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
65match
Lisa Jane Clayton
Concerns involve the car park's 7th-floor wall design, which facilitates climbing, and inadequate CCTV monitoring and security staffing. Little action has been taken despite prior incidents at this location and previous concerns raised.
Matched on
terms: design
PFD report
65match
Lynn Gormly
The low-level design of Queensgate Car Parks and other city centre car park walls does not effectively prevent individuals from jumping. This design contrasts with modern car parks and poses a risk to both individuals and pedestrians below.
Matched on
terms: design
PFD report
65match
Simon Charles
The coroner noted concerns regarding the lack of preventative measures at Hells Mouth, a known location for individuals contemplating suicide, suggesting the provision of support agency phone numbers and natural barriers at the cliff edge.
Matched on
terms: suicide
PFD report
65match
James Forryan
The coroner raised concerns about the easy accessibility of websites and forums that openly promote suicide methods, noting insufficient regulation and enforcement action against such platforms.
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
Tommy Faisali
The coroner identified insufficient qualifications for staff assessing psychiatric referrals and noted gaps in the completion and communication of risk assessments, including suicide risk, within mental health teams, exacerbated by a lack of continuity of care.
Matched on
terms: suicide
PFD report
61match
Darren Mindham
The coroner noted that Pentobarbital, a drug commonly used in suicides, is classified under Schedule 3 of the Misuse of Drugs Regulations 2001, which has less strict controls than Schedule 2, impacting access.
Matched on
terms: suicide
PFD report
61match
Miles Naylor
The jury identified a need for Bradford District Care NHS Foundation Trust to review ligature risks from personal items. Concerns also arose about the design of doors on Oakdale ward, suggesting hinge pin covers.
Matched on
terms: design
PFD report
61match
Joseph Dent
Concerns relate to the bridge's accessible parapet, its known discussion as a suicide location, and the lack of monitored CCTV or lighting to detect at-risk individuals. Pedestrians at the base are also at risk from falling persons.
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
Large helium canisters are readily available to the public without sales restrictions or control valves to limit gas release. The coroner also identified readily available online information that provides detailed guidance on how to commit suicide and links to purchase relevant products.
Matched on
terms: suicide
PFD report
57match
Alasdair Penny
The coroner raised concerns about a bridge being the site of two suicides, noting the ease with which its railings can be mounted. The report questions whether additional protection could be implemented to minimise recurrence.
Matched on
terms: suicide
PFD report
57match
Thomas Harris
The coroner raises concerns about the ready availability of toxic helium gas online and on the high street. The report requests action to regulate its sale, canister size, and valve design to prevent misuse.
Matched on
terms: design
PFD report
57match
Michael Berry
A 'Safer Cell', intended for reduced risk, contained an obvious ligature point due to an inwardly opening window. The coroner suggested design solutions could remove this risk.
Matched on
terms: design
PFD report
57match
Karen Wiggins
The coroner noted a history of suicidal falls from multi-storey car parks in Swindon, including Fleming Way. Concerns were raised about the absence of physical barriers to prevent jumping and the lack of Samaritans contact information at these sites.
Matched on
classifier match
PFD report
57match
Bradley Trevarthen
The coroner raised concerns regarding the extensive availability of self-harm and suicide-related content online for young people, noting that this material risks normalising such actions and goes beyond appropriate freedom of expression.
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 raises concerns about preventing people from falling.
Matched on
terms: suicide
PFD report
57match
Natasha Abrahart
The mental health trust and GP practice did not follow NICE guideline CG90, which requires a 1-week follow-up for patients under 30 or with increased suicide risk when starting antidepressants, to monitor for side effects including suicide risk.
Matched on
terms: suicide
PFD report
57match
Wayne Boughen
HMP Leeds did not have any certified safer cells (anti-ligature cells) at the time of the death and still does not. Even cells with increased safety features do not meet the certified standard, enabling the individual to suspend himself in an ordinary cell.
Matched on
terms: enabling
PFD report
57match
Chloe English
The coroner noted that existing suicide prevention measures at a known location were not effective, as the deceased was able to jump within 2 minutes 30 seconds of entering the area.
Matched on
terms: suicide
PFD report
53match
Daniel Campbell
The coroner noted disrepair in sections of fencing and walls separating a public footpath from the railway line, which created easy opportunities for individuals to access the railway.
Matched on
classifier match
PFD report
53match
Joanna Orpin
The coroner noted the absence of mental health support signage at Culver Cliff, a location where individuals in mental distress are frequently found. Despite recommendations from police and psychiatrists, these signs have not been reinstated.
Matched on
classifier match
PFD report
53match
Tina Murray
Plastic bags were accessible to Tina Murray despite her identified risk to herself in relation to them. The coroner noted the importance of robust risk assessments and safety measures for residents with mental health conditions, dementia, and learning disabilities at Belgravia Care Home.
Matched on
classifier match
CQC action
53match
Salford Royal Hospital
The service must ensure all areas of the department are suitable and properly maintained. This includes but is not limited to the size and design of the department and rooms used for assessing a patient’s mental health.
Matched on
terms: design
CQC action
53match
Durham Diagnostics and Treatment Centre
The service must review designated mental health assessment rooms regularly to identify any changes that may impact on patient safety.
Matched on
terms: design
CQC action
52match
St Benedict's Hospice
The service must ensure that children and young people with a mental health condition are risk assessed for their mental health needs, self-harm or suicide and are cared for in a safe environment that has been appropriately risk assessed.
Matched on
terms: suicide
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
The risk care plan for Mr Walker was insufficient in scope and depth and was not revisited or revised. There was no clear rationale provided for decreasing observation levels, despite the patient expressing suicidal thoughts.
Matched on
classifier match
PFD report
49match
Peter Patrick Adrian Barnes
Hospital systems for sharing patient information and clinician decisions between staff were inadequate and unaudited. Also, family involvement in care decisions and providing comprehensive information to police for absent patients lacked proper systems.
Matched on
classifier match
PFD report
49match
Samantha MacDonald
The coroner noted that a window restrictor in student accommodation was easily broken without tools, allowing a student to exit the window. It was suggested that risk assessments and more robust restrictors are appropriate in student accommodation to prevent falls.
Matched on
classifier match
PFD report
49match
Mihangel ap Dafydd
The coroner noted that windows in service user areas at Morlais Ward are not ligature-free, and despite plans for this work following a death, it has not yet been undertaken.
Matched on
classifier match
PFD report
49match
Miles Abel
Concerns were raised regarding the GP referral procedure to the Community Mental Health Team, specifically the lack of an audit trail for faxed requests and inconsistent follow-up calls to confirm receipt. This meant the CMHT might be unaware of patient referrals.
Matched on
classifier match
PFD report
49match
Susan Hamlett
The coroner noted that a wooden access gate and fence to the railway line at Lower Farm Road offered little deterrence to access. Recommendations to replace this with a more significant fence have not been actioned.
Matched on
classifier match
PFD report
49match
Charles Pitcher
The coroner noted that the Tamar Bridge barrier is easily traversed, leading to 11 recorded jumps in the past decade, and asked for a review of procedures to reduce future deaths. Concerns were also raised about the risk this poses to those on Wolseley Road and the absence of sufficient preventative measures compared to other significant bridges.
Matched on
classifier match
PFD report
49match
Sam Molyneux
The coroner noted that not all old prison wings have anti-barricade doors, which can delay staff access during emergencies. Concerns were also raised that Mr Molyneux was not on an ACCT plan despite expressing threats of self-harm.
Matched on
classifier match
PFD report
49match
Ben Walmsley
The coroner identified a lack of a mechanism to notify schools when pupils attempted to access blocked content related to self-harm on school computers. Concerns were also raised about whether enhanced monitoring functionality is mandatory for all schools.
Matched on
classifier match
PFD report
49match
Emma Butler
The coroner noted insufficient monitoring of plastic cutlery on the ward, which was used for self-harm, and inadequate searching processes for patients returning from unescorted leave, allowing self-harm materials to be brought in. Concerns were also raised about significant variations in the conduct and recording of hourly observations.
Matched on
classifier match
PFD report
49match
Brian Goodman
The coroner noted that a door closing mechanism, identified as a ligature point in Mr Goodman's room, was not changed, and the same mechanisms remain in use in other properties managed by One Support.
Matched on
classifier match
PFD report
49match
Jane Livingston
Gateway assessors lacked full access to patient notes, which could result in assessments and treatment plans being based on incomplete information.
Matched on
classifier match
PFD report
49match
Annette Lewis
The coroner noted the absence of fences at Tennyson Down cliff edge and a lack of signs providing support numbers for individuals experiencing mental distress, suggesting similar improvements to those planned for Culver Cliff.
Matched on
classifier match
PFD report
49match
Heather Page
The coroner identified a high number of fatalities on a section of track with multiple accessible pedestrian crossings, noting that Network Rail's efforts to reduce these risks have been hampered by local authority opposition.
Matched on
classifier match
PFD report
49match
Zoe Zaremba
The coroner noted the mental health service wrongly attributed Emotionally Unstable Personality Disorder to an autistic individual, causing distress and a breakdown of trust. This included a misunderstanding of autism, underdeveloped provisions for autistic conditions, and a lack of adapted psychological therapy and coordinated care within the service.
Matched on
classifier match
CQC action
49match
The Whittington Hospital
The trust should ensure an environmental risk assessment is carried in all maternity areas and emergency call bells are ligature free.
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 coroner noted a lack of understanding regarding how controlling and coercive behaviour can negatively affect a person's decision-making ability. Concerns were raised that the Mental Capacity Act 2005, as currently drafted, does not fully recognise this impact.
Matched on
classifier match
PFD report
45match
Glen Jordan
The coroner noted that a holdall bag with an attached strap was left in the patient's room after staff checks, raising concerns about balancing personal item removal with least restrictive policies.
Matched on
classifier match
PFD report
45match
Helen Millard
The coroner highlighted an incongruity in the 'traffic light' classification of ligature points in psychiatric facilities, where ligatures one metre or less are 'amber' despite posing an extreme risk. It was suggested all such points should be classified as 'red' for urgent elimination.
Matched on
classifier match
PFD report
45match
Mwitumwa Ngenda
The coroner raised concerns regarding the appropriateness of urgent preventative measures on the bridge to prevent similar future incidents.
Matched on
classifier match