Source · IAPDC

Ligature Deaths in Prisons in England and Wales: Trends and Reduction Strategies

Published: 1 August 2025 Sector: Prisons & Probation Type: Thematic Report Recommendations: 12 No formal response recorded

Index summary

Analysis of ligature death trends in prisons (1999-2024). Finds ligature deaths account for 89% of self-inflicted deaths. Contains 12 recommendations across cell design, monitoring, risk assessment and research.

Original evidence

Government response

Index summary
No formal government response published. Report discussed at Ministerial Board on Deaths in Custody (November 2024) prior to final publication. Report published April 2025.

Recommendations

12 items
Recommendation 1 · Link to recommendation

Addressed to: HMPPS, MoJ · Open

Recommendation · source text

Encourage cross-establishment sharing of prison audit findings to improve consistency in cell design and suicide prevention approaches between prisons, so that priorities and action plans could be identified to establish a national ligature death prevention strategy.

No response text is recorded for this recommendation.

Recommendation 2 · Link to recommendation

Addressed to: HMPPS, MoJ · Open

Recommendation · source text

Establish national "minimum expectations" in cell ligature safety standards.

No response text is recorded for this recommendation.

Recommendation 3 · Link to recommendation

Addressed to: HMPPS · Open

Recommendation · source text

Review and remove ligature points in both new-built and old cells (particularly those on windows, beds, and doors or cell gates) while maintaining an unrestrictive and humane environment, with reference to cellular accommodation design guides and checklists.

No response text is recorded for this recommendation.

Recommendation 4 · Link to recommendation

Addressed to: HMPPS · Open

Recommendation · source text

High-priority areas should be identified to guide ongoing work addressing ligature points such as windows in older prisons, with progress reviewed regularly.

No response text is recorded for this recommendation.

Recommendation 5 · Link to recommendation

Addressed to: HMPPS · Open

Recommendation · source text

Personnel involved in designing ligature-resistant cells should recognise that a low height of ligature point does not indicate safety.

No response text is recorded for this recommendation.

Recommendation 6 · Link to recommendation

Addressed to: HMPPS · Open

Recommendation · source text

Explore the usability of alternative materials for ligature-resistant bedding in cells.

No response text is recorded for this recommendation.

Recommendation 7 · Link to recommendation

Addressed to: HMPPS · Open

Recommendation · source text

Establish criteria in the level of supervision required for 'at risk' prisoners to ensure prompt response to ligature use events by staff.

No response text is recorded for this recommendation.

Recommendation 8 · Link to recommendation

Addressed to: HMPPS, NHS · Open

Recommendation · source text

Improve information sharing and communication between prison staff and other professionals, particularly with healthcare services.

No response text is recorded for this recommendation.

Recommendation 9 · Link to recommendation

Addressed to: HMPPS · Open

Recommendation · source text

Post-incident early reviews should be conducted to identify factors, including potential ligature points in prisoners' environment, which may have been inadequately addressed to prevent death.

No response text is recorded for this recommendation.

Recommendation 10 · Link to recommendation

Addressed to: HMPPS · Open

Recommendation · source text

Risk assessment and intervention frameworks should be evidence-based (e.g., by considering findings from high quality research identifying risk factors).

No response text is recorded for this recommendation.

Recommendation 11 · Link to recommendation

Addressed to: HMPPS · Open

Recommendation · source text

Improve risk assessment by incorporating findings of new evidence on role of structured approaches to support professional decision-making, particularly at the end of the ACCT process.

No response text is recorded for this recommendation.

Recommendation 12 · Link to recommendation

Addressed to: HMPPS, researchers · Open

Recommendation · source text

Encourage collaboration between prison establishments and researchers to evaluate impact of changes to policies and efficacy of existing and new suicide prevention strategies.

No response text is recorded for this recommendation.

Report details

Published
1 August 2025
Sector
Prisons & Probation
Type
Thematic Report

Status breakdown

Open 12

Addressees

HMPPS, MoJ2
HMPPS8
HMPPS, NHS1
HMPPS, researchers1

Source links