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.
Source spread
Where this theme appears
This theme appears across 15 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
92 PFD reports
3 committee recs
5 HSSIB recs
17 CQC actions
7 PPO recs
5 IOPC recs
13 IMB recs
1 IMB report
1 Scottish FAI
4 detention investigation recs
3 PHSO decisions
2 LGO/SPSO decisions
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.
Inquiry recommendations(2)
18 — Policy on cell furniture
Recommendation: As soon as practicable, the Prison Service should assess the popularity of the bolted-down furniture made from white wood which is currently being trialled. It should then formulate a policy about the most appropriate form of furniture for use in …
Unknown
4 — Placing at-risk prisoners with a cellmate
Recommendation: The Prison Service should retain its practice of placing prisoners who are at risk of suicide or self-harm, but who are not so vulnerable as to require being on suicide watch at all times or accommodated in a safer cell, …
Unknown
Prevention of Future Deaths reports(92)— showing 50 strongest matches
Joanna Hillard
Concerns: 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.
Response (Department of Health and Social Care): • The Department of Health and Social Care committed to delivering new policies under the Violence Against Women and Girls (VAWG) strategy, including 'Steps to Safety' to train general practice … (AI summary)
Responded
John Walker
Concerns: 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.
Response (Sussex Partnership NHS Foundation Trust): • The Trust revised risk care planning documents and confirmed regular audits are completed to ensure adequate standards. • A Nurse Consultant provided training to staff on documenting the rationale … (AI summary)
Responded
Peter Patrick Adrian Barnes
Concerns: 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.
Overdue
Lisa Jane Clayton
Concerns: 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.
Overdue
Luke Jacob Goodwin
Concerns: 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.
Overdue
Lynn Gormly
Concerns: 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.
Response (Invesco): • A feasibility study identified a web-net system as the preferred solution for infilling and over-cladding car park openings. • Planning approval for the web-net system is to be sought … (AI summary)
Overdue
Alasdair Penny
Concerns: 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.
Response (Sussex Police): • The East Grinstead Neighbourhood Joint Action Group implemented six Samaritans signs on the bridge. • Street Pastors and the local police team continue to patrol the bridge. • An … (AI summary)
Response (West Sussex County Council): • The council will investigate the technical feasibility of increasing the height of the bridge parapet. • If a solution is determined, the council intends to undertake the alterations within … (AI summary)
Responded
Tommy Faisali
Concerns: 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.
Overdue
Samantha MacDonald
Concerns: 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.
Response (Campus Living Villages): • Campus Living Villages reviewed its risk assessments for falls from windows and prepared new assessments distinguishing between accidental and deliberate acts. • The organisation implemented daily external checks for … (AI summary)
Response (Department fro Business Innovation and Skills): • The Department noted that City Living Villages (CLV) prepared new risk assessments concerning accidental falls from windows. • The Department noted that City Living Villages (CLV) implemented additional measures … (AI summary)
Responded
Thomas Harris
Concerns: 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.
Overdue
Mihangel ap Dafydd
Concerns: 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.
Response (Welsh Government): • The Welsh Government stated it would issue an addendum to Health Building Note 35 by the end of the month, highlighting ligature-free design requirements for mental health unit facilities. … (AI summary)
Response: • The Health Board undertakes an annual point of ligature audit programme across its mental health and learning disability in-patient units, which identified potential risks with windows on Morlais Ward. … (AI summary)
Responded
Darren Mindham
Concerns: 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.
Response (Department of Health): • The Department of Health advised the coroner to redirect the Regulation 28 letter concerning Pentobarbital classification to the Advisory Council on the Misuse of Drugs (ACMD) Secretariat. • The … (AI summary)
Responded
Miles Abel
Concerns: 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.
Response (Department of Health): • The Department of Health noted that Endless Street Surgery had implemented a strengthened system for referring patients to the Community Mental Health Team. (AI summary)
Response (The Endless Street Doctors Surgery): • The surgery has instituted a new Standard Operating Procedure for urgent fax referrals. • A fax log documentation system has been implemented to record who sent faxes, and the … (AI summary)
Responded
Susan Hamlett
Concerns: 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.
Response (Hamlette Network Rail): • The wooden gate will be upgraded by 2 December 2016. • A multi-agency site visit was organised to scope additional fencing. • Over 500 metres of Class 1 palisade … (AI summary)
Responded
Glen Jordan
Concerns: 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.
Response (Glen Jordan): • The Trust has reviewed its search policy and its policy for the management of presenting clinical risks. • A process for implementing revised policies has commenced, including staff education. … (AI summary)
Overdue
Charles Pitcher
Concerns: 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.
Overdue
Simon Charles
Concerns: 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.
Response (National Trust): • The National Trust is in contact with Cornwall Samaritans to investigate options for introducing signage at Hells Mouth. • The National Trust anticipates installing signs on its own land … (AI summary)
Responded
Helen Millard
Concerns: 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.
Overdue
Daniel Campbell
Concerns: 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.
Response (National Rail): • Network Rail included fencing upgrades in its 2018 renewals plan for the section where the incident occurred. • Network Rail stated it would repair or restore smaller sections of … (AI summary)
Responded
Sam Molyneux
Concerns: 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.
Response (HM Prison Probation Service): • The revised ACCT form and accompanying policy will direct staff to consider emergency access, including the presence of an anti-barricade door, when making decisions about the location of a … (AI summary)
Responded
Michael Berry
Concerns: 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.
Overdue
Mwitumwa Ngenda
Concerns: The coroner raised concerns regarding the appropriateness of urgent preventative measures on the bridge to prevent similar future incidents.
Overdue
George Dyson
Concerns: The coroner raises concerns about the appropriateness of protective safety measures on North Bridge, Halifax, and highlights the need to urgently consider implementing immediate measures to prevent future fatalities.
Response (Calderdale Council): • The Council completed a feasibility study in July 2018 to identify options for preventing suicides at North Bridge. • The Council's Cabinet approved the installation of anti-climb mesh and … (AI summary)
Responded
Karen Wiggins
Concerns: 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.
Overdue
Jordan Sheils
Concerns: The coroner expressed concern about the need to expedite measures for deterring tragedies at the location, particularly through the introduction of anti-climbing mesh and prominently displayed CCTV cameras overlooking the bridge.
Response (Calderdale Council): • Calderdale Council installed an additional CCTV camera on North Bridge on 23 November 2018. • The council submitted planning and listed building consent applications for anti-climb mesh and steeple … (AI summary)
Responded
Ben Walmsley
Concerns: 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.
Overdue
Emma Butler
Concerns: 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.
Response (Oxford Health NHS Trust): • The Trust is considering replacing plastic spoons with a more breakage-resistant alternative and will update policies on patient searching and observations. • Leave documentation and welcome packs will be … (AI summary)
Responded
Brian Goodman
Concerns: 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.
Response (One Housing): • One Housing stated it would work with its property services division to investigate alternative closures for fire doors in schemes identified as having a higher risk of suicide. • … (AI summary)
Responded
Benjamin Murray
Concerns: The coroner noted insufficient mental health disclosure on UCAS applications and to prospective universities, alongside the absence of formal investigation reports by universities following student deaths to identify lessons learned.
Response (University of Bristol): • The University communicates with prospective students to encourage mental health disclosure and supports UCAS in finding alternative declaration methods. • The University uses pre-arrival online inductions to gather information … (AI summary)
Response (UCAS): • UCAS provides information and advice pages on health and wellbeing support and developed content with partners to encourage applicants to declare mental health concerns. • UCAS is redeveloping its … (AI summary)
Response (Department for Education): • UCAS is reviewing its 'disability and special needs' question for the 2021 entry cycle to improve mental health disclosure in applications. • Universities UK's 'Suicide-safer Universities' guidance, published in … (AI summary)
Responded
Bradley Trevarthen
Concerns: 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.
Response (Department for Digital Culture Media Sport): • The government published its Online Harms White Paper, outlining plans for legislation to establish a statutory duty of care for online companies. • The Department for Education has made … (AI summary)
Responded
Jane Livingston
Concerns: Gateway assessors lacked full access to patient notes, which could result in assessments and treatment plans being based on incomplete information.
Response (Swansea Bay University Health Board): • An investigation confirmed that entries made during the first duty assessment were available for the later gateway assessment. • The Corporate Legal Team now makes a specific request for … (AI summary)
Responded
Jessica Duckworth
Concerns: The lack of fencing or other preventative measures at a bridge known as a suicide spot raises concerns about preventing people from falling.
Overdue
Joanna Orpin
Concerns: 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.
Response (the Isle of Wight National Trust): • The National Trust confirmed that seven Samaritans signs were in place at Culver Down. • The organisation initiated engagement with Public Health, the Isle of Wight Suicide Prevention & … (AI summary)
Responded
Annette Lewis
Concerns: 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.
Response (the Isle of Wight National Trust): • The National Trust confirmed existing measures at Culver Down, including Samaritans signs, bollards, and a stock fence. • The organisation initiated engagement with Public Health, the Isle of Wight … (AI summary)
Overdue
Miles Naylor
Concerns: 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.
Response (Bradford District NHS Trust): • The Trust reviewed its policy for Blanket Restrictions and introduced a model with a dedicated Consultant Psychiatrist for each inpatient ward. • A new approach to assessing and managing … (AI summary)
Responded
Muhammed Wajid
Concerns: The coroner noted Scammonden Bridge is a known location for fatalities and previous PFD reports have been sent to Kirklees Council and Highways England. Concerns remain that proposed steps to prevent future deaths at the location may not have been fully actioned.
Response (National Highways): • National Highways designed a 2.4m high parapet with anti-climbing features for Scammonden Bridge, with installation planned for Spring/Summer 2020. • An alert help telephone system and a camera surveillance … (AI summary)
Overdue
Natasha Abrahart
Concerns: 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.
Response (AWP): • The Trust distributed a Red Top Alert to relevant personnel, instructing them to follow NICE Guidance for antidepressant prescribing, including requirements for communication with primary care and documentation. • … (AI summary)
Response (the Department for Health and Social Care): • Health Education England (HEE) launched Self Harm and Suicide Prevention Frameworks in October 2018, which highlight the importance of health professionals having knowledge of national guidance, including NICE guidelines, … (AI summary)
Response (University of Bristol): • The practice amended its health assessment template to include a prompt for follow-up after commencing SSRIs and added a field regarding SSRI and suicidality. • The practice moved to … (AI summary)
Responded
Wesley Rowlands
Concerns: Redundant television brackets in HMP Garth cells, including the deceased's, remain in place and constitute ligature points. These will continue to be a risk until removed.
Response (HMP Garth): • Arrangements have been made to review all cells at HMP Garth and remove unused television brackets, with completion expected by February 2021. • The organisation will review similar accommodation … (AI summary)
Responded
Tina Murray
Concerns: 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.
Response (Belgravia Care Home): • Plastic bags have been removed from all residents' bedrooms. • Bags brought in by residents from shops are removed, cut up, and safely disposed of upon return to the … (AI summary)
Responded
Michael Dobson
Concerns: The coroner raises concerns that if cell electricity issues are not resolved until the following day after lockdown, this could create a risk of prisoners harming themselves, suggesting basic maintenance availability during lockdown hours.
Response (Serco Home Affairs HMP Dovegate): • A system has been implemented to remedy electricity faults within cells during out-of-hours periods. • An on-call facilities maintenance officer is available to attend the prison at any time … (AI summary)
Responded
Heather Page
Concerns: 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.
Response (Nottinghamshire County Council): • Nottinghamshire County Council stated it has been and remains supportive of improving level crossing safety. • The Council successfully diverted Barratt No.2 crossing in 2014 following an application from … (AI summary)
Response (Network Rail): • Network Rail stated it is ready and willing to work with the coroner to seek potential solutions to the matters of concern. • Network Rail invited the coroner to … (AI summary)
Response (Derbyshire County Council): • Derbyshire County Council issued an order in 2003 to divert Public Footpath No.7, which was subsequently cancelled. • The council received correspondence in 2015 from Network Rail regarding a … (AI summary)
Response (Broxtowe Borough Council): • Broxtowe Borough Council has scheduled a meeting with Network Rail for 22 October 2021 to discuss potential solutions. • The council stated it would provide an update on the … (AI summary)
Response (Erewash Borough Council): • Erewash Borough Council participated in Network Rail's Level Crossing Closures Programme consultation in July 2015. • The Council submitted a response supporting proposals to improve safety and accessibility at … (AI summary)
Responded
Wayne Boughen
Concerns: 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.
Response (HM Prison and Probation Service): • A revised version of the Assessment, Care in Custody Teamwork (ACCT) process was fully introduced across the male estate, including HMP Leeds, since the inquest. • All staff at … (AI summary)
Overdue
Joseph Dent
Concerns: 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.
Response (Durham County Council): • Durham County Council initiated a Multi-agency Assurance Review (MAAR) following the death, which resulted in a community response including the dissemination of support information and the mobilisation of mental … (AI summary)
Responded
Chloe English
Concerns: 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.
Response (Calderdale Metropolitan Borough Council): • The Council installed anti-climb mesh, steeple coping, Samaritan signs, and improved CCTV coverage in 2019. • Temporary fencing has been installed to increase the overall height of protection. • … (AI summary)
Responded
Jack Ritchie
Concerns: The coroner noted insufficient regulation, warnings, and information to prevent gambling by an addicted individual. Concerns were also raised about inadequate treatment options due to a lack of training for medical professionals, particularly GPs, and insufficient education for young people on gambling harms.
Overdue
James Forryan
Concerns: 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.
Response (Department of Health and Social Care): • The Government confirmed that the Online Safety Bill will require in-scope companies to remove illegal content, including that which encourages or incites suicide, and will list encouraging or assisting … (AI summary)
Responded
Emma Pring
Concerns: The coroner noted that older versions of anti-ligature clothing, which the deceased used to form a ligature, remain in circulation and may provide false reassurance to staff regarding self-harm risk, despite subsequent product improvements by the manufacturer.
Response (Ramsdens Solicitors): • The client notified customers who had been supplied with similar products. • The client recommended customers check their stock of seclusion garments for damage, especially those supplied before April … (AI summary)
Responded
Matthew Caseby
Concerns: The coroner identified issues at the Priory Hospital with record-keeping accuracy and the timely updating of risk assessments. Concerns were also raised regarding the failure to learn from previous incidents to improve courtyard fence safety and the absence of national guidelines for perimeter security in mental health units.
Response (Gillian Keegan MP): • Officials were asked to investigate the recommendation for national guidelines for perimeter fences and security in acute mental health unit outside areas. • Officials will collect data on ward … (AI summary)
Response (Priory Group): • The Priory Group issued staff bulletins and updated policies on accurate record-keeping, shift handovers, and clinical risk assessment, incorporating inquest learnings and adding prompts to its incident reporting system. … (AI summary)
Responded
Zoe Zaremba
Concerns: 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.
Response (TEWV): • The Trust has begun to examine records of patients with both an Autism marker and an Emotionally Unstable Personality Disorder (EUPD) diagnosis to understand the rationale and validity of … (AI summary)
Response (Tees Esk and Wear Valleys NHS Foundation Trust 21 June): • The Trust identified 134 patients with both autism and Emotionally Unstable Personality Disorder diagnoses and commenced a review of these records to assess diagnostic validity and patient communication. • … (AI summary)
Response (Humber and North Yorkshire Health Care Partnership): • The Integrated Care Board (ICB) is considering the commissioned pathway for specialist autism therapy. • The ICB and Tees Esk and Wear Valley NHS Foundation Trust (TEWV) are committed … (AI summary)
Response (NHS England): • NHS England allocated £7 million for local areas to test ways to improve autism diagnostic pathways. • NHS England supported autism training for staff in adult mental health inpatient … (AI summary)
Response (Department of Health and Social Care): • Registered providers are required to ensure staff receive specific training on learning disability and autism from July 2022. • The government is investing £70 million in 2022/2023 to improve … (AI summary)
Responded
James Booth
Concerns: The Priory had inadequate garden fence security, and national guidance for 'locked ward' perimeter fencing was absent. Insufficient information exchange at handovers, with uncompleted forms, hindered recognition of emerging behaviour.
Response (Priory Group): • A review of shift handovers in July and August 2022 found them satisfactory, and safety bulletins were issued across the Priory Healthcare portfolio. • An electronic handover template is … (AI summary)
Response (Department of Health and Social Care): • Department officials worked with stakeholders to explore expanding the evidence base on physical barriers in patient safety. • The National Confidential Inquiry into Suicide and Safety in Mental Health … (AI summary)
Responded
Select committee recommendations(3)
#36 —
Recommendation: 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 …
Response attribution not verified
#26 — Include provisions in Bill requiring enhanced tier premises to consider security in building design.
Recommendation: The Government should include provision in the Bill to require new publicly accessible buildings, which would fall within the category of enhanced tier premises, to consider security in the design of the building.
Response status not verified
#25 — Publicly accessible new builds should incorporate security considerations into their design.
Recommendation: We agree that the Draft Terrorism Bill could be strengthened by making it a requirement for publicly accessible new builds to consider security in the design of the building.
Response status not verified
HSSIB safety recommendations(5)
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 …
Safety Observation
Mental health inpatient settings
HSSIB recommends that the Department of Health and Social Care undertakes assessment of the capital requirements of the built environments across high-secure services in England and develops plans to ensure the long-term safety of patients, staff and the public.
Safety Recommendation
Keeping children and young people with mental health needs safe: the design of the paediatric …
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.
Safety Recommendation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
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 …
Safety Observation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
HSSIB recommends that the Department of Health and Social Care, with input from stakeholders including NHS England, identifies the short-, medium- and long-term requirements of NHS mental health built environments to ensure they enable delivery of safe and therapeutic care …
Safety Recommendation
CQC inspection actions(17)
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.
Must Do
Royal Shrewsbury Hospital
The trust must ensure the mental health room exit complies with statutory requirement.
Must Do
Royal Preston Hospital
The trust must ensure patients with a mental health concern are cared for in a room that is free from objects that could be used to self-harm
Must Do
The Whittington Hospital
The trust should ensure an environmental risk assessment is carried in all maternity areas and emergency call bells are ligature free.
Should Do
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.
Must Do
Bushey Fields Hospital
Ensure that the health-based places of safety reflect the national guidance regarding environment to ensure people using services are protected against the risks of potentially unsafe or unsuitable premises.
Should Do
William Harvey Hospital
The trust should ensure ligature risk is reassessed and added to the risk register for the paediatric emergency department.
Should Do
The Princess Royal Hospital
The trust must ensure the mental health room exit complies with statutory requirement.
Must Do
Mount Vernon Cancer Centre
The trust must ensure that environmental risk assessments, including ligature risk assessments, are completed and monitored to assess the risk of harm to vulnerable patients.
Must Do
King George Hospital
The service should continue to find solutions to minimise environmental risks to mental health patients.
Should Do
Kettering General Hospital
The service should ensure it introduces a ligature managed and confidential environment for patients experiencing mental health crisis.
Should Do
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.
Must Do
St Benedict's Hospice
The service must review designated mental health assessment rooms regularly to identify any changes that may impact on patient safety.
Must Do
Royal Derby Hospital
Complete and regularly review ligature risk assessments of the maternity environment.
Should Do
Durham Diagnostics and Treatment Centre
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.
Must Do
Mount Vernon Cancer Centre
The trust must ensure that the design of the ward is secure, suitable for purpose for which they are being used, properly used and properly maintained.
Must Do
Chorley and South Ribble Hospital
The trust must ensure patients with a mental health concern are cared for in a room that is free from objects that could be used to self-harm
Must Do
PPO death in custody recommendations(7)
Governors of prisons with MCBS units
Governors should ensure that safe and appropriate practices are always followed in the supply of razors to prisoners in MCBS units.
The Governor
The Governor should ensure that officers check the condition of door hinge securing bolts when making their daily cell fabric checks.
The Director and Head of Healthcare
remove or restrict prisoners’ access to items such as razors, when they present a risk of harm by cutting;
The Governor of HMP Berwyn
The Governor should ensure that: prisoners are not placed in cells that do not meet the minimum requirements, in accordance with PSI 17/2012.
The Governor of HMP Berwyn
The Governor should ensure that: cell conditions are properly checked and documented;
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: cell conditions are properly checked and documented, especially in circumstances where prisoners have alerted staff to faults that may require repair; repairs are promptly reported and fully documented and that there is a clear audit …
IOPC learning recommendations(5)
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 …
IMB individual recommendations(13)
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
Leeds (2022)
In respect of self-inflicted deaths in custody, is there more that could be done to reduce the likelihood of such incidents happening again?
Governor / Director
Erlestoke (2023)
What immediate actions will be taken to address the inadequate and potentially dangerously deficient constant watch cell?
Governor / Director
Leeds (2024)
Is the Minister satisfied that all necessary resources are being delivered to significantly reduce self-inflicted deaths?
Other
In Progress
Feltham (2024)
Will the YCS look at changing the policy where any boy who removes parts from his laptop, in order to make a weapon, is given a replacement after only 28 days? Will the YCS also look at the design of laptops so they do not include removable strips of rigid metal or other removable parts that can be sharpened into …
HMPPS
In Progress
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
Noted
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
In Progress
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
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
Erlestoke (2023)
What actions will be taken to improve first night accommodation?
Governor / Director
Eastwood Park (2024)
Finalise proposals to replace residential unit 7, ensuring the replacement building is subject to a feasibility study/whole-life costing and provides a permanent building with a gender-specific, trauma-informed design in accordance with the Female Offender Strategy Delivery Plan 2022-2025.
HMPPS
In Progress
Five Wells (2025)
What improvements are planned to remedy faults in the design of new prisons, such as poor ventilation, lack of facilities, poor physical security, which have been identified in IMB reports?
Ministry of Justice
Noted
Feltham (2025)
Change the policy where a boy who removes parts from his laptop, in order to make a weapon, is given a replacement after only 28 days; and look at the design of laptops so they do not include removable strips of rigid metal or other removable parts that can be sharpened into weapons.
HMPPS
Health investigations(4)
Independent investigation: Antonio Tommaso, New Barnet (2014) — Rec 2
The Trust ensures that equipment that is currently free-standing (bench, basketball hoop) in the garden area of the ward from which Mr EF went missing is fixed to the floor. The aim is to put barriers in place, recognising that a recreational area can be high risk
london
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 38
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all in-patient units have appropriate security arrangements in place, and that these arrangements are regularly reviewed and updated.
midlands
Independent investigation into the care and treatment of Mr EF — Rec 2
The Trust ensures that equipment that is currently free-standing (bench, basketball hoop) in the garden area of the ward from which Mr EF went missing is fixed to the floor. The aim is to put barriers in place, recognising that a recreational area can be high risk
Mr EF who committed a homicide in May 2014. Mr EF was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust
london
An independent investigation into the care and treatment of Emily … — Rec 12
TEWV must provide assurance that all ligature risks identified in Tunstall Ward in 2019 have been addressed.
An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Detention investigations(4)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 18
IND pulls together the lessons on design from the Yarl’s Wood experience (size, long corridors, siting of the control room, construction materials etc) and ensures that they underpin the production of any future footprints or alternative designs submitted by contractors.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 11
IND reviews the location of command suites in existing and future removal centres.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 10
the use of remotely-operated locks for zone gates be considered in all future removal centre designs, taking account of any fire safety requirements.
Immigration Detention
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
Independent reviews(7)
Harris Review: Deaths in Custody — Rec 13
All cells that have achieved certified to “Safer Cell” standards should then be maintained to that standard unless there is a documented decision by the Governor to allow the “Safer Cell” designation for that cell to cease.
Justice & Legal
Harris Review: Deaths in Custody — Rec 12
NOMS should provide sufficient capital funds to allow for the building or the modernisation of sufficient cells to “Safer Cell” standards to meet that assessment and also for the subsequent maintenance of the sufficient cells to that standard.
Justice & Legal
Harris Review: Deaths in Custody — Rec 11
Each establishment, guided by instructions from NOMS if necessary, should review their estate and their population demographics and make a formal ongoing assessment of the minimum number of “Safer Cells” that are considered necessary to accommodate those requiring this additional protection.
Justice & Legal
Harris Review: Deaths in Custody — Rec 10
Window design in safer cells should allow an air flow and be free of possible attachment points for a ligature.
Justice & Legal
Wessely Review — Rec 87
A review should be undertaken of the physical requirements for ward design for mental health units (e.g. the building notes, regulatory standards).
Health & Social Care
Accepted
Hackitt Review — Rec 2.6
Government should ensure that there is thorough assessment by the JCA of detailed design plans for HRRBs and sufficient assurance that dutyholders are in place and relevant responsibilities are being met in order to give permission for building work to legally commence. This should be in line with paragraphs 2.29-2.32. …
Building Safety
Accepted
Hackitt Review — Rec 1.3
The regulatory framework should treat the building as a single entity (a system encompassing sub-systems) and a new over-arching Approved Document should be published describing the system and the holistic analyses that must be completed when undertaking building work. This should define the requirement to understand the interactions of the …
Building Safety
Accepted
PHSO casework decisions(3)
P-001550 — Essex Partnership University NHS Foundation Trust
Mr D complained his son sustained severe injuries under Trust care due to a failure to ensure his safety and move him to a more secure unit.
NHS in England
Sep 2022
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.
NHS in England
May 2023
P-004700 — Independent Case Examiner
Mr E complained DWP and ICE did not recommend sufficient financial remedy or service improvements after DWP failed to follow correct procedures regarding his suicidal ideation.
UK Government
Jan 2026
LGO / SPSO decisions(2)
21-018-706 — Hampshire County Council
Summary: Mr X complained that the Council failed to carry out a proper risk assessment when it changed his daughter, D’s, care plan and stopped his visits in response to the COVID-19 pandemic. He said this resulted in D’s suicide attempt. We find that there was fault in the Council’s …
LGO (Local Government & …
Education
Upheld
Dec 2022
NIPSO-17293 — South Eastern Health and Social Care Trust
Our investigation found that the South Eastern Trust failed to properly assess the risks faced by a patient, and could have done more to help him before his death.
NIPSO (NI Public Service…
Health & Social Care
May 2021