Ligature points
92 items
1 source
Accessible ligature points in prison cells and mental health wards, posing a risk of self-harm and suicide.
Cross-Source Insight
Ligature points has been flagged across 1 independent accountability source:
92 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (92)
Mujahid Adam
Concerns: Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used for vulnerable prisoners, allowed access to ligature material which was missed during daily checks.
Pending
Brody O’Brien
Concerns: An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.
Pending
Stuart Berry
Concerns: Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, contributed to the death.
Response: HMPPS has developed interim upskilling sessions on self-harm and suicide risks for prison officers, and the Safety Support Skills training module is under national review. Four ligature-resistant cells were completed …
Response: HCRG is strengthening interfaces, retraining reception nurses, and has introduced a dedicated Early Days in Custody (EDiC) Nurse role to lead an action plan for improving care standards. They have …
Overdue
Samuel Stewart
Concerns: No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for support and policy enforcement.
Response: HM Prison and Probation Service confirms that following a positive drug test on an ISFL wing, prison staff are required to refer the prisoner to the Forward Trust, who then …
Response: Practice Plus Group clarifies that healthcare was not informed of the positive drug test, which prevented them from taking action. They then detail their existing process for managing positive drug …
Overdue
Aaron Taylor
Concerns: Prison staff failed to open an ACCT process after a self-harm incident and lacked ACCT training. Keyworker sessions for vulnerable prisoners were not consistently conducted, with staff unaware of required frequency.
Response: HMPPS ensures all new officers receive training on suicide and self-harm prevention, including ACCT processes. HMP Garth has issued staff notices and a Governor's order in October and November 2025 …
Responded
Matthew Singh Prevention of future deaths report
Concerns: High availability and use of illicit psychoactive substances persist at HMP Berwyn, posing significant risks to prisoner health and contributing to future deaths.
Response: HMPPS has implemented physical security enhancements, including anti-drone measures and window improvements, and invested over £40 million this financial year. They have also established Incentivised Substance Free Living Units in …
Overdue
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
Richard Hunt
Concerns: Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened by the absence of central oversight for wing office fault reporting.
Overdue
Steven Hart
Concerns: Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not being carried out to standard, contributing to the death.
Overdue
Hilary Chapman
Concerns: The updated section 17 leave policy does not reflect the new processes for discussing and prescribing leave, creating a gap between practice and documented policy, with no review expected until 2026.
Pending
Brian Burrows
Concerns: Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells and ACCT checks, risking inadequate responses.
Overdue
Charles Stonley
Concerns: Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their risk of self-harm and death.
Overdue
Azroy Dawes-Clarke
Concerns: The anti-ligature bedding failed, allowing ligature creation. Prison officers had inconsistent training on ACCT processes, first aid, and the Mental Capacity Act, leading to unclear responses during medical emergencies and conveyance.
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
Henok Gebrsslasie
Concerns: Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as a solution, these crucial safety measures have not been implemented in a psychiatric unit for over 42 months.
Responded
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
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
Yemisi Cielto-Opaleye
Concerns: Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post Injection Syndrome.
Responded
Brandon Johnson
Concerns: Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training to perform robust, positive-response checks in cells.
Responded
Yasmin Adams
Concerns: Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on personality disorder/learning disability, and vulnerable prisoners were held in unsuitable cells.
Responded
Daniel Beckford
Concerns: Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.
Overdue
Yuri Hatton
Concerns: Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising unconsciousness had not been implemented.
Overdue
Ash Bannister
Concerns: Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to prolonged unsupervised periods.
Responded
Cariss Stone
Concerns: Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward with known self-harm risks, posing significant safety concerns.
Responded
Narjit Gill
Concerns: Mental health practitioners failed to remove a visible ligature from Mr Gill's home despite his expressed suicidal ideation.
Responded
Georgia Dehaney-Perkins
Concerns: A patient with a self-harm history was placed in a room with a faulty anti-ligature mechanism without risk assessment, and medication risks with alcohol were not communicated. Inconsistent recording of alcohol consumption and ignored family concerns compromised patient safety.
Responded
Wyndham Thomas
Concerns: The absence of in-cell ligature point risk assessments, ligature point maps, and mandatory "Safer Cells" in prisons creates critical missed opportunities to prevent self-harm by ligation.
Responded
Manoel Santos
Concerns: Delays in notifying foreign national offenders of immigration detention and inadequate access to legal advice are compounded by poor inter-agency communication and a lack of specialist prison staff for immigration matters.
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
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
Jason Williams
Concerns: Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor prison staff record-keeping due to insufficient refresher training, compromised care.
Responded
Susan Perry
Concerns: Medication cupboard keys were left in easily accessible, unlocked locations nearby, compromising medication security and creating a significant risk of service users accessing and misusing drugs.
Responded
John White
Concerns: The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, bespoke training for officers responding to mental health crisis incidents is not widely available.
Overdue
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
Sergio Dunkley
Concerns: Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance for anti-ligature fixtures, posing a significant safety risk.
Overdue
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
Amanda Gibbens
Concerns: Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to remove self-harm items, despite prior warnings.
Overdue
Carl Walters
Concerns: The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and preventative measures overlooked.
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
Corin Bonaparte
Concerns: HMP Dartmoor failed to open a mandatory ACCT for a self-harming prisoner, indicating inadequate training, and an ambulance was dangerously delayed at the prison gate during an emergency.
Responded
Rohan Singh
Concerns: A mental health ward failed to prevent a patient from retaining dangerous contraband despite searches. Staff made false observation records due to a culture of impunity, and critical monitoring protocols after rapid tranquilisation were not followed.
Responded
Azra Hussain
Concerns: Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.
Responded
Christopher Swain
Concerns: Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a failure to provide staff escorts for sectioned patients being transferred.
Responded
Lee Davies
Concerns: The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, compounded by a lack of observation and CCTV in the garden.
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
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
Gareth Warburton
Concerns: Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.
Overdue
Luke Jones
Concerns: Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of future deaths.
Overdue
Jane Livingston
Concerns: Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.
Responded
Shannon Quinn
Concerns: Multiple failures in multi-agency communication, inadequate staff training, and poor risk management regarding ligature use, patient observations, and resuscitation significantly compromised care for a patient with complex mental health needs.
Overdue
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
Bethany Tenquist
Concerns: Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights critical deficiencies in self-harm prevention protocols.
Responded
Robert McLoughlin
Concerns: The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.
Overdue
Deidre Harvey
Concerns: External consultants had insufficient input into mental health patients' physical care, bureaucratic processes delayed rectifying ligature points, and the system for managing dangerous patient items was ineffective.
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
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
Vilhelmas Borkertas
Concerns: A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting profiles.
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).
Responded
Liam Thomas
Concerns: The patient had access to restricted plastic bags, possibly due to inadequate environmental safety checks on the ward. Additionally, communication with the supportive family regarding the patient's elevated risk was insufficient.
Responded
Francesca Whyatt
Concerns: Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and the failure to automatically treat ligature incidents as Serious Untoward Incidents (SUIs), despite the rapid risk of death.
Overdue
Sean Plumstead
Concerns: Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a risk of future deaths due to poor record-keeping.
Responded
Daniel Dunkley
Concerns: The provided text outlines the circumstances of the deceased being found hanging in his cell and his subsequent death, but details no specific systemic failures or coroner's concerns.
Overdue
Wendy Telfer
Concerns: Inadequate training for physical healthcare staff on mental health needs and Mental Health Act application is a concern. A severe national shortage of psychiatric beds also caused critical delays in patient transfer, contributing to preventable deaths.
Responded
Christopher Brennan
Concerns: The adolescent psychiatric unit lacked specific policies for managing self-harm risks from items, and emergency equipment did not include laryngoscopes, despite their prior successful use in airway obstructions.
Overdue
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
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
Leslie Matthews
Overdue
Samuel Blair
Concerns: Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 information, a nurse failing to acknowledge radio calls, and not immediately bringing a defibrillator.
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
Diane Knight
Concerns: The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, requiring alternative patient privacy methods.
Responded
Craig Chappell
Concerns: Inadequate information sharing and a lack of formal mechanisms for communicating family concerns hindered support. Prison staff also lacked sufficient guidance on supporting potential abuse victims, relying inappropriately on presentation.
Pending
Stuart Baumber
Concerns: Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks a structured national pro forma, leading to inconsistent risk assessments and over-reliance on current prisoner demeanour.
Overdue
Isobel Griffin and Jane Clark
Concerns: Critical failures in risk assessment, handover, and documentation were evident, with staff not reading notes, inadequate patient monitoring, and non-ligature-proof ward doors contributing to self-harm risks.
Overdue
Dale Proverbs
Concerns: Observation policies for secluded mental health patients were found to be inadequate under the current Code of Practice, which could lead to future fatalities. Higher observation standards previously in place would likely have prevented the death.
Responded
Cherylin Norrell-Goldsmith
Concerns: Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not being readily available to prison staff on non-medical records. Data retention issues also exist.
Overdue
Peter Farebrother
Concerns: Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an unsafe environment. The effectiveness of the "sloping door" design against hanging was also questioned.
Overdue
Lucy Moffatt
Concerns: Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical Department of Health alert.
Responded
James Boylan
Concerns: Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental health unit.
Overdue
Michaela Christoforou
Concerns: All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
Responded
Mark Bartholomew
Concerns: Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not readily available and observation records lacked detail, hindering timely intervention and oversight.
Overdue
Andrew Hall
Concerns: Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Overdue
Christopher Shapley
Concerns: Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.
Overdue
Lee MacPherson
Concerns: Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
Overdue
Carl Morris
Responded
Lisa Inkin
Concerns: A severe shortage of local specialist psychiatric beds, critical communication failures between services, and inadequate staff training led to delayed escalation of suicidal intent and insufficient supervision for eating disorder patients.
Overdue
Stuart Aaron Collins
Concerns: Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was left accessible to the patient.
Response: The Trust disputes the concerns, stating Mr Collins was triaged on arrival and observations were taken according to policy, which did not trigger more frequent monitoring. They also reminded staff …
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
Mina Topley-Bird
Concerns: Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for ligature points were unconfirmed, and risk assessment processes remained incomplete.
Responded
Shona Campbell
Concerns: Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had access to ligatures, and risk assessments were not properly updated.
Pending