Design flaws enabling suicide
Environmental design flaws (e.g., car park barriers) that allow surprisingly easy access to means of suicide, coupled with poor visibility of support signage.
155 items
10 sources
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
81match
Lynn Gormly
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.
Matched on
terms: design, suicide
PFD report
75match
Stephen Lawson
The car park has a history of suicides and easy access to the external barrier wall. There are also very few visible 'Samaritans' signs for pedestrians entering the car park.
Matched on
terms: suicide
PFD report
73match
Michael Berry
A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw that could be easily avoided.
Matched on
terms: design, flaw
PFD report
69match
Lisa Jane Clayton
Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history of similar incidents, highlight serious failures in suicide prevention measures.
Matched on
terms: suicide
PFD report
69match
Mwitumwa Ngenda
Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future suicide attempts.
Matched on
terms: design, suicide
PFD report
65match
Muniza Mehrban
This marks the fourth death in three years at the multi-storey car park due to individuals jumping, indicating an urgent need for suicide prevention measures at the location.
Matched on
terms: suicide
PFD report
65match
Alasdair Penny
Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent spontaneous jumps from the bridge.
Matched on
terms: suicide
PFD report
65match
Charles Pitcher
The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate compared to other significant bridges.
Matched on
terms: suicide
PFD report
65match
Simon Charles
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.
Matched on
terms: suicide
Scottish FAI
64match
Jack McKenzie
1. SPS should take steps to make standard cells at Polmont safer by identifying and removing, as far as reasonably practicable, ligature anchor points present in such cells. In that regard it should: a. Develop a standardised toolkit for auditing cells for the presence of ligature anchor points; b. Use the foregoing toolkit to conduct an audit of...
Matched on
terms: design, suicide
PFD report
61match
Annette Lewis
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.
Matched on
terms: suicide
PFD report
61match
Miles Naylor
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.
Matched on
terms: design
PFD report
57match
Luke Jacob Goodwin
The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, facilitates self-harm and raises serious safety concerns.
Matched on
terms: suicide
PFD report
57match
Ahmad Khan
Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for individuals, including children.
Matched on
classifier match
PFD report
57match
Adam Connelly
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.
Matched on
classifier match
PFD report
57match
Thomas Harris
Date of report: 28 April 2016 Ref: 2016 – 0182 Deceased name: Thomas Harris Coroners name: Rachel Redman Coroners Area: Kent Central and South East Category: Product related deaths; Suicide (from 2015) This report is being sent to: The Right Honourable Theresa May MP
Matched on
terms: suicide
PFD report
57match
Darren Mindham
Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could reduce suicide rates.
Matched on
terms: suicide
PFD report
57match
Helen Millard
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.
Matched on
terms: flaw
PFD report
57match
Thomas Coyne
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.
Matched on
classifier match
PFD report
57match
Karen Wiggins
Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent individuals from jumping.
Matched on
classifier match
PFD report
57match
Brian Goodman
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.
Matched on
terms: suicide
PFD report
57match
Jessica Duckworth
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.
Matched on
terms: suicide
PFD report
57match
Muhammed Wajid
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.
Matched on
terms: suicide
PFD report
57match
Natasha Abrahart
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.
Matched on
terms: suicide
Committee recommendation
51match
#36 - Eighth Report - Children and young people’s mental health
We are deeply concerned about the increasing numbers of children and young people who experience self-harm and suicide and the quality of care they are able to access. Much more needs to be done to tackle suicide and self-harm amongst children and young people. In particular, given the link between self-harm in children and young people and later...
Matched on
terms: suicide
PFD report
49match
John Walker
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.
Matched on
classifier match
PFD report
49match
Peter Patrick Adrian Barnes
Hospital systems were inadequate for communicating observed patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.
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classifier match
PFD report
49match
Carl Morris
Date of report: 3 March 2014 Ref: 2014-0092 Deceased name: Carl Morris Coroners name: Robert Chapman Coroners Area: Cumbria (North & West) Category: Other related deaths This report is being sent to: The Professional Association of Diving Instructors
Matched on
classifier match
PFD report
49match
Tommy Faisali
Psychiatric GP referrals are handled by unqualified staff, and risk assessments are not consistently completed or documented, leading to uncommunicated patient risks and a lack of care continuity within mental health teams.
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classifier match
PFD report
49match
Samantha MacDonald
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.
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classifier match
PFD report
49match
Mihangel ap Dafydd
Windows in Morlais Ward service user areas are not ligature-free, posing a safety risk, and planned remedial work has not yet been completed.
Matched on
classifier match
PFD report
49match
Archie Hall
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.
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classifier match
PFD report
49match
Susan Hamlett
The British Transport investigation revealed that the deceased gained access to the railway line through an access gate that provided little deterrence, and the area around the gate should be replaced with a more significant fence as a matter of urgency.
Matched on
classifier match
PFD report
49match
Daniel Campbell
Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, increasing the risk of death.
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classifier match
PFD report
49match
Sam Molyneux
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).
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classifier match
PFD report
49match
Ben Walmsley
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.
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classifier match
PFD report
49match
Alfonso Sinclair
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.
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classifier match
PFD report
49match
Benjamin Murray
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.
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classifier match
PFD report
49match
Jane Livingston
Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.
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classifier match
PFD report
45match
Joanna Hillard
The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can impair a person's decision-making ability.
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classifier match
PFD report
45match
Martin Leslie Brown
The certificate for a road resurfacing product (Milepave) contained ambiguous wording regarding speed limit applicability and road types, risking its inappropriate use on unsuitable roads.
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classifier match
PFD report
45match
Kyle Hull
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.
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classifier match
PFD report
45match
Miles Abel
The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to confirm faxes were sent, and follow-up phone calls were not always made.
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classifier match
PFD report
45match
Glen Jordan
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.
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classifier match
PFD report
45match
Frazer Livesey
Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.
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classifier match
PFD report
45match
Natasha Ford
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.
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classifier match
PFD report
45match
George Dyson
The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following previous similar incidents.
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classifier match
PFD report
45match
Jordan Sheils
The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to deter tragedies being under consideration.
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classifier match
PFD report
45match
James McLaren
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.
Matched on
classifier match
PFD report
45match
Emma Butler
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.
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classifier match