to suicidal patients with a history of overdose attempts.
Responded
Sandra Senior
Concerns: Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.
Responded
Guy Scotchford
Concerns: An active website provides detailed instructions and direct purchasing links for substances to end one's life, posing a significant risk to vulnerable individuals.
Responded
Adrian Gallagher
Concerns: An online book providing explicit, step-by-step suicide instructions, including methods to avoid detection, is readily accessible with inadequate age verification, posing a significant risk to vulnerable individuals.
Responded
Chloe Macdermott
Concerns: Online forums encourage suicide by providing methods without age restrictions or help signposting, and harmful content is not effectively removed. Lethal products are also easily purchased via international online retailers and delivered to the UK without effective border controls.
Overdue
Bronwen Morgan
Concerns: Vulnerable individuals are able to access websites that facilitate and promote self-harm and suicide methods, enabling them to acquire information and means to cause their own death.
Overdue
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
Gordon Rodger
Concerns: Network Rail declined to install anti-trespass measures at Askam station, despite unusual accessibility points near a golf club, raising concerns about easy access for individuals intending self-harm.
Responded
Arezou Tirgari
Concerns: Insufficient action has been taken to prevent individuals from jumping from a specific roof terrace, leading to two deaths in eight weeks and an ongoing risk of further fatalities.
Responded
Seth Thind
Concerns: A bridge lacked safety barriers, emergency help points, mental health signage, and CCTV, despite a high number of crisis incidents and fatalities, indicating insufficient preventative measures.
Responded
Sandra Kirk
Concerns: Ligature risk policies inadequately address potential ligature items like clothing, focusing instead on anchor points and avoiding 'blanket restrictions' without sufficiently identifying actual risks to vulnerable patients.
Responded
Ezra Tamiem
Concerns: A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without plans for remedy.
Overdue
James Booth
Concerns: Inadequate garden fence security at a mental health facility, without national guidance, and a critical breakdown in information exchange at shift handovers led to a failure in appreciating emerging patient risks.
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
Matthew Caseby
Concerns: Poor record-keeping accuracy, failure to update risk assessments, and inadequate serious incident investigations contribute to an unsafe environment with an insecure courtyard fence and ligature risks. National perimeter fence guidelines are lacking.
Responded
Emma Pring
Concerns: "Anti-ligature" safety clothing failed, allowing self-harm and potentially providing staff with false reassurance. Older, riskier versions of the product remain in circulation, requiring urgent action.
Responded
James Forryan
Concerns: Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such harmful online content.
Responded
Jack Ritchie
Concerns: Systemic failures in gambling regulation, inadequate warnings and information, insufficient treatment for addiction, and a lack of training for medical professionals contributed to a preventable death.
Overdue
Chloe English
Concerns: Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump within minutes of arrival, indicating current safeguards are insufficient.
Responded
Joseph Dent
Concerns: A bridge's design provides easy access to parapets and lacks effective suicide prevention measures like adequate barriers, monitoring, or detection for at-risk individuals.
Responded
Ann Geraghty
Concerns: Cardiac monitors' alarms self-terminate upon rhythm correction, failing to alert staff to serious, self-resolving events like ventricular standstill, and the manufacturer has not provided a solution.
Responded
Wayne Boughen
Concerns: HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for self-harm in an ordinary cell.
Responded
Heather Page
Concerns: Numerous pedestrian crossings require walking on tracks, contributing to a high fatality rate on a specific section, exacerbated by local authority opposition to track rationalisation efforts.
Responded
Lucy Colgate
Concerns: The danger of inward-opening doors in confined spaces for epilepsy sufferers is not widely recognized, whereas an outward-opening door could have prevented the death.
Responded
Michael Dobson
Concerns: Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. This creates a potential for prisoners to self-harm.
Responded
Tina Murray
Concerns: A care home failed to prevent a vulnerable resident from accessing plastic bags, despite staff awareness of self-harm risk, indicating a systemic failure in removing means of harm.
Responded
William Israel
Concerns: Public misunderstanding of live rail dangers is exacerbated by inadequate, outdated, and poorly placed warning signage, alongside inconsistent station security measures when unstaffed.
Responded
Wesley Rowlands
Concerns: Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.
Responded
Luiz Anjos
Concerns: Easy access over the footbridge parapet and sides at the location remains a significant safety concern, despite other identified issues having been remedied.
Responded
Annette Lewis
Concerns: There is a lack of protective fencing and crucial Samaritan signage at Tennyson Down cliff, despite a known risk of individuals in mental distress attempting suicide at this and similar sites.
Overdue
Miles Naylor
Concerns: Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward doors, specifically regarding access to hinge pins, at a mental health facility.
Responded
Muhammed Wajid
Concerns: Scammonden Bridge is a notorious suicide location, and previous recommendations to Kirklees Council and Highways England for suicide prevention measures may not have been fully implemented.
Overdue
Joanna Orpin
Concerns: Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress there monthly and repeated recommendations for their reinstallation being ignored.
Responded
Jessica Duckworth
Concerns: The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an ongoing risk of future deaths from falls.
Overdue
Jane Livingston
Concerns: Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.
Responded
Natasha Abrahart
Concerns: NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not followed by the mental health trust or GP.
Responded
Benjamin Murray
Concerns: Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student deaths indicate systemic gaps in student support.
Responded
Alfonso Sinclair
Concerns: A distressed individual's overtly odd and illegal behaviour at a tube station went unnoticed and unchallenged by staff, despite CCTV, due to a lack of system to alert odd behaviour or alarms at platform end barriers.
Responded
Bradley Trevarthen
Concerns: School friends were aware of the deceased's increasing suicidal ideation and methods explored online but failed to report it to adults, partly due to fear of device bans.
Responded
Brian Goodman
Concerns: A known ligature point in the patient's room was not addressed, and similar hazardous door closing mechanisms remain in use in other properties, despite a history of suicide attempts by hanging.
Responded
Emma Butler
Concerns: Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created self-harm risks, compounded by variable hourly observation practices.
Responded
Bertram Crawford
Concerns: A dangerous cluster of student deaths from the bridge, including three this year and four in two years, raises serious concerns about safety at this historical site.
Responded
Ben Walmsley
Concerns: The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking missed safeguarding opportunities.
Overdue
Jordan Sheils
Concerns: The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to deter tragedies being under consideration.
Responded
James McLaren
Concerns: Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of people sheltering inside and potentially becoming trapped.
Responded
Stephen Lawson
Concerns: The car park has dangerously easy access to external walls, allowing use of crash barriers as steps to jump, compounded by insufficient Samaritan signs.
Responded
Karen Wiggins
Concerns: Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent individuals from jumping.
Overdue
George Dyson
Concerns: The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following previous similar incidents.
Responded
Michael Berry
Concerns: A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw that could be easily avoided.
Overdue
Mwitumwa Ngenda
Concerns: Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future suicide attempts.
Overdue
Natasha Ford
Concerns: A previous self-harm incident involving a plastic bag led to temporary restrictions, but these were later removed due to a policy change prioritizing reduced restrictive practices.
Responded
Sam Molyneux
Concerns: Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not placed on an appropriate monitoring plan (ACCT).
Responded
Daniel Campbell
Concerns: Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, increasing the risk of death.
Responded
Thomas Coyne
Concerns: Inadequate CCTV coverage at the station and the absence of physical barriers at platform ends allowed unmonitored access to the tracks, posing a serious safety risk.
Overdue
Simon Charles
Concerns: Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact numbers and planting natural barriers along the cliff edge.
Responded
Frazer Livesey
Concerns: Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.
Responded
Helen Millard
Concerns: The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk and should be categorized as "red" for urgent elimination.
Overdue
Charles Pitcher
Concerns: The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate compared to other significant bridges.
Overdue
Glen Jordan
Concerns: Staff failed to remove a holdall bag with an attached strap, a ligature risk, from a patient's room, highlighting a lapse in safety checks.
Overdue
Susan Hamlett
Responded
Miles Abel
Responded
Archie Hall
Concerns: The Orwell Bridge has easily accessible walkways with a low concrete wall offering inadequate fall prevention. There are no physical deterrents or handholds, posing a significant risk of falls that has led to multiple deaths.
Responded
Darren Mindham
Concerns: Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could reduce suicide rates.
Responded
Mihangel ap Dafydd
Concerns: Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been completed.
Responded
Samantha MacDonald
Concerns: A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for robust risk assessments and more secure devices in such buildings.
Responded
Kyle Hull
Concerns: Inadequate CCTV coverage and monitoring may fail to detect risks of self-harm, property damage, or identify dangerous areas like fragile roofs, hindering early intervention.
Responded
Adam Connelly
Concerns: The low height of walls accessing a railway footbridge allowed easy public access to tracks, creating a significant risk of future fatalities that Network Rail needs to address.
Overdue
Alasdair Penny
Concerns: Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent spontaneous jumps from the bridge.
Responded
Lynn Gormly
Concerns: The Queensgate Car Parks' low walls are ineffective in preventing suicides and pose a risk to pedestrians. Design improvements like higher barriers, as seen in modern car parks, are needed to deter jumps.
Overdue
Ahmad Khan
Concerns: Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for individuals, including children.
Overdue
Carl Morris
Responded