Themes | Mental Health | The Accountability Index

Ligature points

Accessible ligature points in prison cells and mental health wards, posing a risk of self-harm and suicide.

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Jun 2014 · Cumbria (South & East)

Unidentified ligature points, inadequate patient searching for contraband, poor communication of escalating risks, and incomplete GRIST assessments contributed to the patient's death in a mental health unit.

Matched on exact phrase terms: ligature, point

Cherylin Norrell-Goldsmith

Oct 2014 · Surrey

Concerns include accessible ligature points in cells, insufficient multi-disciplinary input in ACCT reviews, and critical medical information not being readily available to prison staff on non-medical records. Data retention issues also exist.

Matched on exact phrase terms: ligature, point

Aug 2018 · South Wales Central

External consultants had insufficient input into mental health patients' physical care, bureaucratic processes delayed rectifying ligature points, and the system for managing dangerous patient items was ineffective.

Matched on exact phrase terms: ligature, point

Wesley Rowlands

Oct 2020 · Lancashire and Blackburn with Darwen

Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.

Matched on exact phrase terms: ligature, point

Mar 2021 · Birmingham and Solihull

Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.

Matched on exact phrase terms: ligature, point

David Sutherland

1. SPS should develop a standardised toolkit for auditing cells for the presence of ligature anchor points at HMP Barlinnie and use the toolkit to conduct an audit of potential ligature points within all standard cells. Following from this audit, SPS should take steps to make standard cells at HMP Barlinnie safer by identifying and removing, as far...

Matched on exact phrase terms: ligature, point

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 exact phrase terms: ligature, point

Katie Allan; William Brown

1. Double bunk beds should be removed from all cells in any wing or hall within Polmont in which young prisoners are accommodated. SPS must take all necessary measures to ensure that no young prisoner is in future accommodated on a single occupancy basis in a cell in which there is a double bunk bed. 2. All door...

Matched on exact phrase terms: ligature, point

Isobel Griffin and Jane Clark

Feb 2015 · Northamptonshire

For Jane Clark, challenging events were not handed over, the nurse in charge did not read the notes before granting leave, risk assessment was ill-informed, not discussed, and poorly documented; for Isobel Griffin, there were issues with key worker allocation, updating risk assessments, clinician reviews, medication management, and ligature points.

Matched on exact phrase terms: ligature, point

Oct 2016 · East Riding and Kingston-upon-Hull

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 exact phrase terms: ligature, point

Mina Topley-Bird

County Durham and Darlington

Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for ligature points were unconfirmed, and risk assessment processes remained incomplete.

Matched on exact phrase terms: ligature, point

Not all ligature points had been considered within the environment.

Matched on exact phrase terms: ligature, point

May 2018 · Bedfordshire & Luton

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: ligature, point

Jul 2022 · Bedfordshire and Luton

A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without plans for remedy.

Matched on terms: ligature, point

Apr 2019 · London Inner (North)

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: ligature, point

IOPC learning recommendation

Recommendation - Sussex Police, May 2021

The IOPC recommends that Sussex should: a) inform custody officers and staff of the risk of allowing detainees to keep face masks in cells. Such items can be modified to form a ligature which can be used to cause injury to a detainee intent on causing harm to themselves. and b) inform custody officers and staff that the...

Matched on terms: ligature

Dr Sara Lilian Macrae

(i) When staff in a secure mental health ward are presented with evidence that a patient has vocalised suicidal ideation and demonstrated means to complete suicide by presentation of a ligature, urgent action to search that patient’s room and person for any other potential ligatures ought to be taken. In addition, consideration should be given to placing the...

Matched on terms: ligature

Jan 2020 · West Yorkshire (West)

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: ligature

Jun 2021 · West Yorkshire Eastern

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 terms: ligature

Sep 2022 · Surrey

Ligature risk policies inadequately address potential ligature items like clothing, focusing instead on anchor points and avoiding 'blanket restrictions' without sufficiently identifying actual risks to vulnerable patients.

Matched on terms: ligature, point

IOPC learning recommendation

Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, June 2022

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 custody staff understand the ligature risk associated with plimsolls provided to detainees. Where a detainee is assessed as being at current risk of self-harming, any mitigation to the risk...

Matched on terms: ligature

Michaela Christoforou

May 2014 · London (North)

All staff at the unit did not carry ligature cutters, posing a significant risk in preventing self-harm incidents.

Matched on terms: ligature

Mar 2015 · Peterborough

Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks a structured national pro forma, leading to inconsistent risk assessments and over-reliance on current prisoner demeanour.

Matched on terms: ligature

Sep 2019 · Black Country

Multiple failures in multi-agency communication, inadequate staff training, and poor risk management regarding ligature use, patient observations, and resuscitation significantly compromised care for a patient with complex mental health needs.

Matched on terms: ligature

Apr 2022 · Mid Kent and Medway

"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 terms: ligature

May 2022 · Sefton, St Helens and Knowsley

Newly built mental health units lack mandatory requirements or regulations for fitting ligature alarms on doors, despite guidance for anti-ligature fixtures, posing a significant safety risk.

Matched on terms: ligature

Manchester City

Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had access to ligatures, and risk assessments were not properly updated.

Matched on terms: ligature

Oct 2022 · South Wales Central

The distribution of ligature cutters to frontline police officers remains incomplete, posing a risk in emergency situations. Additionally, bespoke training for officers responding to mental health crisis incidents is not widely available.

Matched on terms: ligature

IOPC learning recommendation

Man died after an attempt to take his own life during a police response – South Wales Police,...

The IOPC recommends that all Police forces should consider equipping all operational police vehicles with some form of implement that would be capable of cutting a ligature of a width greater than a few millimetres. Training should also be given to officers in how and when to use such a piece of equipment. The item of equipment will...

Matched on terms: ligature

IMB recommendation

The Board reiterates the concerns of Dame Anne Owers in her letter of 11 November 2020 to the Director General of Prisons regarding the decision that the making of a ligature by prisoners is no longer a nationally reportable self-harm incident.

Matched on terms: ligature

IOPC learning recommendation

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 others. Hampshire Constabulary should review their custody policies to clarify guidance around the provision of cutlery. Firstly, in...

Matched on terms: ligature

IOPC learning recommendation

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 detainee or others. Custody leads are specifically asked to: a) Note and inform their staff that plastic cutlery...

Matched on terms: ligature

Mihangel ap Dafydd

May 2016 · Carmarthenshire and Pembrokeshire

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 terms: ligature

Francesca Whyatt

Aug 2017 · London Inner (West)

Key safety gaps include no risk assessment for ward configuration, inadequate guidance on agency staff observation competency, and the failure to automatically treat ligature incidents as Serious Untoward Incidents (SUIs), despite the rapid risk of death.

Matched on terms: ligature

Corin Bonaparte

May 2021 · Exeter and Greater Devon

An ACCT was not opened despite the patient seeking help from the mental health department at HMP Dartmoor and revealing recent self-harm, suggesting inadequate training; the ambulance was kept waiting 8 minutes at the main gate, suggesting inadequate arrangements for swift ambulance departure in emergencies.

Matched on classifier match

HSSIB recommendation

Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients...

HSSIB recommends that NHS England, working with other relevant national bodies, develops guidance on how to reduce and respond to non-anchored ligature risks. This will help staff to support people who attempt to hurt themselves with non-anchored ligatures and improve patient safety whilst maintaining a therapeutic environment.

Matched on terms: ligature

Kettering General Hospital

The service should ensure it introduces a ligature managed and confidential environment for patients experiencing mental health crisis.

Matched on terms: ligature

Ellesmere Port Hospital

The trust must ensure that patients identified with a mental health condition are cared for in a safe ligature free environment and have appropriate risk assessments completed.

Matched on terms: ligature

PPO recommendation

The Head of Custodial Contracts, in conjunction with the MoJ Prison Infrastructure Team and MoJ Property Directorate Technical...

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 to ensure that the anti-ligature features remain effective.

Matched on terms: ligature

IMB recommendation

Usk and Prescoed (2021)

With respect to the promotion of prison safety, the Board supports the concerns of Dame Anne Owers (letter to the Director General of Prisons, November 2020) regarding the decision that making a ligature (also known as noose making) by prisoners should no longer be a nationally reportable self-harm incident.

Matched on terms: ligature

Christopher Shapley

Mar 2014 · Cardiff & the Vale of Glamorgan

Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.

Matched on classifier match

Mar 2014 · Teesside

Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.

Matched on classifier match

Mark Bartholomew

May 2014 · Manchester (North)

Inadequate emergency response included missing patient details and lost documentation. Critical delays occurred because ligature cutters were not readily available and observation records lacked detail, hindering timely intervention and oversight.

Matched on terms: ligature

Peter Farebrother

Jun 2014 · Shropshire, Telford & Wrekin

Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an unsafe environment. The effectiveness of the "sloping door" design against hanging was also questioned.

Matched on terms: ligature

Dec 2015 · Milton Keynes

There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.

Matched on classifier match

May 2016 · London Inner (North)

Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 information, a nurse failing to acknowledge radio calls, and not immediately bringing a defibrillator.

Matched on classifier match

Sep 2016 · Black Country

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 terms: ligature

Sep 2017 · Liverpool & Wirral

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

Robert McLoughlin

Oct 2018 · West Yorkshire (East)

The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.

Matched on terms: ligature

Bethany Tenquist

Mar 2019 · Brighton and Hove

Flawed room checks and inadequate staff training led to dangerous items remaining accessible to vulnerable patients. This highlights critical deficiencies in self-harm prevention protocols.

Matched on classifier match

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