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

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.

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

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.

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

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

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

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

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

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.

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

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.

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