Ligature points
Accessible ligature points in prison cells and mental health wards, posing a risk of self-harm and suicide.
Source spread
Where this theme appears
This theme appears across 17 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
80 PFD reports
2 committee recs
3 HSSIB recs
33 CQC actions
3 PPO recs
18 IOPC recs
40 IMB recs
10 IMB reports
5 Scottish FAIs
5 Article 2 learning points
2 detention investigation recs
4 LGO/SPSO decisions
13 CJINI reports
9 CQC enforcement actions
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.
Prevention of Future Deaths reports(80)— showing 50 strongest matches
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 Inkin
Concerns: The coroner raised concerns about the shortage of local psychiatric beds, communication gaps between services and out-of-area providers, and insufficient staff training and escalation protocols regarding suicidal intent at Cygnet ward.
Overdue
Christopher Shapley
Concerns: The Person Escort Record form lacked a section for prior hospital treatment and had issues with securely attaching warning documents, hindering information transfer to the prison. Furthermore, prison staff did not always review all available risk information, and efforts to find a suitable cellmate were insufficient.
Overdue
Andrew Hall
Concerns: Inadequate documentation and communication among mental health, healthcare, and prison staff regarding the deceased's condition and self-harm risk were identified. Also noted were insufficient observation, unadministered medication, and deficiencies in CCTV systems and staff training.
Response (HM Prison and Probation Service): • The prison stated that ACCT reviews include recorded information from the mental health team, and mental health staff receive ACCT training, with further courses arranged for visiting psychiatrists. • … (AI summary)
Overdue
Mark Bartholomew
Concerns: The coroner noted an inadequate response to external emergency services, with a lack of critical patient details and mislaid documentation. Concerns were also raised about the unavailability of ligature cutters in an emergency and insufficient detail in observation records.
Overdue
Michaela Christoforou
Concerns: The coroner noted that staff at the unit did not carry ligature cutters.
Response: • Nine sets of ligature cutters have been located throughout Rhodes Farm. • Clinical staff will carry ligature cutters for a six-month trial period. • A protocol covering the carrying … (AI summary)
Responded
James Boylan
Concerns: The coroner noted removable bathroom rails created ligature points, staff were unaware they were removable, and an undetected blade was brought onto the ward. Concerns were also raised about fragmented communication preventing an overall view of the patient's escalating condition and the incomplete dissemination of assessments.
Response (Department of Health): • NHS England has developed resources and audit tools to support clinical staff in mental health risk assessment and multidisciplinary working. • NHS England has developed further suicide prevention measures … (AI summary)
Overdue
Peter Farebrother
Concerns: Concerns involved delayed patient transfer and staff's non-recognition of constant observation status due to inadequate handover, alongside the return of a ligature risk belt. The report also noted an ineffective sloping door designed to prevent hanging and reduced staff risk awareness on the ward.
Overdue
Cherylin Norrell-Goldsmith
Concerns: The coroner raises concerns about open pipe work in cells as potential ligature points for vulnerable prisoners. Additionally, there are concerns regarding insufficient multi-disciplinary input at ACCT reviews and a lack of accessible recording of significant medical events on non-medical records for prison staff.
Response (HM Prison and Probation Service): • HMP Downview's local policies and procedures have been reviewed and strengthened. • A system to inform staff of ACCTs will be reintroduced, and new recording and communication practices for … (AI summary)
Overdue
Isobel Griffin and Jane Clark
Concerns: Concerns include inadequate information handover, staff not reading patient notes before making critical decisions, and poor or outdated risk assessment documentation. The coroner also noted delayed patient reviews and the presence of non-ligature-proof doors.
Overdue
Stuart Baumber
Concerns: The coroner identified that many prison cell doors lack current anti-ligature strips due to no national retrofit programme. There is also an absence of a national pro forma for the ACCT process, leading to over-reliance on current risk assessment.
Overdue
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
Craig Chappell
Concerns: The report identifies a lack of formal communication for family concerns and insufficient guidance for prison staff on supporting potential abuse victims. Non-healthcare staff also inappropriately relied on a subject's presentation without further investigation.
Overdue
Diane Knight
Concerns: The coroner noted that placing towels over doors could conceal patient attempts to cause themselves harm and prevent proper staff monitoring. This practice should be reviewed, and alternative methods for patient privacy considered.
Response (Diane Knight): • The practice of covering bedroom windows with towels has been discontinued. • A trust-wide safety briefing was produced and published to all staff regarding the risks of obscuring observation … (AI summary)
Responded
Daniel Byrne
Concerns: The coroner noted repeated issues identified by the PPO regarding the failure to assess risk of self-harm in new prisoners at Woodhill. A specific concern was that nursing staff did not participate in Mr Byrne's health screen or first review.
Response (Daniel Byrne): • The reception screening tool was strengthened to include more detailed questions on mental health and self-harm risk, and staff were trained in its use. • The number of experienced … (AI summary)
Response (Daniel Byrne Response2): • Reviews of all aspects of safer custody and healthcare services at HMP Woodhill have been commissioned. • The Entry to Custody Risk Assessment (ECRA) record is being introduced in … (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
Samuel Blair
Concerns: The coroner highlighted a lack of comprehensive mental health assessment and proper record-keeping regarding Mr Blair's medication upon prison reception. Also noted were delays in emergency response, including communication of ambulance gate location and difficulties in accessing resuscitation equipment.
Response (London Ambulance Service NHS Trust): • The London Ambulance Service (LAS) updated its Computerised Gazetteer to record multiple vehicular entrances for HMP Pentonville and requested prison staff to specify the entrance during 999 calls. • … (AI summary)
Response (Care Uk): • Care UK stated it would collaborate with Barnet, Enfield and Haringey Mental Health Trust (BEH-MHT) to implement their action plan and ensure all healthcare staff are aware of it. … (AI summary)
Response (HM Prison and Probation Service): • HM Prison and Probation Service issued Prison Service Instruction 29/2015, which requires establishments to conduct First Aid risk assessments. HMP Pentonville confirmed its local risk assessment is up to … (AI summary)
Overdue
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
Christopher Brennan
Concerns: The coroner identified a lack of specific policy for managing self-harm risks from items in an adolescent psychiatric unit, which led to inconsistency. Concerns also included the absence of a laryngoscope in the unit's emergency equipment, an item previously used successfully.
Overdue
Wendy Telfer
Concerns: The coroner noted insufficient training for physical healthcare staff regarding mental health needs and the application of the Mental Health Act. Concerns were also raised about the persistent lack of available psychiatric beds, which caused delays in patient transfer.
Response (Northern Eastern and Western Devon NHS Trust): • The CCG monitors delayed discharge data from mental health wards through local boards and contract review meetings. • Devon Partnership NHS Trust (DPT) has temporarily repurposed rehabilitation unit capacity … (AI summary)
Response (Royal Devon and Exeter NHS Trust): • The Royal Devon and Exeter NHS Trust stated that its Liaison Psychiatry Team provided formal training on the Mental Health Act (MHA) to at least 496 staff in 2016, … (AI summary)
Response (Devon Partnership NHS Trust): • The Trust established a central bed management team, secured additional contracted bed capacity, and extended the operational times of Crisis Resolution and Home Treatment teams. • The Trust implemented … (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
Deidre Harvey
Concerns: The coroner identified insufficient input from outside consultants into the care of mental health patients, delays in rectifying ligature points due to bureaucratic processes, and a lack of effective systems for tracking dangerous items taken from and returned to patients.
Response (Welsh Government): • Welsh Government officials will discuss the incident at the all Wales Serious Incidents Group in October. • The Welsh Government will keep the case and the learning that arises … (AI summary)
Response: • An Action Plan for Improvement was developed and updated to reflect the concerns identified. • A safe system for recording items stored in and taken from patient PODS has … (AI summary)
Response (NHS England): • NHS Improvement undertook a search of the National Reporting and Learning System. • NHS Improvement stated it would support the MHRA in ensuring any future changes to monitoring reach … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) assessed data related to the concern regarding hydroxychloroquine levels. • The MHRA sought advice from the Commission on Human Medicines' Pharmacovigilance … (AI summary)
Response (Department of Health Social Care): • NHS England committed to increasing the number of people with serious mental illness whose physical health needs are met by 280,000 by 2020/21. • NHS England, in conjunction with … (AI summary)
Responded
Daniel Dunkley
Concerns: The coroner noted that three referrals for mental health assessments for Mr Dunkley were not carried out before his death, and a scheduled assessment was not communicated to him or his unit.
Overdue
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
Francesca Whyatt
Concerns: The coroner identified a lack of risk assessment for the East Wing ward's multi-floor layout and insufficient formal guidance on observation competency for agency staff. Further concerns included a lack of clear policy for classifying and investigating ligature incidents as Serious Untoward Incidents.
Response (Priory Hospital): • The hospital confirmed that environmental risk assessments, including ligature and safety audits, are conducted twice yearly and refreshed annually. • A new requirement has been added to Policy H43, … (AI summary)
Overdue
Sean Plumstead
Concerns: Winchester Prison has inadequate systems for storing and retrieving telephone recordings and staff interview recordings, often providing only summary transcripts. This lack of proper retention of important electronic and documentary evidence with specific prisoner records is a recurring issue, posing a risk for future deaths.
Response (HM Prison Probation Services): • HMP Winchester has assigned temporary staff to transcribe encrypted telephone call recordings and implemented a new protocol for information and evidence gathering. • Recordings of staff interviews have been … (AI summary)
Response (Carillion): • Carillion familiarised itself with PSI64/2011 and its updates to ensure compliance with HMPPS policies. • Carillion contacted HMPPS to support Prison Governors in ensuring staff receive appropriate training. • … (AI summary)
Response (HM Prison Probation Services.2): • The Introduction to Safer Custody course was replaced by the Introduction to Suicide and Self-Harm Prevention (SASH) course in May 2017. • The SASH course is delivered to all … (AI summary)
Responded
Liam Thomas
Concerns: The coroner raised concerns regarding a patient's access to restricted plastic bags and the effectiveness of environmental checks. There was also a need for improved communication between staff and the patient's family, particularly concerning elevated risk information.
Response (Oxford Health NHS Trust): • The Trust issued new guidance for staff on managing restricted plastic bags and introduced a new standard operating procedure for environmental checks. • A Carer's Handbook and ward welcome … (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
Robert McLoughlin
Concerns: The coroner noted low staffing at HMP Leeds on the evening of 19th February 2016. On the morning of 20th February, low staffing levels meant no Landing Officer was present, preventing ACCT reviews for several hours.
Overdue
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
Bethany Tenquist
Concerns: The coroner identified that checks for dangerous items in patient rooms were incomplete and flawed, citing an instance where a dressing gown cord was left available after other items were removed. This highlights an unsatisfactory system for room checks or insufficient staff training.
Response (Sussex NHS Trust): • The Trust investigated the reported communication issue with the Police, engaging with the Chief Constable and ensuring the Deputy Chief Nurse oversees information provision. • The Trust and the … (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
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
Shannon Quinn
Concerns: The coroner identified inconsistent medical note sharing and a lack of a joint care plan between the Mental Health Trust and care home. Insufficient staff training and inadequate self-harm risk management, including observation adherence, were also noted.
Response (Camino Healthcare): • The service is in the process of closing and is anticipated to be fully closed within 6 to 8 weeks. • Camino Healthcare undertook a review of the service … (AI summary)
Response (CQC): • The CQC conducted comprehensive inspections of Oak House in May and June 2019, identifying serious concerns regarding risk management, incident reporting, and managerial oversight. • The CQC took urgent … (AI summary)
Overdue
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
Christopher Swain
Concerns: The coroner identified inconsistent patient observation practices, with staff not always entering rooms, leading to uncertainty about when a patient was last seen. Additional concerns included deficiencies in mental health review, care planning, and record keeping, as well as insufficient staff for escorting sectioned patients.
Response (Sussex Partnership NHS Foundation Trust): • The Trust refreshed guidance on patient observations, introduced pocket guides and easy-read posters, and updated mandatory training for all staff. • A review of professional conduct was completed, and … (AI summary)
Responded
Azra Hussain
Concerns: The coroner noted that family concerns about a patient's reported suicide attempt were not recorded, shared, or acted upon, nor included in the MDT meeting. There were also unmitigated ligature risks identified in an en-suite bathroom following an assessment.
Response (Birmingham and Solihull Mental Health NHS Foundation Trust): • The Trust implemented a system for a form to be completed in advance of multidisciplinary team (MDT) meetings, requiring family input to be sought and considered. • The Trust … (AI summary)
Response (Health and Safety Executive): • The Health and Safety Executive stated that the safety of the environment for patients, including the management of ligature points, falls within the remit of the Care Quality Commission. … (AI summary)
Response (NHS Birmingham and Solihull ICB): • Serious adverse incidents are subject to root cause investigation and monitoring to ensure identified actions are implemented. • A piece of work to assess and mitigate ligature points in … (AI summary)
Response (CQC): • CQC placed conditions on the trust's registration in November 2020, requiring action to address ligature risks, improve risk assessments, and enhance care planning. • CQC is receiving monthly updates … (AI summary)
Responded
Mina Topley-Bird
Concerns: Concerns included the electronic notes system's inability to upload PDF medical records and difficulties printing in shared premises. The coroner also noted an incomplete patient safeguarding risk assessment process and unassured ligature point inspections.
Response (Dept. of Health and Social Care): • Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) implemented a process for forwarding patient information from the home Trust by email to the admitting ward nurse. • TEWV … (AI summary)
Response (West Park Hospital): • The Trust implemented a checklist for out-of-area patients and increased liaison team staffing to address IT system limitations. • The suicide prevention environmental survey was revised, and an extensive … (AI summary)
Responded
Rohan Singh
Concerns: Concerns include a patient retaining prohibited items on a mental health ward despite searches, and staff making false observation entries. There was also insufficient post-tranquilisation monitoring, reflecting a wider organisational issue.
Response (Metropolitan Police Service): • The Metropolitan Police Service stated it would publish an Operational Notice by 30th June 2021 to instruct officers on recording seized property and communicating transfers. • The Metropolitan Police … (AI summary)
Response (East London NHS Foundation Trust): • The Trust implemented immediate changes to its Rapid Tranquilisation (RT) policy, requiring Registered Nurses for monitoring and specific eyesight observations post-administration. • The patient search policy is being revised, … (AI summary)
Response (Department of Health Social Care): • The East London NHS Foundation Trust revised its patient search policy, including guidance on information handover and disposal of seized items, and implemented staff training on drug awareness, search, … (AI summary)
Responded
Corin Bonaparte
Concerns: 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.
Response (HM Prison and Probation Service): • A new version of the Assessment Care in Custody and Teamwork (ACCT) system was rolled out, and associated training is being delivered to all staff, including healthcare colleagues. • … (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
Amanda Gibbens
Concerns: The coroner noted that Level 3 constant observations were performed using monitor screens, meaning patients were not always directly visible, and this practice was not explicitly prohibited. There were also concerns that the process for searching patient bedrooms for prohibited items was ineffective.
Overdue
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
Sergio Dunkley
Concerns: The coroner noted the absence of statutory requirements or mandatory regulations for fitting ligature alarms in newly built mental health units, and that existing guidance for anti-ligature fixtures is not mandatory.
Overdue
Shona Campbell
Concerns: The coroner identified issues with inadequate contemporaneous clinical record-keeping and communication among staff, along with incomplete patient observations and care plans. Further concerns noted patients' access to ligatures, insufficient staff training and supervision, and a lack of clear clinical assessment for repeated self-harm attempts.
Pending
Ezra Tamiem
Concerns: The coroner noted that a device forming a ligature point was present in cells on the healthcare wing, including the one where Mr Tamiem died, despite "safer cells" being designed to remove such points. There were no plans to address this identified risk.
Overdue
Sandra Kirk
Concerns: The ligature risk reduction policy and audit tools do not provide guidance on minimising potential ligatures, such as items of clothing. The policy prioritises avoiding blanket restrictions over identifying real risks, and should be improved to recognise and address specific clothing items as ligature risks.
Response (NHS England): • NHS England established a new programme to support the sector with tackling quality and safety concerns within Mental Health, Learning Disabilities and Autism inpatient services. • NHS England is … (AI summary)
Response (NHS England): • NHS England reported that Cygnet is providing ligature training for new staff and has a contraband list in place across inpatient areas. • NHS England stated that national guidance … (AI summary)
Responded
John White
Concerns: The coroner noted delays in distributing ligature cutters to frontline officers, with only approximately 25% issued by October 2022. Concerns were also raised about the lack of specific training for response officers on handling situations involving suspended individuals.
Overdue
Select committee recommendations(2)
#33 —
Recommendation: In addition to our recommendations on the use of restraint that we set out in our report on the treatment of autistic people and people with learning disabilities, the use of prone restraint on children and young people should be …
Response attribution not verified
#28 — Prisons used as places of safety, despite Government aims to end the practice
Recommendation: We were shocked and appalled to hear that prisons are used as a place of safety. We acknowledge and welcome that the Government aims to end this practice in the Mental Health Bill. We request details of how this will …
Response attribution not verified
HSSIB safety recommendations(3)
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services …
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 …
Safety Recommendation
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 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. Social …
Safety Recommendation
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
CQC inspection actions(33)
Worthing Hospital
The trust must ensure that all patients on medical wards receive regular risk assessments upon admission and throughout their stay and take all reasonable steps to mitigate any identified risks. This includes mouth care, skin and nutritional assessments as well …
Must 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
Weston General Hospital
Take action to address the continuing risks of identified ligature points, particularly non-communal areas.
Must Do
Royal Victoria Infirmary
The service must ensure risk assessments have been carried out to minimise ligature risks and ensure that the premises and equipment used by the service users are done so in a safe way.
Must Do
Royal Victoria Infirmary
The service must ensure risk assessments have been carried out to minimise ligature risks and ensure that the premises and equipment used by the service users are done so in a safe way.
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
Queen's Hospital
The service must improve the safety of the rooms used for paediatric mental health patients.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust should ensure ligature risk is reassessed and added to the risk register for the paediatric emergency department.
Should Do
Pilgrim Hospital
The trust should ensure patients at risk of self harm or suicide are cared for in a safe environment meeting standards recommended by the Psychiatric Liaison Accreditation network (PLAN) and mental health risk assessments and care plans are completed for …
Should 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
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.
Must Do
Croydon University Hospital
The trust should ensure an environmental risk assessment is carried in all maternity areas and emergency call bells are ligature free.
Should 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
St Benedict's Hospice
The service must provide appropriate environmental risk assessment and mitigation for the wards of all ligature risks including the use of ligature cutters and staff trained to use these, if required.
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
UHBW Bristol Campus
The service should ensure staff are aware of the location of ligature cutters.
Should 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
Royal Derby Hospital
Complete and regularly review ligature risk assessments of the maternity environment.
Should Do
Poole Hospital
Review and risk assess ligature risks for the new ward environments following the reconfiguration.
Should Do
Penrith Community Hospital
The serviceshouldidentify,assess,scoreandmitigateligaturerisksinthemidwiferyledunitandthisshouldbesharedwithstaffwhoworkthere.
Should Do
James Paget Hospital
The service must ensure environmental ligature and ligature point risk assessments are completed and actioned.
Must Do
Durham Diagnostics and Treatment Centre
The service must provide appropriate environmental risk assessment and mitigation for the wards of all ligature risks including the use of ligature cutters and staff trained to use these, if required.
Must 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
Calderdale Royal Hospital
The service should consider the regular reviews of ligature risk assessments across the service.
Should Do
Bushey Fields Hospital
The use of seclusion must be correctly recorded and practice monitored against the Code of Practice. The trust must ensure that areas used for seclusion are safe and risks removed and the appropriate safeguards put into place.
Should Do
Bridlington Hospital
The service should consider having a designated ligature free room in its urgent and emergency care service at Scarborough hospital for patients suffering from mental health illnesses.
Should Do
Sunnyside
Not all ligature points had been considered within the environment.
Should Do
We Can Recover CIC
The service did not ensure that staff have access to a ligature risk assessment and that the ligature risk assessment clearly identified ligature risks and mitigation.
Must Do
The Princess Royal Hospital
The trust must ensure the mental health room exit complies with statutory requirement.
Must Do
Royal Bolton Hospital
The trust should ensure that mental health risk assessments including environmental assessments are thoroughly completed.
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
PPO death in custody recommendations(3)
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 officers check the condition of door hinge securing bolts when making their daily cell fabric checks.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that prison staff manage prisoners at risk of suicide and self-harm in line with PSI 64/2011, in particular that they: remove ligatures from prisoners at the earliest opportunity; hold multidisciplinary case reviews …
IOPC learning recommendations(18)
National recommendation - National Police Chiefs' Council, April 2019
The IOPC recommends that the National Police Chiefs' Council (NPCC) ensures that all forces are made aware of this risk and the injury caused by the use of an alarm cord as a ligature in this case. All forces should …
Man sustained a serious injury while in custody – Cleveland Police, August …
The IOPC recommends that Cleveland Police should take steps to ensure that custody officers follow Authorised Professional Practice when determining and recording levels of obsevation for detainees. This should include consideration of whether: - any changes are required to force …
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 …
Man died after an attempt to take his own life during a …
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 …
Man died after an attempt to take his own life during a …
The IOPC recommends that South Wales Police 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 …
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 custody staff understand the ligature risk associated with plimsolls provided to …
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 - Derbyshire Constabulary, April 2026
The IOPC recommends that Derbyshire Constabulary should review and update its operational guidance and officer training on responding to suicide-related incidents to ensure officers clearly understand the legal powers available to them to remove items that pose an immediate risk …
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 …
Man sustained a serious injury while in custody – Cleveland Police, August …
The IOPC recommends that Cleveland Police should review the working practices used in custody, specifically in relation to CCTV observations, to ensure that the principles set out in the Authorised Professional Practice (APP) are followed. This should include consideration of; …
Recommendation - North Yorkshire Police, March 2021
The IOPC recommends that North Yorkshire Police should: - re-position/re-configure the CCTV cameras within the cells at Scarborough custody suite to ensure that there is comprehensive CCTV coverage of the interior of cells. In particular, any re-positioning/re-configuration of CCTV cameras …
Man dies after becoming unwell in custody - Essex Police, November 2017
An investigation into the death of a man following his detention at Grays Police Station found that there was not full CCTV coverage of the holding cell in which he had been placed. This was because the CCTV camera in …
Man dies after becoming unwell in custody - Essex Police, November 2017
Our investigation into the death of a man following his detention at Grays Police Station found that there was not full CCTV coverage of the holding cell in which he had been placed. This was because the CCTV camera in …
Recommendations - Humberside Police, January 2022
The IOPC recommends that Humberside Police consider implementing the use of metal detecting wands in their Custody Suites. This follows a Death or Serious Injury (DSI) incident whereby a detainee was able to hide a razor blade within a copy …
Recommendation - Greater Manchester Police, July 2025
The IOPC recommends that Greater Manchester Police (GMP) should, as part of their action to replace their custody system, review their provision for risk assessment completion. This includes consideration of adding prompts for custody officers to carry out risk assessments …
IMB annual reports(10)
Bristol (2020)
HMP Bristol, a Category B local prison, navigated the reporting year (August 2019 – July 2020) under significant COVID-19 restrictions, which impacted the daily regime but also led to a more settled environment and improved staff morale. Despite efforts, safety ratings remained low, with high levels of self-harm, violence, and increased use of force incidents. Challenges persisted with delayed mental health transfers, unsuitable Victorian accommodation for disabled prisoners, and resource issues affecting key work and healthcare.
PRISON
Key concerns
Cookham Wood (2020)
The IMB report for HMYOI Cookham Wood covers 1 August 2019 – 31 August 2020, focusing heavily on the impact of the COVID-19 lockdown. While staff are commended for their caring approach and efforts to maintain safety and welfare, particularly during initial lockdown, the severe and protracted regime resulted in boys being locked in their rooms for over 23 hours a day, raising significant concerns about inhumane treatment, especially for those in segregation or with mental health issues. Key challenges include the unfit Phoenix segregation unit, national shortages of mental health beds, delays in transferring young adults, and an increasing remand population, all exacerbated by the lack of IT capacity during the pandemic.
PRISON
Key concerns
Cardiff (2020)
HMP Cardiff maintained a reasonably safe environment with low violence, but self-harm incidents increased to 712, with four deaths in custody (three self-inflicted). The COVID-19 pandemic severely restricted the regime, impacting purposeful activity, time out of cell (1.5 hours daily), and overall prisoner wellbeing. Persistent staffing shortages hampered healthcare and mental health services, while disparities for BAME prisoners in areas like segregation and dangerous prisoner labels remained a concern.
PRISON
Key concerns
Eastwood Park (2020)
This IMB annual report for HMP/YOI Eastwood Park for the year ending October 2020 highlights the significant impact of the COVID-19 pandemic on prison operations and monitoring. While staff efforts and communication were generally commendable, concerns persist regarding rising self-harm incidents, ongoing violence towards staff, and the continuous flow of illicit substances. The Board remains particularly concerned about the prolonged segregation of a brain-injured prisoner and the lack of appropriate secure specialist facilities for women with complex needs.
PRISON
Key concerns
Foston Hall (2020)
HMP/YOI Foston Hall operated under severe COVID-19 restrictions for most of the year, leading to drastic regime changes, including confinement to cells for most of the day. Despite significant staff commitment and efforts by healthcare and resettlement services, key concerns persist regarding persistently high self-harm, staff assaults, and use of force, alongside infrastructure issues in D wing and the CSU. The report highlights the inhumane impact of the restricted regime and the challenges in maintaining essential services and progression opportunities.
PRISON
Key concerns
Dungavel House IRC (2024)
The Independent Monitoring Board for Dungavel House IRC reports a generally safe and humane environment for detainees in 2024, with good staff-detainee relationships and healthcare provision. Key concerns include the uncertainty of detainees' futures, high numbers of night-time arrivals and departures, and ongoing issues with roof accessibility and building maintenance. The Board also noted that female facilities are considered inadequate.
IRC
Key concerns
Bure (2025)
HMP Bure, a Category C training prison for sexual offenders, holds 639 prisoners against an operational capacity of 643. While commendable for humane treatment, high time out of cell, and low violence metrics, the Board identifies critical challenges. These include budget cuts impacting education and purposeful activity, inadequate healthcare for the aging population, and persistent staffing shortages affecting regime and support. National policy issues around prisoner wages and property management also remain significant concerns for the Board.
PRISON
Key concerns
Bronzefield (2020)
HMP/YOI Bronzefield, a local female prison, effectively managed the initial COVID-19 lockdown, maintaining a nearly virus-free environment, but the sustained restricted regime led to a significant rise in self-harm and mental health concerns. Key issues included a high proportion of prisoners released without stable accommodation, persistent challenges with timely mental health transfers, and a shortage of cell keys affecting prisoner property security. Despite these, the Board noted positive developments in food quality, key worker implementation, and effective education provision during the pandemic.
PRISON
Key concerns
Gatwick IRC (2024)
Gatwick IRC experienced a volatile year ending March 2024, marked by high levels of violence, self-harm, and one death in custody. The Board expresses significant concerns over inadequate safeguards for vulnerable detainees, long detention periods, and systemic failures in healthcare, particularly around Rules 34 and 35. Detainees also face issues with interpretation services, excessive handcuffing, and an inhumane regime with long lock-up times and increased segregation.
IRC
Key concerns
Pentonville (2020)
HMP/YOI Pentonville, a category B/C local prison, faces significant challenges in providing a safe and rehabilitative environment. While staff demonstrated resilience during COVID-19, and some improvements were made in drug reduction and key working, the prison's deteriorating infrastructure, high levels of violence, and persistent issues with regime delivery severely impacted prisoner welfare and resettlement. The Board highlights a lack of investment, poor maintenance, and inadequate staffing as root causes, resulting in concerns about safety, healthcare access, and purposeful activity.
PRISON
Key concerns
IMB individual recommendations(40)
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2020)
That a gap be created at the top of the toilet doors, at Festival Court HR, to allow DCOs to monitor the safety of detainees.
Governor / Director
Norwich (2021)
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.
HMPPS
Noted
Leicester (2024)
Can funds be found for replacing cell windows and grills?
HMPPS
Rejected
Manchester (2020)
Can the minister expedite approval of the necessary funding [for safer custody windows]?
Ministry of Justice
In Progress
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
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.
HMPPS
Rejected
Wandsworth (2022)
The number of out of use cells, particularly in the care and separation unit (CSU), was a concern. Is there a plan to accelerate the repair of damaged cells and to a standard that reduces the potential for future damage?
Governor / Director
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
Erlestoke (2023)
What immediate actions will be taken to address the inadequate and potentially dangerously deficient constant watch cell?
Governor / Director
Dungavel House (2023)
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. This remains an issue due to the accessibility of the fire escape stair.
Governor / Director
Dungavel House IRC (2024)
As has been mentioned in previous reports, accessibility to roofs is an ongoing issue and the installation of preventative measures to ensure that roofs are not accessible to detained persons was commenced during the year.
Governor / Director
Implemented
Pentonville (2020)
Will you commit to funding the repair or replacement of all remaining insecure cell windows and grilles, which were identified four years ago as needing urgent attention?
Other
In Progress
Five Wells (2024)
When will the low mobility cells be made safe and brought into full use?
Governor / Director
Swaleside (2025)
Again, there is a lack of sufficient constant-watch cells during times of crisis. The Board noted the response last year that in-patient department cells were being considered, but no decision appears to have been made and G wing’s cell has been intermittently out of action. When will a decision be made?
HMPPS
In Progress
Lancaster Farms (2022)
To ensure that any work in regard to toilets in double cells is addressed: broken screens, lack of toilet seats, etc.
Governor / Director
Wandsworth (2020)
The Board was very concerned that the 12-bed Addison unit remained unfit for purpose, with insufficient beds and cells frequently awaiting repair. The waiting time for a bed in the unit was up to seven days. What is being done to improve capacity for mentally ill prisoners?
Ministry of Justice
In Progress
Isis (2020)
ensure that plans are in place to prevent a return to the levels of self-harm over the first three months of the year, when a normal regime is resumed (see section 4.2)
Governor / Director
Lancaster Farms (2021)
To ensure that work previously planned to introduce screening of toilets within double cells is completed as soon as possible (paragraph 5.1.2).
Governor / Director
Buckley Hall (2021)
Install CCTV in the healthcare waiting area (6.1.17)
Governor / Director
Wormwood Scrubs (2022)
When can we expect more stringent guidance on cell clearance?
HMPPS
Bedford (2022)
We hope that this year the segregation unit will finally be moved from its underground location.
Governor / Director
Wormwood Scrubs (2023)
HMPPS should refurbish the antiquated cell bell system.
HMPPS
Werrington (2023)
What more can be done to enhance safety to ensure the reduction of young people making protective weapons?
Governor / Director
Elmley (2024)
Remove prisoners’ access to razor blades as an instrument of self-harm and replace these with safer electric shavers.
HMPPS
In Progress
North West and Midlands STHF (2025)
Whilst the detaining officers have a direct view to constantly watch and monitor detained individuals within the holding room at East Midlands Airport, the Board recommends that the facility be upgraded to include the current safety and security standards used in new facilities.
Home Office
Bure (2025)
Due to the number of self-harm incidents using razor blades, will the Governor consider removing wet shave razors and replace them with electric shavers, as is happening across other prison establishments?
Governor / Director
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
Swaleside (2021)
The lack of in-cell telephony in the inpatients department (IPD) still needs to be addressed. (see sections 5.4 and 6.1)
HMPPS
In Progress
Wakefield (2023)
Some elements of the prison’s physical security require immediate improvement.
HMPPS
Exeter (2023)
Address the deficiencies in the temporary CSU?
Governor / Director
Buckley Hall (2023)
When will CCTV be installed in Healthcare?
Governor / Director
Bure (2024)
The prison lacks CCTV, resulting in some prisoners feeling unsafe. Can consideration be made for funding to be made available to resolve this issue?
HMPPS
In Progress
Wormwood Scrubs (2020)
Will the minister ensure that sufficient funds continue to be available to the prison for the continuation and enhancement of measures taken to increase the safety of prisoners?
Ministry of Justice
In Progress
Norwich (2022)
Are there plans for refurbishment of the outdated buildings e.g. the healthcare unit, L wing, E wing and the segregation unit, alongside the planned refurbishment of a previously closed wing and the installation of a new M wing?
HMPPS
Partially Accepted
Buckley Hall (2022)
Provide the funding to install CCTV in the healthcare building.
HMPPS
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
Bullingdon (2024)
The prison continues to be a violent and unsafe environment for both prisoners and staff. What more can the Prison Service do to address this issue?
HMPPS
In Progress
Isle of Wight (2024)
Will the Prison Service urgently prioritise funds for the installation of enhanced security gates at both sites, in line with the security arrangements at other LTHSE establishments?
HMPPS
In Progress
Hull (2024)
Will the prison service directly review the capital funding needed within HMP Hull to improve security measures?
HMPPS
In Progress
Health investigations(6)
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
An independent investigation into the care and treatment of Christie … — Rec 3
TEWV and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) must ensure that any young person with a recent history of self-ligature has a written care plan that identifies how staff (or families in the case of a community setting) are to care for the young person, and mitigate …
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Christie … — Rec 1
Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) must provide significant assurance to the Trust Board and its commissioners that it has a robust environmental and ligature risk assessment process and the ability to respond effectively and urgently to mitigate risks identified through this process.
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
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: Adel Makar, Westcliff on Sea (2006) — Rec 23
The Orchard Unit Management Team should consider the environment, including the provision of furniture which is difficult to move; and the consistent use of non-breakable crockery and cutlery to reduce patient and staff injury.
east_of_england
Scottish Fatal Accident Inquiries(5)
Anthony McMahon
Be that as it may, I consider it, conscious as I am of the benefit of hindsight, unwise to allow any prisoner who is assessed as a suicide risk access to a belt. Such access is a fact relevant to this death which SPS may wish to consider.
Mar 2018
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 as reasonably …
May 2026
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 patient on …
Dec 2024
Health
4 recs
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 potential ligature …
May 2025
Custody
7 recs
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 stops of …
Jan 2025
Custody
25 recs
Article 2 learning points(5)
— LP 2
We recommend that HMPPS and NHSE/I consider specific guidance for the process of ligature cut down to ensure optimum management of the unconscious patient. This will include clarification of whether emergency bags should contain a soft cervical collar as a standard item.
HMPPS
Accepted
— LP 10
If it has not already done so, HMP Whitemoor may wish to consider reviewing current arrangements in relation to prisoners’ access to razor blades. The prison should be satisfied that any arrangements for access also provides for an appropriate level of protection from harm for both staff and other prisoners.
HMP Whitemoor
Accepted
— LP Q
The daily cell fabric check should include the inspection of the securing bolts on the anti-barricade lock plates.
HMPPS
— LP P
Consideration should be given to placing ‘Impact Screwdrivers’ into each wing office to facilitate the removal of seized and damaged bolts on anti-barricade lock plates.
HMPPS
— LP 12
There needs to be a clear policy on levels of observations to be used and the criteria for placement in a safer cell or under constant observation and these should be fully documented in an individual’s ACCT document and healthcare records.
HMP Altcourse and HMPPS
Accepted
Detention investigations(2)
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
Assessment of government progress in implementing the report on the … — Rec 7
No immigration detention facility should be built in future with a barely screened toilet inside a shared room, and this set-up should be upgraded in all existing facilities.
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
Harris Review: Deaths in Custody — Rec 9
All light fittings within cells should as standard be tested to ensure that they are not able to bear the weight of a young adult before any cell can be signed off as being fit for purpose as a safer cell.
Justice & Legal
Harris Review: Deaths in Custody — Rec 5
NOMS must identify and keep a record of the number of certified ‘Safer Cells’ (PSI 17/2012) both in use and available for use across the estate.
Justice & Legal
Harris Review: Deaths in Custody — Rec 4
HMIP must conduct a thematic review on Safer Cells, which includes an analysis of what the right number of safer cells is for each prison and YOI. The review should identify which prisons are maintaining enough cells at the correct ‘Safer Cells’ level. Once this is established, whether the prison …
Justice & Legal
LGO / SPSO decisions(4)
201304806 — Scottish Prison Service
Mr C, who is a prisoner, complained that the built-in DVD player on his in-cell TV set did not work. He did not feel it was fair to pay the full TV service charge when his set was defective. However, the prison confirmed that Mr C was paying for access …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Jun 2014
201305611 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison did not address his concerns about the temperature in his residential hall. We made enquiries of the Scottish Prison Service (SPS), and found that complaints were received from prisoners about the temperature in the hall. Steps were taken to resolve …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jul 2014
201103838 — Scottish Prison Service
Mr C, who is a prisoner, complained that at times the Scottish Prison Service (SPS) had required him to share a cell that was not of an adequate size to accommodate two prisoners. He had been sharing a cell that was intended as a single, but which has been fitted …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2012
201603221 — Scottish Prison Service
Mr C complained that the Scottish Prison Service (SPS) had failed to follow relevant procedures to ensure his safety in a shared cell. In particular, he said that he should not have had to share a cell with a prisoner whom he alleged had attacked him. Mr C said that …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2017
CJINI inspection reports(13)
Prisoner Escort and Court Custody Arrangements in Northern Ireland: A Follow-Up Review of inspection recommendations
Prosecution and the Courts, Court Custody, Prisoner Safety,…
Apr 2014
The Safety of Prisoners held by the Northern Ireland Prison Service
Prisons, Prisoner Safety
Oct 2014
The Safety of Prisoners held by NIPS
Prisons, Prisoner Safety
Oct 2014
Police Custody: The detention of persons in police custody in Northern Ireland
Policing, Police Custody
Mar 2016
A Review into the operation of Care and Supervision Units in the Northern Ireland Prison Service: A Follow-Up Review
Prisons, Prisoner Safety
Sep 2023
Police Custody: The detention of persons in police custody in Northern Ireland. A Follow-Up Review of Inspection Recommendations
Policing, Police Custody
Jul 2025
Report on an announced inspection of Maghaberry Prison (19 – 23 March 2012)
Maghaberry Prison, Prisons
Dec 2012
Police Custody – A Follow-Up Review of inspection recommendations
Policing, Police Custody
Feb 2013
Ash House Hydebank Wood Women’s Prison (18-22 February 2013)
Hydebank Wood Women’s Prison, Prisons
Oct 2013
Hydebank Wood Young Offenders Centre (18–22 February 2013)
Prisons, Hydebank Wood Secure College
Oct 2013
The Safety of Prisoners held by the Northern Ireland Prison Service
Prisons, Prisoner Safety
Nov 2019
Police Custody: The detention of persons in police custody in Northern Ireland
Policing, Police Custody
Sep 2020
An inspection of Prisoner Escort and Court Custody arrangements in Northern Ireland
Prosecution and the Courts, Court Custody, Prisoner Safety,…
Oct 2010
CQC enforcement actions(9)
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) took enforcement action, serving Greater Manchester Mental Health NHS Foundation Trust with two Section 29A warning notices. One notice related to ligature and fire risks, and the other to staffing and governance, requiring significant improvements …
Nov 2022
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
CQC issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an unannounced focused inspection in November at Woodlands Hospital. Inspectors found staff had not completed mandatory training, risk assessments and care plans were not appropriately completed, …
Woodlands Hospital
Feb 2023
Conditions Imposed: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission imposed conditions on Greater Manchester Mental Health NHS Foundation Trust following an unannounced inspection in March 2024. The conditions require the trust to make improvements in specific areas, including effective service management, ensuring a clean, smoke-free …
Acute wards for adults of working age and psychia…
Dec 2024
Warning Notice: Devon Partnership NHS Trust
The Care Quality Commission (CQC) told Devon Partnership NHS Trust it must make urgent improvements on Delderfield ward and complete its ligature minimisation work across its acute wards and psychiatric intensive care units. This directive followed an inspection in June …
Aug 2020
Urgent Enforcement Action: Birmingham and Solihull Mental Health NHS Foundation Trust
The Care Quality Commission imposed urgent conditions on the registration of Birmingham and Solihull Mental Health NHS Foundation Trust following focused inspections. Inspectors found several concerns, including ligature risks across services and unsafe storage and transport of medicines. The conditions …
Jan 2021
Warning Notice: Oxleas NHS Foundation Trust
The Care Quality Commission (CQC) served Oxleas NHS Foundation Trust with a warning notice, requiring immediate improvements to its mental health wards for older people. An inspection found out-of-date ligature risk assessments, a lack of clear mitigation for high-risk ligature …
Greenwich, Bromley, Bexley
Dec 2020
Criminal Prosecution: University Hospitals Sussex NHS Foundation Trust
The trust was fined after a young person absconded from a ward in March 2022, was found within hospital grounds having ligatured, and died shortly afterwards. Sentenced at Brighton Magistrates' Court with £25,405 costs.
Nov 2025
£200000
Criminal Prosecution: Sussex Partnership NHS Foundation Trust
The trust admitted failing to provide safe care and treatment to Jamie Osborne, who died on the hospital wing of Lewes Prison in February 2016. The court heard ligature risks were inadequately assessed and prescribed medication was not given. Fined …
£200000
Conditions Imposed: Isle of Wight NHS Trust
Immediately after an inspection, CQC placed conditions on the registration of the trust to minimise the risk of patients being exposed to harm. The trust was required to operate an effective system to prioritise patients needing access to community mental …
Apr 2017