Ligature points

Accessible ligature points in prison cells and mental health wards, posing a risk of self-harm and suicide.

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Jun 2014 · Cumbria (South & East)

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.

Matched on exact phrase terms: ligature, point

Cherylin Norrell-Goldsmith

Oct 2014 · Surrey

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.

Matched on exact phrase terms: ligature, point

Aug 2018 · South Wales Central

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.

Matched on exact phrase terms: ligature, point

Wesley Rowlands

Oct 2020 · Lancashire and Blackburn with Darwen

Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.

Matched on exact phrase terms: ligature, point

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 exact phrase terms: ligature, point

Isobel Griffin and Jane Clark

Feb 2015 · Northamptonshire

For Jane Clark, challenging events were not handed over, the nurse in charge did not read the notes before granting leave, risk assessment was ill-informed, not discussed, and poorly documented; for Isobel Griffin, there were issues with key worker allocation, updating risk assessments, clinician reviews, medication management, and ligature points.

Matched on exact phrase terms: ligature, point

Oct 2016 · East Riding and Kingston-upon-Hull

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 exact phrase terms: ligature, point

Not all ligature points had been considered within the environment.

Matched on exact phrase terms: ligature, point

May 2018 · Bedfordshire & Luton

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: ligature, point

Apr 2019 · London Inner (North)

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: ligature, point

IOPC learning recommendation

Recommendation - Sussex Police, May 2021

The IOPC recommends that Sussex should: a) inform custody officers and staff of the risk of allowing detainees to keep face masks in cells. Such items can be modified to form a ligature which can be used to cause injury to a detainee intent on causing harm to themselves. and b) inform custody officers and staff that the...

Matched on terms: ligature

Dr Sara Lilian Macrae

(i) When staff in a secure mental health ward are presented with evidence that a patient has vocalised suicidal ideation and demonstrated means to complete suicide by presentation of a ligature, urgent action to search that patient's room and person for any other potential ligatures ought to be taken. In addition, consideration should be given to placing the...

Matched on terms: ligature

Jan 2020 · West Yorkshire (West)

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: ligature

IOPC learning recommendation

Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, June 2022

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 custody staff understand the ligature risk associated with plimsolls provided to detainees. Where a detainee is assessed as being at current risk of self-harming, any mitigation to the risk...

Matched on terms: ligature

Michaela Christoforou

May 2014 · London (North)

All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.

Matched on terms: ligature

Mar 2015 · Peterborough

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.

Matched on terms: ligature

Sep 2019 · Black Country

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.

Matched on terms: ligature

IOPC learning recommendation

Man died after an attempt to take his own life during a police response – South Wales Police,...

The IOPC recommends that all Police forces should consider equipping all operational police vehicles with some form of implement that would be capable of cutting a ligature of a width greater than a few millimetres. Training should also be given to officers in how and when to use such a piece of equipment. The item of equipment will...

Matched on terms: ligature

IMB recommendation

The Board reiterates the concerns of Dame Anne Owers in her letter of 11 November 2020 to the Director General of Prisons regarding the decision that the making of a ligature by prisoners is no longer a nationally reportable self-harm incident.

Matched on terms: ligature

IOPC learning recommendation

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 others. Hampshire Constabulary should review their custody policies to clarify guidance around the provision of cutlery. Firstly, in...

Matched on terms: ligature

IOPC learning recommendation

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 detainee or others. Custody leads are specifically asked to: a) Note and inform their staff that plastic cutlery...

Matched on terms: ligature

Mihangel ap Dafydd

May 2016 · Carmarthenshire and Pembrokeshire

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 terms: ligature

Francesca Whyatt

Aug 2017 · London Inner (West)

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.

Matched on terms: ligature

PPO recommendation

The Head of Custodial Contracts, in conjunction with the MoJ Prison Infrastructure Team and MoJ Property Directorate Technical...

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 to ensure that the anti-ligature features remain effective.

Matched on terms: ligature

IMB recommendation

Usk and Prescoed (2021)

With respect to the promotion of prison safety, the Board supports the concerns of Dame Anne Owers (letter to the Director General of Prisons, November 2020) regarding the decision that making a ligature (also known as noose making) by prisoners should no longer be a nationally reportable self-harm incident.

Matched on terms: ligature

Christopher Shapley

Mar 2014 · Cardiff & the Vale of Glamorgan

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.

Matched on classifier match

Mar 2014 · Teesside

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.

Matched on classifier match

Mark Bartholomew

May 2014 · Manchester (North)

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.

Matched on terms: ligature

Peter Farebrother

Jun 2014 · Shropshire, Telford & Wrekin

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.

Matched on terms: ligature

Dec 2015 · Milton Keynes

There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.

Matched on classifier match

May 2016 · London Inner (North)

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.

Matched on classifier match

Sep 2016 · Black Country

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.

Matched on terms: ligature

Sep 2017 · Liverpool & Wirral

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).

Matched on classifier match

Robert McLoughlin

Oct 2018 · West Yorkshire (East)

The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.

Matched on terms: ligature

Bethany Tenquist

Mar 2019 · Brighton and Hove

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.

Matched on classifier match

Katie Allan; William Brown

Remove double bunk beds from young prisoner cells; replace door-stops with anti-ligature designs; pilot signs of life technology; restrict access to belts and cords; system for court documentation to reach SPS on admission; 24-hour family reporting number; 72-hour TTM presumption for all young admissions; enhanced risk assessment forms; improved electronic documentation; increased staff training frequency

Matched on terms: ligature

IMB annual report

HMP Bristol, a Category B local prison, navigated the reporting year (August 2019 – July 2020) under significant COVID-19 restrictions, which impacted the daily regime but also led to a more settled environment and improved staff morale. Despite efforts, safety ratings remained low, with high levels of self-harm, violence, and increased use of force incidents. Challenges persisted with...

Matched on classifier match

IMB annual report

HMP Cardiff maintained a reasonably safe environment with low violence, but self-harm incidents increased to 712, with four deaths in custody (three self-inflicted). The COVID-19 pandemic severely restricted the regime, impacting purposeful activity, time out of cell (1.5 hours daily), and overall prisoner wellbeing. Persistent staffing shortages hampered healthcare and mental health services, while disparities for BAME prisoners...

Matched on classifier match

IMB annual report

Foston Hall (2020)

HMP/YOI Foston Hall operated under severe COVID-19 restrictions for most of the year, leading to drastic regime changes, including confinement to cells for most of the day. Despite significant staff commitment and efforts by healthcare and resettlement services, key concerns persist regarding persistently high self-harm, staff assaults, and use of force, alongside infrastructure issues in D wing and...

Matched on classifier match

Jan 2015 · London (North)

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.

Matched on classifier match

Jul 2015 · London Inner (West)

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.

Matched on classifier match

Oct 2015 · Exeter and Greater Devon

The practice of placing towels over doors on the unit obstructed staff monitoring and could conceal self-harm attempts, requiring alternative patient privacy methods.

Matched on classifier match

Christopher Brennan

Dec 2016 · London (South)

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.

Matched on classifier match

Feb 2017 · Exeter and Greater Devon

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.

Matched on classifier match

May 2017 · Milton Keynes

The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.

Matched on classifier match

Vilhelmas Borkertas

Oct 2017 · London Inner (North)

A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting profiles.

Matched on classifier match

Sep 2017 · Oxfordshire

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.

Matched on classifier match

Jan 2018 · Manchester (West)

Date of report: 19 January 2018 Ref: 2018-0022 Deceased name: William Lound Coroners name: Kevin McLoughlin Coroners Area: Manchester (West) Category: Hospital Death (Clinical Procedures and medical management) related deaths; Mental Health related deaths This report is being sent to: Greater Manchester Mental Health NHS Trust

Matched on classifier match

Feb 2018 · Black Country

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.

Matched on classifier match

Nov 2018 · Manchester (West)

Date of report: 2 November 2018 Ref: 2018-0339 Deceased name: Karl Cassimjee Coroners name: Timothy Brennand Coroners Area: Manchester (West) Category: Hospital Death (Clinical Procedures and medical management) related deaths; Mental Health related deaths This report is being sent to: Greater Manchester Mental Health NHS Trust; Manchester Royal Infirmary

Matched on classifier match

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