Design flaws enabling suicide
Environmental design flaws (e.g., car park barriers) that allow surprisingly easy access to means of suicide, coupled with poor visibility of support signage.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
81match
Lynn Gormly
The Queensgate Car Parks' low walls are ineffective in preventing suicides and pose a risk to pedestrians. Design improvements like higher barriers, as seen in modern car parks, are needed to deter jumps.
Matched on
terms: design, suicide
PFD report
81match
Joseph Dent
A bridge's design provides easy access to parapets and lacks effective suicide prevention measures like adequate barriers, monitoring, or detection for at-risk individuals.
Matched on
terms: design, suicide
PFD report
73match
Michael Berry
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: design, flaw
PFD report
69match
Lisa Jane Clayton
Inadequate physical deterrents on a car park wall, insufficient CCTV monitoring and understaffed security, coupled with a history of similar incidents, highlight serious failures in suicide prevention measures.
Matched on
terms: suicide
PFD report
69match
Mwitumwa Ngenda
Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future suicide attempts.
Matched on
terms: design, suicide
PFD report
65match
Alasdair Penny
Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent spontaneous jumps from the bridge.
Matched on
terms: suicide
PFD report
65match
Charles Pitcher
The bridge barrier is too easy to bypass, leading to multiple suicides, and current safety measures are inadequate compared to other significant bridges.
Matched on
terms: suicide
PFD report
65match
Simon Charles
Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact numbers and planting natural barriers along the cliff edge.
Matched on
terms: suicide
HSSIB recommendation
65match
Insulin: supporting safe self-administration for patients in the community with a mental health problem
Organisations involved in the manufacture of insulin pen devices used by the NHS can improve patient safety by: 1) understanding where devices are being used outside of their intended purpose; and 2) exploring the potential to design devices that would reduce the risk of intentional overdose of insulin for self-harm. HSSIB suggests safety learning for integrated care boards...
Matched on
terms: design
Scottish FAI
64match
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. This toolkit should, in particular, (i) identify both obvious and...
Matched on
terms: design, suicide
PFD report
61match
Thomas Harris
Helium's easy availability online and on the high street, along with the size and valve of canisters, facilitates its use in suicide attempts.
Matched on
terms: suicide
PFD report
61match
Annette Lewis
There is a lack of protective fencing and crucial Samaritan signage at Tennyson Down cliff, despite a known risk of individuals in mental distress attempting suicide at this and similar sites.
Matched on
terms: suicide
PFD report
61match
Miles Naylor
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: design
PFD report
61match
James Forryan
Easily accessible websites openly promote and provide guidance on suicide methods, contributing to deaths. There is a lack of sufficient regulation and enforcement against such harmful online content.
Matched on
terms: suicide
PFD report
61match
Zoe Zaremba
Autism was misunderstood, leading to misdiagnosis and inappropriate treatment. Underdeveloped services lacked person-centred care, specialist therapy, and effective inter-provider communication, increasing suicide risk for autistic individuals.
Matched on
terms: suicide
HSSIB recommendation
61match
Keeping children and young people with mental health needs safe: the design of the paediatric ward — HSSIB
HSSIB recommends that NHS England, in collaboration with key stakeholders, updates ‘Health Building Note 23: Hospital accommodation for children and young people’ to include the therapeutic environment for supporting children and young people with mental health needs.
Matched on
terms: design
PFD report
57match
Luke Jacob Goodwin
The unrestricted sale of large helium canisters without flow control valves, combined with readily available online suicide guides, facilitates self-harm and raises serious safety concerns.
Matched on
terms: suicide
PFD report
57match
Darren Mindham
Pentobarbital, a Schedule 3 drug, is frequently used in suicides due to less strict controls; stricter regulation could reduce suicide rates.
Matched on
terms: suicide
PFD report
57match
Helen Millard
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
terms: flaw
PFD report
57match
Karen Wiggins
Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent individuals from jumping.
Matched on
classifier match
PFD report
57match
Brian Goodman
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: suicide
PFD report
57match
Jessica Duckworth
The lack of fencing or other preventative measures at a bridge known as a suicide spot creates an ongoing risk of future deaths from falls.
Matched on
terms: suicide
PFD report
57match
Muhammed Wajid
Scammonden Bridge is a notorious suicide location, and previous recommendations to Kirklees Council and Highways England for suicide prevention measures may not have been fully implemented.
Matched on
terms: suicide
PFD report
57match
Natasha Abrahart
NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not followed by the mental health trust or GP.
Matched on
terms: suicide
PFD report
57match
Chloe English
Existing suicide prevention measures at a known high-risk location proved ineffective, as the deceased was able to jump within minutes of arrival, indicating current safeguards are insufficient.
Matched on
terms: suicide
PFD report
53match
Tina Murray
Plastic bags, which posed a risk to the deceased, appear to have been accessible within Belgravia Care Home.
Matched on
classifier match
PHSO casework decision
52match
P-001995 - Leeds and York Partnership NHS Foundation Trust
Miss O complained Trust staff failed their duty of care by releasing her when mentally unwell, not supporting her after suicide attempts, and being unavailable, causing significant harm.
Matched on
terms: suicide
Committee recommendation
51match
#36 - Eighth Report - Children and young people’s mental health
We are deeply concerned about the increasing numbers of children and young people who experience self-harm and suicide and the quality of care they are able to access. Much more needs to be done to tackle suicide and self-harm amongst children and young people. In particular, given the link between self-harm in children and young people and later...
Matched on
terms: suicide
PFD report
49match
John Walker
Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.
Matched on
classifier match
PFD report
49match
Peter Patrick Adrian Barnes
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.
Matched on
classifier match
PFD report
49match
Tommy Faisali
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
PFD report
49match
Samantha MacDonald
A broken window restrictor in student accommodation, despite meeting standards, allowed a fatal fall, highlighting the need for robust risk assessments and more secure devices in such buildings.
Matched on
classifier match
PFD report
49match
Mihangel ap Dafydd
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
classifier match
PFD report
49match
Susan Hamlett
The British Transport investigation revealed that the deceased gained access to the railway line through an access gate that provided little deterrence, and the area around the gate should be replaced with a more significant fence as a matter of urgency.
Matched on
classifier match
PFD report
49match
Daniel Campbell
Broken and disrepaired fencing separating a public footpath from the railway line created easy opportunities for impulsive trespass, increasing the risk of death.
Matched on
classifier match
PFD report
49match
Sam Molyneux
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
PFD report
49match
Ben Walmsley
The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking missed safeguarding opportunities.
Matched on
classifier match
PFD report
49match
Benjamin Murray
Low rates of mental health disclosure in university applications and the absence of formal investigation reports following student deaths indicate systemic gaps in student support.
Matched on
classifier match
PFD report
49match
Jane Livingston
Gateway assessors lacked full access to patient notes, risking incomplete assessments and treatment plans based on insufficient information.
Matched on
classifier match
PFD report
49match
Michael Dobson
Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. This creates a potential for prisoners to self-harm.
Matched on
classifier match
PFD report
49match
Wayne Boughen
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.
Matched on
classifier match
PFD report
49match
Emma Pring
"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.
Matched on
classifier match
PFD report
49match
Matthew Caseby
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.
Matched on
classifier match
HSSIB recommendation
48match
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to adults — HSSIB
Those involved in the design of new and upgraded built environments for mental health inpatient settings can improve patient safety and the delivery of therapeutic care by involving relevant stakeholders in design processes. Stakeholders include people with lived experience (patients and staff) and experts in human factors and ergonomics. Any design should also consider the changing needs of...
Matched on
terms: design
PFD report
45match
Joanna Hillard
The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can impair a person's decision-making ability.
Matched on
classifier match
PFD report
45match
Miles Abel
The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to confirm faxes were sent, and follow-up phone calls were not always made.
Matched on
classifier match
PFD report
45match
Glen Jordan
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
classifier match
PFD report
45match
George Dyson
The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following previous similar incidents.
Matched on
classifier match
PFD report
45match
Jordan Sheils
The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to deter tragedies being under consideration.
Matched on
classifier match
PFD report
45match
Emma Butler
Inadequate control of plastic cutlery on the ward and inconsistent search procedures for patients returning from leave created self-harm risks, compounded by variable hourly observation practices.
Matched on
classifier match