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
Source spread
Where this theme appears
Design flaws enabling suicide has been flagged across 10 independent accountability sources:
116 PFD reports
3 committee recs
7 PPO recs
5 IOPC recs
1 IMB report
13 IMB recs
1 Scottish FAI
4 detention investigation recs
3 PHSO decisions
2 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 (116) — showing 50 strongest matches
Joanna Hillard
Concerns: 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.
Responded
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
Muniza Mehrban
Concerns: 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.
Overdue
Martin Leslie Brown
Concerns: 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.
Response (British Board of Agrement): The BBA has revised paragraph 3.1 of Certificate 06/H120, removing the reference to rural roads, and will reissue the certificate with the revised wording by December 2013.
Overdue
Peter Patrick Adrian Barnes
Concerns: 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patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.
Overdue
Lisa Jane Clayton
Concerns: 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.
Overdue
Luke Jacob Goodwin
Concerns: 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.
Overdue
Carl Morris
Response (PADI Europe): PADI will include an additional statement in the 'Learning Agreement' to further enforce the issue of medical illness to both the Instructor and student diver with regards to doctor's approval …
Responded
Ahmad Khan
Concerns: Easy access to a low perimeter wall, facilitated by a nearby barrier, creates a dangerous fall hazard for individuals, including children.
Response (Sheffield City Council): Sheffield City Council found no breach of planning control or building regulations at the car park. However, they have suggested alterations to Q Park Ltd to prevent similar incidents and …
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.
Response (Invesco): The organisation has installed over 200 automated cameras, including PTZ cameras with motion sensors on the top level of the car park. They have also upgraded the security control room, …
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.
Response (Sussex Police): Sussex Police highlights that the East Grinstead Neighbourhood Joint Action Group implemented 6 Samaritans signs on the bridge, and the Street Pastors and police continue to patrol the bridge.
Response (West Sussex County Council): West Sussex County Council will investigate the technical feasibility of increasing the height of the parapet on College Lane Bridge and intends to undertake alterations within this financial year if …
Responded
Tommy Faisali
Concerns: 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.
Overdue
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.
Response (Network Rail): Network Rail will install shorter palisade pales and raise the height of the stepped parapet with engineering brick. The works are expected to be completed by the end of October …
Overdue
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.
Response (response): The auction mart company plans to install CCTV with night vision and movement detection, linked to mobile phones of company management, but is currently seeking financing; a final decision is …
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.
Response (Campus Living Villages): CLV has reviewed its risk assessment and measures in place to protect student safety relating to opening windows, provided training to CLV staff on mental health, put in place key …
Response (Department fro Business Innovation and Skills): The Department proposes to write to UUK and GuildHE by early July to ask them to ensure that HEIs are doing all they can to ensure the safety of students …
Responded
Thomas Harris
Overdue
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.
Response (Welsh Government): The Welsh Government will issue an addendum to Health Building Note 35, highlighting the requirement for ligature-free design in both new and existing acute mental health unit facilities. They have …
Response: The Health Board will repeat ligature audits across mental health and learning disability in-patient units and submit prioritised recommendations for consideration by the 2016/17 Capital programme regarding replacement, repair or …
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.
Response (Department of Health): The Department of Health states that the classification of Pentobarbital is a matter for the Advisory Council on the Misuse of Drugs (ACMD), not the Department of Health, and advises …
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.
Response (National Highways): Highways England commissioned a review of preventative measures for suicides on the Orwell Bridge and are reviewing the effectiveness of the telephones located at either end of the bridge, and …
Responded
Miles Abel
Concerns: 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.
Responded
Susan Hamlett
Concerns: 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.
Responded
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.
Response (Glen Jordan): The Trust will include a statement in its search policy to enhance the definition of "belongings" to include items used to keep or transport belongings (e.g., bags). They have also …
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
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.
Response (National Trust): The National Trust is investigating options for signage at Hells Mouth with the Cornwall Samaritans and anticipates installing signs on their land before Easter. They do not plan to plant …
Responded
Frazer Livesey
Concerns: Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.
Response (IMPACT): Impact will survey all residential properties with staff on site by the end of March 2017 to identify window styles and sizes, and will commence removing fixed restrictors and replacing …
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
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.
Response (National Rail): Network Rail has included fencing upgrades in their 2018 renewals plan for the section of track where the incident occurred. Further works will be planned to improve the robustness of …
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
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).
Response (HM Prison Probation Service): HM Prison & Probation Service will revise the ACCT form and PSI 64/2011 Safer Custody policy to direct staff to consider emergency access, including the presence of an anti-barricade door, …
Responded
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.
Response (CAS): CAS Behavioural Health has introduced a blanket policy restricting the use of plastic bags in all their hospitals, following a review of their Reducing Restrictive Practice policy after the incident.
Overdue
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
George Dyson
Concerns: The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following previous similar incidents.
Response (Calderdale Council): Calderdale Council completed a feasibility study to identify suicide prevention options for the North Bridge, but the parapet option was rejected due to structural concerns. They plan to install anti-climb …
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
Stephen Lawson
Concerns: 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.
Response (Bedford Borough Council): The council is assessing steel barriers and caging in car parks, to be completed within three months. It is also risk assessing car parks, reviewing emergency procedures and providing staff …
Responded
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.
Response (Calderdale Council): Calderdale Council submitted planning and listed building consent applications for anti-climb mesh and steeple coping on North Bridge, with works expected to be complete by May 2019. CCTV has been …
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.
Response (Health and Safety Executive): The HSE clarifies the meaning of 'secure' in the WISH WASTE 25 guidance, stating that it requires a risk assessment to determine appropriate measures to prevent bin access, but does …
Response (ESA): The ESA has been raising awareness of the dangers of people in waste containers since 2009 through various means, including the press, a cross-sector steering group, a safety week, a …
Response (CIWM): CIWM has produced imagery promoting the use of WASTE25 guidance and encourages waste producers and waste collectors to check the bins while filling and unloading, which has been shared on …
Response (LGA): The LGA will include an item on the risk of death and injury in large bins in relevant LGA bulletins and updates to councils to raise awareness at a national …
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
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.
Response (Transport for London): London Underground will review its training for front-line station staff on spotting unusual suicidal behaviour to include customer behaviours at the gateline and ticket hall, with changes implemented by late …
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.
Response (Oxford Health NHS Trust): The Trust has already implemented measures like case discussion groups and reflective practice groups run by psychotherapists. They also have MDT handovers every morning and provide more access to psychological …
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.
Response (One Housing): One Housing will work with their property services to explore alternative fire door closures in high-risk schemes and implement ASIST suicide intervention skills training for staff.
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.
Response (University of Bristol): The University has shared its mental health and wellbeing strategies with sector colleagues and provided support to other institutions where student deaths have occurred. From September 2019 the SPRG will …
Response (UCAS): UCAS is redesigning the question about disabilities, special needs, or mental health issues on the application form, with a roundtable discussion planned for July and implementation in 2020 for the …
Response (Department for Education): The department will work with Universities UK to remind HE providers of the recommendation to carry out serious incident reviews. Public Health England is happy to work alongside partners to …
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.
Response (Department for Digital Culture Media Sport): The UK government published its Online Harms White Paper which sets out plans for legislation to make the UK the safest place in the world to be online, establishing a …
Responded
Jane Livingston
Concerns: Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.
Response (Swansea Bay University Health Board): • A detailed review of the information in the report has been undertaken by the Quality and Safety team for the Mental Health Swansea locality at Swansea Bay University Health …
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
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.
Response (the Isle of Wight National Trust): The National Trust is engaging with Public Health, the Suicide Prevention & Intervention team, and the IOW Samaritans to discuss suicide prevention on their land. They will conduct an internal …
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.
Response (the Isle of Wight National Trust): The Isle of Wight National Trust is engaging with Public Health, the Suicide Prevention & Intervention team, IOW Samaritans, and the Police to review and improve suicide prevention measures on …
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.
Response (Bradford District NHS Trust): Bradford District Care NHS Foundation Trust has reviewed its policy for Blanket Restrictions and implemented daily safety checks in inpatient areas. Work has begun to install high specification full door …
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.
Response (National Highways): Highways England is planning to deliver a bridgeworks scheme including a new pedestrian barrier and vehicle barrier at Scammonden Bridge, pending funding. It will also deliver an alert/help telephone system …
Overdue
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.
Response (AWP): The trust issued a "Red Top Alert" to medical personnel regarding NICE guidelines for prescribing anti-depressants (CG90), including communication with primary care and documentation. It will also be discussed at …
Response (University of Bristol): The University practice now books appointments to review patients starting SSRIs within one week, and clinicians ideally book the next appointment before the patient leaves, with a message to alert …
Response (the Department for Health and Social Care): The Department acknowledges the concerns and highlights existing guidelines and initiatives, including updated NICE guidelines on antidepressant prescription and various government-funded projects to improve student mental health support and reduce …
Responded
Committee Recommendations (3)
#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
#26 — Include provisions in Bill requiring enhanced tier premises to consider security in building design.
Recommendation: The Government should include provision in the Bill to require new publicly accessible buildings, which would fall within the category of enhanced tier premises, to consider security in the design of the building.
No Published Response
#25 — Publicly accessible new builds should incorporate security considerations into their design.
Recommendation: We agree that the Draft Terrorism Bill could be strengthened by making it a requirement for publicly accessible new builds to consider security in the design of the building.
No Published Response
PPO Death in Custody Recommendations (7)
Governors of prisons with MCBS units
Governors should ensure that safe and appropriate practices are always followed in the supply of razors to prisoners in MCBS units.
The Governor
The Governor should ensure that officers check the condition of door hinge securing bolts when making their daily cell fabric checks.
The Director and Head of Healthcare
remove or restrict prisoners’ access to items such as razors, when they present a risk of harm by cutting;
The Governor of HMP Berwyn
The Governor should ensure that: prisoners are not placed in cells that do not meet the minimum requirements, in accordance with PSI 17/2012.
The Governor of HMP Berwyn
The Governor should ensure that: cell conditions are properly checked and documented;
The Head of Custodial Contracts, in conjunction with the MoJ …
The Head of Custodial Contracts, in conjunction with the MoJ Prison Infrastructure Team and MoJ Property Directorate Technical Standards, should review: • Whether any changes to cell door design are needed. • The frequency of cell door maintenance checks needed …
The Governor
The Governor should ensure that: cell conditions are properly checked and documented, especially in circumstances where prisoners have alerted staff to faults that may require repair; repairs are promptly reported and fully documented and that there is a clear audit …
IOPC Learning Recommendations (5)
Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, …
The IOPC recommends that the National Police Chiefs Council (NPCC) shares the learning from this IOPC investigation with all force custody leads, asking them to take steps to ensure metal rebate strips (also known as rectification strips) fitted to cell …
Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, …
The IOPC recommends that the Ministry of Justice (MOJ) amends the Police Custody Suites Design Guide to reflect that any sharp edges on metal rebate strips (also known as rectification strips) fitted to custody cell doors should be removed during …
Recommendation - Merseyside Police, November 2019
The IOPC recommends that what the force refers to as ‘observation rooms’ are brought up to the same health & safety standards as cells, wherever possible. This recommendation comes as a result of a DSI investigation carried out by Merseyside …
Recommendation - Hampshire Constabulary, November 2020
The IOPC recommends that Hampshire Constabulary should ensure that all custody staff are made aware of the risk of leaving detainees with unsupervised access to cutlery, as such items can be manipulated to cause serious injury to the detainee or …
National recommendation - National Police Chiefs Council, November 2020
The IOPC recommends that the NPCC ensures that custody staff at all police forces are made aware of the risk of leaving detainees with unsupervised access to cutlery, as such items can be manipulated to cause serious injury to the …
IMB Recommendations (13)
Dungavel House IRC (2020)
The board repeats its recommendation from its 2019 report that consideration should be given to installing robust preventative measures to ensure that roofs are not accessible to detainees. This would help towards the safety of detainees and staff.
Governor / Director
Leeds (2022)
In respect of self-inflicted deaths in custody, is there more that could be done to reduce the likelihood of such incidents happening again?
Governor / Director
Erlestoke (2023)
What immediate actions will be taken to address the inadequate and potentially dangerously deficient constant watch cell?
Governor / Director
Leeds (2024)
Is the Minister satisfied that all necessary resources are being delivered to significantly reduce self-inflicted deaths?
Other
Feltham (2024)
Will the YCS look at changing the policy where any boy who removes parts from his laptop, in order to make a weapon, is given a replacement after only 28 days? Will the YCS also look at the design of laptops so they do not include removable strips of rigid metal or other removable parts that can be sharpened into …
HMPPS
Foston Hall (2020)
Although the care and separation unit (CSU) is currently undergoing renovation, the underlying problems with its physical size and layout mean it is likely to continue to have serious limitations which will impact on the experience of women held there (see paragraph 5.2.1).
HMPPS
Exeter (2020)
Will the Governor prioritise the fitting of bedrails to top bunk beds in all cells to reduce the risks of injury and litigation? (See paragraph 5.1.1).
Governor / Director
Dungavel House IRC (2022)
As has been mentioned in previous reports, consideration should be given to installing robust preventative measures to ensure that roofs are not accessible to detained persons. This would help towards the safety of residents and staff.
Governor / Director
Five Wells (2023)
What plans are there to ensure that design omissions in this new design prison are addressed in future builds?
Ministry of Justice
Erlestoke (2023)
What actions will be taken to improve first night accommodation?
Governor / Director
Eastwood Park (2024)
Finalise proposals to replace residential unit 7, ensuring the replacement building is subject to a feasibility study/whole-life costing and provides a permanent building with a gender-specific, trauma-informed design in accordance with the Female Offender Strategy Delivery Plan 2022-2025.
HMPPS
Five Wells (2025)
What improvements are planned to remedy faults in the design of new prisons, such as poor ventilation, lack of facilities, poor physical security, which have been identified in IMB reports?
Ministry of Justice
Feltham (2025)
Change the policy where a boy who removes parts from his laptop, in order to make a weapon, is given a replacement after only 28 days; and look at the design of laptops so they do not include removable strips of rigid metal or other removable parts that can be sharpened into weapons.
HMPPS
Detention Investigations (4)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 18
IND pulls together the lessons on design from the Yarl’s Wood experience (size, long corridors, siting of the control room, construction materials etc) and ensures that they underpin the production of any future footprints or alternative designs submitted by contractors.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 11
IND reviews the location of command suites in existing and future removal centres.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 10
the use of remotely-operated locks for zone gates be considered in all future removal centre designs, taking account of any fire safety requirements.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 24
I recommend that GSL urgently establishes an area within the main compound for the care of those at risk of suicide and self-harm.
Immigration Detention
PHSO Casework Decisions (3)
P-001550 — Essex Partnership University NHS Foundation Trust
Mr D complains the Trust failed to keep his son safe from self-injury while under its care.
NHS in England
Sep 2022
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-004700 — Independent Case Examiner
Mr E complains DWP and ICE did not recommend sufficient financial remedy or service improvements after the DWP failed to follow the correct procedure in March 2023, when he said on the phone he was going to take his own life.
UK Government
Jan 2026
LGO / SPSO Decisions (2)
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
NIPSO-17293 — South Eastern Health and Social Care Trust
Our investigation found that the South Eastern Trust failed to properly assess the risks faced by a patient, and could have done more to help him before his death.
NIPSO (NI Public Service…
Health & Social Care
May 2021