Ligature points
Accessible ligature points in prison cells and mental health wards, posing a risk of self-harm and suicide.
192 items
11 sources
Source spread
Where this theme appears
Ligature points has been flagged across 11 independent accountability sources:
104 PFD reports
2 committee recs
2 CQC actions
3 PPO recs
17 IOPC recs
10 IMB reports
40 IMB recs
3 Scottish FAIs
5 Article 2 learning points
2 detention investigation recs
4 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 (104) — showing 50 strongest matches
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patient information and serious incidents from nursing staff to the Responsible Clinician, leading to incomplete or outdated data for care decisions.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
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 (South Tees Hospitals NHS Foundation Trust): The Trust states that they have undertaken a full investigation and discussed the matter at a senior level. They maintain that the patient was assessed on arrival at A&E and …
Overdue
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
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
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
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
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.
Response (HM Prison and Probation Service): Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is …
Overdue
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
Michaela Christoforou
Concerns: All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.
Response: Care UK has now located nine sets of ligature cutters throughout Rhodes Farm. Clinical staff will carry ligature cutters for a six month trial period commencing in September 2014 and …
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.
Response (Department of Health): The Department of Health states that NHS England has identified the need for both a Mental Health Patient Safety Expert Group and an Expert Safety Primary Care Group to improve …
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.
Response (CQC): The CQC is reviewing its registration process to include specific questions on safety alerts, and piloting pre-inspection methodology to assess dissemination of safety alerts by providers.
Response (Department of Health): The Department of Health discussed the report with the CQC, who will take steps to improve the implementation of Safety Alerts, including Department of Health Alerts.
Responded
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
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.
Response (HM Prison and Probation Service): The Ministry of Justice Estate Directorate is providing 'safer cells' in new construction and refurbishment projects. HMP Downview's local policies and procedures have been reviewed and strengthened, and the NHS …
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.
Response (Department of Health): The Department of Health notes that Partnerships in Care (PIC) redrafted their policies to conform exactly to the 2008 Mental Health Act 1983 Code of Practice. Staff failure in this …
Responded
Isobel Griffin and Jane Clark
Concerns: 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.
Overdue
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
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
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.
Overdue
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.
Response (Diane Knight): Devon Partnership NHS Trust will discontinue the practice of patients obscuring windows in bedroom doors, issue a patient safety alert, and is developing a Respect and Dignity Audit to consider …
Responded
Daniel Byrne
Concerns: 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.
Overdue
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
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.
Response (London Ambulance Service NHS Trust): The London Ambulance Service updated its Computerised Gazetteer to include multiple entrances to HMP Pentonville, and included specific reference to HMP Pentonville in refresher training for EOC staff, requiring confirmation …
Response (Care Uk): Care UK refers to the response provided by BEH-MHT for some concerns, and states they will collaborate with them to ensure their action plan is implemented. They have implemented a …
Response (HM Prison and Probation Service): NOMS states that the local risk assessment at Pentonville is up to date, and there is a sufficient number of staff trained in first aid. Prison control room staff have …
Overdue
Leslie Matthews
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA has brought the Coroner's concerns to the attention of the manufacturer and requested that they evaluate whether additional clarity in information could be incorporated at the next Instructions …
Response (County Durham and Darlington NHS Trust): All oxygen flowmeters across the Trust have been checked and faults logged. Equipment Controllers/Department Managers are now performing weekly checks of all flowmeters, using a checklist devised by the Medical …
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
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
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.
Response (Northern Eastern and Western Devon NHS Trust): The CCG is monitoring timely discharge performance data, the DPT contract review meeting also monitors the rates of delayed discharges from mental health wards through data reported to NEW Devon …
Response (Royal Devon and Exeter NHS Trust): The Trust describes mental health training delivered, including specific programmes with Devon Partnership Trust (DPT). It argues that in this case, staff sought and followed specialist advice from the DPT …
Response (Devon Partnership NHS Trust): The Trust undertook a Root Cause Analysis investigation with the Royal Devon and Exeter NHS Foundation Trust (RD&E), the actions from which are completed and part of regular management supervision. …
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
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.
Response (Welsh Government): The Welsh Government will discuss the incident at the all Wales Serious Incidents Group in October to improve learning and develop/disseminate further guidance across professional groups. They will also keep …
Response: The University Health Board has implemented a safe system of work for recording items stored in patient PODS, disseminated risk management policies via ward meetings with staff sign-off, and is …
Response (NHS England): NHS Improvement supported the MHRA by searching the National Reporting and Learning System, which reinforced the importance of annual eye screening for patients on long-term Hydroxychloroquine. They stand ready to …
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA acknowledged the concerns and requested further information regarding the case to determine if regulatory action is required, including observed drug concentrations, symptoms of overdose, concomitant medications, post-mortem sample …
Response (Department of Health Social Care): NHS England is working to ensure that by 2020/21, 280,000 more people with serious mental illness have their physical health needs met. NHS Improvement issued an Estates and Facilities Alert …
Responded
Daniel Dunkley
Concerns: The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.
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
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.
Response (Priory Hospital): The Priory Hospital Roehampton details environmental and health and safety risk assessments undertaken and coordinated with Policy H43 Observation and Engagement throughout the ward. The Incident Management; Reporting and Investigation …
Overdue
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
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.
Response (HM Prison Probation Services): HMP Winchester has taken on a temporary staff member to transcribe telephone calls, implemented a new protocol for information gathering, transcribed interview discs, and ordered a secure storage facility for …
Response (Carillion): Carillion has contacted HMPPS and proposed a formal instruction for staff to undergo SASH training, is ready to issue a notice to site managers to make staff available, and suggested …
Response (HM Prison Probation Services.2): The prison has issued notices to staff regarding emergency call bell response times and to prisoners about the misuse of call bells. The prison is also checking ECB response times …
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.
Response (Oxford Health NHS Trust): Following the death, guidance was issued to staff that plastic bags must be removed at reception, or staff must accompany the visitor/patient to the room, allow them to remove items, …
Responded
William Lound
Response (Greater Manchester Mental Health NHS Foundation Trust): The Trust has filled all substantive consultant appointments across inpatient areas within Manchester services and is developing proposals for forensic in-reach to support consultants and CMHTs; a rolling programme for …
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
Mohammed Ahmed
Overdue
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
Karl Cassimjee
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.
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
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.
Response (Sussex NHS Trust): Sussex NHS Trust will improve communication pathways with the Police and improve guidance to staff regarding contacting the Police following serious incidents.
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
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.
Response (HM Prison and Probation Service): HMP Berwyn has implemented various measures to tackle psychoactive substances, including improved gate searching, changes in the supervision of domestic visits, safe detoxification on reception, and extended mandatory drug testing. …
Overdue
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
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
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.
Response (Camino Healthcare): Camino Healthcare has undertaken a significant review, appointed a new Executive team, evaluated training, provided further training in Intensive Life Support and Basic First Aid, and made changes to make …
Response (CQC): CQC took urgent enforcement action against Oak House, imposing conditions on the provider's registration. The provider submitted an action plan to deliver new training to staff, which CQC will follow …
Overdue
Wesley Rowlands
Concerns: Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.
Response (HMP Garth): HMP Garth has arranged for the Prison Maintenance Group to review all cells and remove unused television brackets, with completion expected by February 2021. They are also reviewing accommodation in …
Responded
Committee Recommendations (2)
#33 —
Recommendation: In addition to our recommendations on the use of restraint that we set out in our report on the treatment of autistic people and people with learning disabilities, the use of prone restraint on children and young people should be …
Gov response: The Government is considering this recommendation. Within specialised commissioning, there are a number of programmes of work to reduce restrictive practice. The national Quality Improvement Taskforce for Children and Young People’s Mental Health, Learning disability …
Not Addressed
#28 — Prisons used as places of safety, despite Government aims to end the practice
Recommendation: We were shocked and appalled to hear that prisons are used as a place of safety. We acknowledge and welcome that the Government aims to end this practice in the Mental Health Bill. We request details of how this will …
Gov response: The Mental Health Bill includes a number of vital reforms to support people with severe mental illness in the criminal justice system. These include: • The introduction of a new statutory 28-day time limit for …
Accepted
CQC Inspection Actions (2)
PPO Death in Custody Recommendations (3)
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 officers check the condition of door hinge securing bolts when making their daily cell fabric checks.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that prison staff manage prisoners at risk of suicide and self-harm in line with PSI 64/2011, in particular that they: remove ligatures from prisoners at the earliest opportunity; hold multidisciplinary case reviews …
IOPC Learning Recommendations (17)
National recommendation - National Police Chiefs' Council, April 2019
The IOPC recommends that the National Police Chiefs' Council (NPCC) ensures that all forces are made aware of this risk and the injury caused by the use of an alarm cord as a ligature in this case. All forces should …
Man sustained a serious injury while in custody – Cleveland Police, August …
The IOPC recommends that Cleveland Police should take steps to ensure that custody officers follow Authorised Professional Practice when determining and recording levels of obsevation for detainees. This should include consideration of whether: This follows an incident where a man …
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 …
Man died after an attempt to take his own life during a …
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 …
Man died after an attempt to take his own life during a …
The IOPC recommends that South Wales Police 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 …
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 custody staff understand the ligature risk associated with plimsolls provided to …
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 …
Man sustained a serious injury while in custody – Cleveland Police, August …
The IOPC recommends that Cleveland Police should review the working practices used in custody, specifically in relation to CCTV observations, to ensure that the principles set out in the Authorised Professional Practice (APP) are followed. This should include consideration of; …
Recommendation - North Yorkshire Police, March 2021
The IOPC recommends that North Yorkshire Police should: Until any work on re-positioning/re-configuring any CCTV facilities are completed North Yorkshire Police should put in place interim measures to mitigate the risks posed by CCTV blind spots in cells. This follows …
Man dies after becoming unwell in custody - Essex Police, November 2017
An investigation into the death of a man following his detention at Grays Police Station found that there was not full CCTV coverage of the holding cell in which he had been placed. This was because the CCTV camera in …
Man dies after becoming unwell in custody - Essex Police, November 2017
Our investigation into the death of a man following his detention at Grays Police Station found that there was not full CCTV coverage of the holding cell in which he had been placed. This was because the CCTV camera in …
Recommendations - Humberside Police, January 2022
The IOPC recommends that Humberside Police consider implementing the use of metal detecting wands in their Custody Suites. This follows a Death or Serious Injury (DSI) incident whereby a detainee was able to hide a razor blade within a copy …
Recommendation - Greater Manchester Police, July 2025
The IOPC recommends that Greater Manchester Police (GMP) should, as part of their action to replace their custody system, review their provision for risk assessment completion. This includes consideration of adding prompts for custody officers to carry out risk assessments …
IMB Annual Reports (10)
Bristol (2020)
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 delayed mental health transfers, unsuitable Victorian accommodation for disabled prisoners, and resource issues affecting key work and healthcare.
PRISON
Key concerns
Cookham Wood (2020)
The IMB report for HMYOI Cookham Wood covers 1 August 2019 – 31 August 2020, focusing heavily on the impact of the COVID-19 lockdown. While staff are commended for their caring approach and efforts to maintain safety and welfare, particularly during initial lockdown, the severe and protracted regime resulted in boys being locked in their rooms for over 23 hours a day, raising significant concerns about inhumane treatment, especially for those in segregation or with mental health issues. Key challenges include the unfit Phoenix segregation unit, national shortages of mental health beds, delays in transferring young adults, and an increasing remand population, all exacerbated by the lack of IT capacity during the pandemic.
PRISON
Key concerns
Cardiff (2020)
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 in areas like segregation and dangerous prisoner labels remained a concern.
PRISON
Key concerns
Eastwood Park (2020)
This IMB annual report for HMP/YOI Eastwood Park for the year ending October 2020 highlights the significant impact of the COVID-19 pandemic on prison operations and monitoring. While staff efforts and communication were generally commendable, concerns persist regarding rising self-harm incidents, ongoing violence towards staff, and the continuous flow of illicit substances. The Board remains particularly concerned about the prolonged segregation of a brain-injured prisoner and the lack of appropriate secure specialist facilities for women with complex needs.
PRISON
Key concerns
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 the CSU. The report highlights the inhumane impact of the restricted regime and the challenges in maintaining essential services and progression opportunities.
PRISON
Key concerns
Dungavel House IRC (2024)
The Independent Monitoring Board for Dungavel House IRC reports a generally safe and humane environment for detainees in 2024, with good staff-detainee relationships and healthcare provision. Key concerns include the uncertainty of detainees' futures, high numbers of night-time arrivals and departures, and ongoing issues with roof accessibility and building maintenance. The Board also noted that female facilities are considered inadequate.
IRC
Key concerns
Bure (2025)
HMP Bure, a Category C training prison for sexual offenders, holds 639 prisoners against an operational capacity of 643. While commendable for humane treatment, high time out of cell, and low violence metrics, the Board identifies critical challenges. These include budget cuts impacting education and purposeful activity, inadequate healthcare for the aging population, and persistent staffing shortages affecting regime and support. National policy issues around prisoner wages and property management also remain significant concerns for the Board.
PRISON
Key concerns
Bronzefield (2020)
HMP/YOI Bronzefield, a local female prison, effectively managed the initial COVID-19 lockdown, maintaining a nearly virus-free environment, but the sustained restricted regime led to a significant rise in self-harm and mental health concerns. Key issues included a high proportion of prisoners released without stable accommodation, persistent challenges with timely mental health transfers, and a shortage of cell keys affecting prisoner property security. Despite these, the Board noted positive developments in food quality, key worker implementation, and effective education provision during the pandemic.
PRISON
Key concerns
Gatwick IRC (2024)
Gatwick IRC experienced a volatile year ending March 2024, marked by high levels of violence, self-harm, and one death in custody. The Board expresses significant concerns over inadequate safeguards for vulnerable detainees, long detention periods, and systemic failures in healthcare, particularly around Rules 34 and 35. Detainees also face issues with interpretation services, excessive handcuffing, and an inhumane regime with long lock-up times and increased segregation.
IRC
Key concerns
Pentonville (2020)
HMP/YOI Pentonville, a category B/C local prison, faces significant challenges in providing a safe and rehabilitative environment. While staff demonstrated resilience during COVID-19, and some improvements were made in drug reduction and key working, the prison's deteriorating infrastructure, high levels of violence, and persistent issues with regime delivery severely impacted prisoner welfare and resettlement. The Board highlights a lack of investment, poor maintenance, and inadequate staffing as root causes, resulting in concerns about safety, healthcare access, and purposeful activity.
PRISON
Key concerns
IMB Recommendations (40)
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2020)
That a gap be created at the top of the toilet doors, at Festival Court HR, to allow DCOs to monitor the safety of detainees.
Governor / Director
Norwich (2021)
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.
HMPPS
Leicester (2024)
Can funds be found for replacing cell windows and grills?
HMPPS
Manchester (2020)
Can the minister expedite approval of the necessary funding [for safer custody windows]?
Ministry of Justice
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
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.
HMPPS
Wandsworth (2022)
The number of out of use cells, particularly in the care and separation unit (CSU), was a concern. Is there a plan to accelerate the repair of damaged cells and to a standard that reduces the potential for future damage?
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
Erlestoke (2023)
What immediate actions will be taken to address the inadequate and potentially dangerously deficient constant watch cell?
Governor / Director
Dungavel House (2023)
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. This remains an issue due to the accessibility of the fire escape stair.
Governor / Director
Dungavel House IRC (2024)
As has been mentioned in previous reports, accessibility to roofs is an ongoing issue and the installation of preventative measures to ensure that roofs are not accessible to detained persons was commenced during the year.
Governor / Director
Pentonville (2020)
Will you commit to funding the repair or replacement of all remaining insecure cell windows and grilles, which were identified four years ago as needing urgent attention?
Other
Five Wells (2024)
When will the low mobility cells be made safe and brought into full use?
Governor / Director
Swaleside (2025)
Again, there is a lack of sufficient constant-watch cells during times of crisis. The Board noted the response last year that in-patient department cells were being considered, but no decision appears to have been made and G wing’s cell has been intermittently out of action. When will a decision be made?
HMPPS
Lancaster Farms (2022)
To ensure that any work in regard to toilets in double cells is addressed: broken screens, lack of toilet seats, etc.
Governor / Director
Wandsworth (2020)
The Board was very concerned that the 12-bed Addison unit remained unfit for purpose, with insufficient beds and cells frequently awaiting repair. The waiting time for a bed in the unit was up to seven days. What is being done to improve capacity for mentally ill prisoners?
Ministry of Justice
Isis (2020)
ensure that plans are in place to prevent a return to the levels of self-harm over the first three months of the year, when a normal regime is resumed (see section 4.2)
Governor / Director
Lancaster Farms (2021)
To ensure that work previously planned to introduce screening of toilets within double cells is completed as soon as possible (paragraph 5.1.2).
Governor / Director
Buckley Hall (2021)
Install CCTV in the healthcare waiting area (6.1.17)
Governor / Director
Wormwood Scrubs (2022)
When can we expect more stringent guidance on cell clearance?
HMPPS
Bedford (2022)
We hope that this year the segregation unit will finally be moved from its underground location.
Governor / Director
Wormwood Scrubs (2023)
HMPPS should refurbish the antiquated cell bell system.
HMPPS
Werrington (2023)
What more can be done to enhance safety to ensure the reduction of young people making protective weapons?
Governor / Director
Elmley (2024)
Remove prisoners’ access to razor blades as an instrument of self-harm and replace these with safer electric shavers.
HMPPS
North West and Midlands STHF (2025)
Whilst the detaining officers have a direct view to constantly watch and monitor detained individuals within the holding room at East Midlands Airport, the Board recommends that the facility be upgraded to include the current safety and security standards used in new facilities.
Home Office
Bure (2025)
Due to the number of self-harm incidents using razor blades, will the Governor consider removing wet shave razors and replace them with electric shavers, as is happening across other prison establishments?
Governor / Director
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
Swaleside (2021)
The lack of in-cell telephony in the inpatients department (IPD) still needs to be addressed. (see sections 5.4 and 6.1)
HMPPS
Wakefield (2023)
Some elements of the prison’s physical security require immediate improvement.
HMPPS
Exeter (2023)
Address the deficiencies in the temporary CSU?
Governor / Director
Buckley Hall (2023)
When will CCTV be installed in Healthcare?
Governor / Director
Bure (2024)
The prison lacks CCTV, resulting in some prisoners feeling unsafe. Can consideration be made for funding to be made available to resolve this issue?
HMPPS
Wormwood Scrubs (2020)
Will the minister ensure that sufficient funds continue to be available to the prison for the continuation and enhancement of measures taken to increase the safety of prisoners?
Ministry of Justice
Norwich (2022)
Are there plans for refurbishment of the outdated buildings e.g. the healthcare unit, L wing, E wing and the segregation unit, alongside the planned refurbishment of a previously closed wing and the installation of a new M wing?
HMPPS
Buckley Hall (2022)
Provide the funding to install CCTV in the healthcare building.
HMPPS
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
Bullingdon (2024)
The prison continues to be a violent and unsafe environment for both prisoners and staff. What more can the Prison Service do to address this issue?
HMPPS
Isle of Wight (2024)
Will the Prison Service urgently prioritise funds for the installation of enhanced security gates at both sites, in line with the security arrangements at other LTHSE establishments?
HMPPS
Hull (2024)
Will the prison service directly review the capital funding needed within HMP Hull to improve security measures?
HMPPS
Scottish Fatal Accident Inquiries (3)
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 patient on …
Dec 2024
Health
4 recs
Scotland
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 potential anchor …
May 2025
Custody
7 recs
Scotland
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
Jan 2025
Custody
25 recs
Scotland
Article 2 Learning Points (5)
— LP 2
We recommend that HMPPS and NHSE/I consider specific guidance for the process of ligature cut down to ensure optimum management of the unconscious patient. This will include clarification of whether emergency bags should contain a soft cervical collar as a standard item.
HMPPS
Accepted
— LP 10
If it has not already done so, HMP Whitemoor may wish to consider reviewing current arrangements in relation to prisoners’ access to razor blades. The prison should be satisfied that any arrangements for access also provides for an appropriate level of protection from harm for both staff and other prisoners.
HMP Whitemoor
Accepted
— LP Q
The daily cell fabric check should include the inspection of the securing bolts on the anti-barricade lock plates.
HMPPS
— LP P
Consideration should be given to placing ‘Impact Screwdrivers’ into each wing office to facilitate the removal of seized and damaged bolts on anti-barricade lock plates.
HMPPS
— LP 12
There needs to be a clear policy on levels of observations to be used and the criteria for placement in a safer cell or under constant observation and these should be fully documented in an individual’s ACCT document and healthcare records.
HMP Altcourse and HMPPS
Accepted
Detention Investigations (2)
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
Assessment of government progress in implementing the report on the … — Rec 7
No immigration detention facility should be built in future with a barely screened toilet inside a shared room, and this set-up should be upgraded in all existing facilities.
Immigration Detention
LGO / SPSO Decisions (4)
201304806 — Scottish Prison Service
Mr C, who is a prisoner, complained that the built-in DVD player on his in-cell TV set did not work. He did not feel it was fair to pay the full TV service charge when his set was defective. However, the prison confirmed that Mr C was paying for access …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Jun 2014
201305611 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison did not address his concerns about the temperature in his residential hall. We made enquiries of the Scottish Prison Service (SPS), and found that complaints were received from prisoners about the temperature in the hall. Steps were taken to resolve …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jul 2014
201103838 — Scottish Prison Service
Mr C, who is a prisoner, complained that at times the Scottish Prison Service (SPS) had required him to share a cell that was not of an adequate size to accommodate two prisoners. He had been sharing a cell that was intended as a single, but which has been fitted …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2012
201603221 — Scottish Prison Service
Mr C complained that the Scottish Prison Service (SPS) had failed to follow relevant procedures to ensure his safety in a shared cell. In particular, he said that he should not have had to share a cell with a prisoner whom he alleged had attacked him. Mr C said that …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2017