Recurring concern

Inadequate frontline training to recognise and respond to suicide and self-harm risk

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First reported 13 Feb 2014•Latest report 7 Apr 2026

Definition

What this concern includes

Includes failures to require, provide, refresh, assess or assure training for frontline or first-contact personnel who may need to recognise, communicate about, assess, escalate or respond to suicide or self-harm risk, including railway, social-care, healthcare and comparable settings.

Not included

Excludes generic mental-health, emergency-response or first-aid training where suicide or self-harm risk is not a material part of the asserted concern.
Excludes failures in suicide-risk assessment, observation, treatment or protective measures when staff training is not the deficient control.
Excludes training for specialist clinicians or other personnel who do not function as frontline or first-contact responders, unless the assertion explicitly concerns their frontline suicide or self-harm response role.
Excludes individual failures to apply adequate training where the relevant training and competence-assurance process was otherwise reliable.

Reports: 17
Individual concerns: 18
Date range: 2014–2026
Stated actions: 28

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service4

Home Office4

Ministry of Justice4

Department of Health and Social Care2

NHS England2

Carillion (AMBS) Limited1

Cygnet Health Care Limited1

Department for Education1

Future Health and Social Care Association C.I.C.1

Govia Thameslink Railway Limited1

Jigsaw Homes Group Limited1

Kent and Medway Mental Health NHS Trust1

Leicestershire Partnership NHS Trust1

Ministry of Defence1

Ministry of Housing, Communities and Local Government1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

7 Feb2020
West Sussex
Concerns raised1
1. Failure to provide suicide intervention training to all frontline police staff
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mark Oliver George Mallinson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mark Oliver George Mallinson made numerous threats to take his own life over several hours after police sought to arrest him, and he died by suicide between 03.20am and 04.24am on 3 December 2018. The principal concern was that suicide-intervention training designed to save lives was not being provided to all frontline police staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide suicide intervention training to all frontline police staff
Wider context from the report
“████████ provided a statement about the training given to police officers in the area of suicide intervention. ████████ stated that he had created a training package for new recruits. This training is designed to give first responders pointers to save lives and to buy time. I received further information during the course of the inquest that most new recruits of Sussex Police in the last 12-18 months had received the training. However this training is not being rolled out to the remainder of the police force. The concern I have is that training specifically designed to save lives is not being provided to all front line staff. ”
Source location
Mark Oliver George Mallinson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
20 Nov2019
Manchester North
Concerns raised1
1. Lack of training and information for security staff on self-harm and suicide risk
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Gary Leyland · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Gary Leyland was found deceased in his supported accommodation on 13 November 2019 after taking excessive prescribed medication, with the inquest conclusion recording suicide and morphine toxicity. Concerns included failures to contact medical or mental health services after suicidal thoughts were disclosed, poor documentation and handover information, the use of security staff for welfare checks without clear evidence of training, and the absence of an updated risk assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of training and information for security staff on self-harm and suicide risk
Wider context from the report
“3. The fact that the expectation was security staff would be expected to conduct welfare checks at a weekend was heard for the first time in evidence. There was no evidence as to how they are trained, what information is provided to them about self -harm and the risk of suicide. This practice was of grave concern to the Court. ”
Source location
Mr Gary Leyland · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Oct2018
Birmingham and Solihull
Concerns raised1
1. Failure of support workers to complete suicide prevention training
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Simon Anthony Graham · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention training.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of support workers to complete suicide prevention training
Wider context from the report
“5. Concern 4: Future Care & Social Care Association have identified that support workers should undertake suicide prevention training. I heard evidence that some support workers have still not undertaken this training despite lone working and support workers continuing to undertake suicide risk assessments. ”
Source location
Simon Anthony Graham · Prevention of Future Deaths report
Page 1 · concerns
Open source report
21 Jun2018
Leicester City and South Leicestershire
Concerns raised1
1. Lack of self-harm training for frontline staff encountering patients with self-inflicted injuries
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Present a paper recommending stronger, more robust safeguarding training for staff caring for people who self-harm.
  Stated by University Hospitals of Leicester NHS TrustStated planned
AI-generated summary

John Charles Hazlewood · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

John Charles Hazlewood died on 31 January 2017 after self-harming with hand tools and consuming a large amount of white spirit. The report identified concerns about psychiatric clinicians’ access to medical records and documentation, failure to involve his partner in assessing his escalating behaviour, monitoring of revised on-call procedures, and a lack of self-harm training for relevant hospital staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of self-harm training for frontline staff encountering patients with self-inflicted injuries
Wider context from the report
“4. University Hospitals of Leicester staff, both Dr and nurse gave evidence to the Court that they had not received any training in self harm, notwithstanding they were both highly likely to encounter patients attending with self-inflicted injuries regularly in both the Emergency Department and in the Acute Medical Admissions unit. With self-harm statistics sad soaring, this is an increasing matter of concern. It is not appropriate to rely on “buying in” psychiatric services and leaving front line staff treating patients with no basic knowledge of this complex area and potential triggers. Training would empower the staff and is likely to assist them both in caring for the patients but also the carers/families who may need advice and support. NICE guidelines CG16 is clear that training should be provided to all staff who may encounter such patients and UHL should therefore reconsider this matter. ”
Source location
John Charles Hazlewood · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Present a paper recommending stronger, more robust safeguarding training for staff caring for people who self-harm.

Verbatim wording from the response
“As you would expect we keep our safeguarding training under regular review and our Head of Safeguarding, ████████, will be presenting a paper to the Safeguarding Assurance Committee on the 15th August 2018 which will recommend strengthening and making more robust our training for all staff who care for people who self-harm. As well as we need to involve an external organisation in the development of this training it is anticipated that this will take approximately 6 months to put in place. In the meantime, and as a result of this inquest, our Head of Safeguarding is to ensure that all UHL staff receive a communication to remind them of the escalation process that they can use if they have any concerns about a patient who they feel is at risk of self-harm. We are working with LPT on this communication and we expect this to be sent out before the 15th August 2018.”

Source location
2018-0189-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 9 July 2018
Open published response
19 Oct2017
Central Hampshire
Concerns raised2
1. Failure to provide ACCT training to all relevant prison staff
2. Failure to train all prisoner-facing Carillion staff in self-harm and suicide prevention
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Deliver SASH suicide and self-harm prevention training to new prisoner-facing staff and roll out refresher training to existing staff.
  Stated by HM Prison and Probation ServiceStated in progress
2. Action
  Train additional staff as SASH trainers to increase capacity for course delivery.
  Stated by HM Prison and Probation ServiceStated planned
3. Action
  Train prisoner-facing Carillion staff and maintain training records for all staff, including directly employed and contracted staff.
  Stated by HM Prison and Probation ServiceStated completed
1. Action
  Issue a Service Manager’s Instruction notifying contractors of suicide and self-harm prevention training requirements and contractual obligations.
  Stated by HM Prison and Probation ServiceStated planned
2. Action
  Requested HMPPS issue a formal instruction identifying prisoner-facing staff required to complete SASH training.
  Stated by Carillion plcStated completed
Respondent positions 5
1. Position
  Refresher-training figures do not mean prisoner-facing staff have never been trained or are deployed unable to recognise suicide and self-harm risk.
  Stated by HM Prison and Probation ServiceDisputes the concern
1. Position
  Refresher-training completion was delayed because the longer course, resourcing challenges and limited availability of qualified trainers constrained delivery.
  Stated by HM Prison and Probation ServiceUnable to act
2. Position
  Carillion disputes that its HMPPS contracts require Carillion staff to undergo self-harm and suicide prevention training.
  Stated by Carillion plcDisputes the concern
3. Position
  HMPPS is responsible for training all prison-facing staff, including Carillion staff, in self-harm and suicide prevention.
  Stated by Carillion plcRedirects responsibility
4. Position
  Carillion cannot provide self-harm and suicide prevention training because it is highly specialist and specific to custodial settings.
  Stated by Carillion plcUnable to act
AI-generated summary

Sean Patrick Plumstead · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sean Plumstead, a convicted prisoner at HM Prison Winchester, died on 18 September 2016 after being found hanging by a ligature in his cell and later having treatment withdrawn following severe brain injury. The report raised concerns about inadequate suicide and self-harm awareness training for prison and prisoner-facing staff, unclear responsibility for training Carillion staff, and delayed responses to emergency cell bells.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide ACCT training to all relevant prison staff
Wider context from the report
“1. ACCT Training I issued a Regulation 28 Report on 4 October 2016 in relation to a death of another prisoner at HMP Winchester ████████ concerning inter alia Assessment Care and Custody and Teamwork (ACCT) training plans and received a response from the Ministry of Justice dated 12 December 2016 in which it was stated that refresher training was taking place for 48 members of staff that month and at least monthly thereafter and that 12 new prison officers were expected to complete the Prison Officer Entry Level Training course that includes training on suicide and self-harm awareness (SASH) and ACCT process before starting work at Winchester by March 2017. In an inquest starting on 13 March 2017 in relation to a death of another prisoner at HMP Winchester ████████ evidence was given by the prison governor that at August 2016 41% of staff had received ACCT training; at the date the evidence was given 61% of staff had received ACCT training; and that the aim was for 80% of staff to receive ACCT training by Autumn 2017. The Assistant Coroner issued a Regulation 28 Report on 11 April 2017 concerning inter alia ACCT training plans and received a response from the Ministry of Justice dated 21 June 2017 which stated that at the date of the letter 120 out of 162 prison officers at HMP Winchester (74%) had received ACCT training. Evidence adduced in the inquest into the death of Mr Plumstead disclosed statistics for the provision of SASH training had been completed as follows: • As at September 2016 77.29% of forward- facing prison service staff • As at September 2016 64.27% of all prison service staff • As at September 2017 72% of forward- facing prison service staff • As at September 2017 57% of prison service staff were “in date” with such training. The evidence was that the current aim is to achieve the 80% target by mid 2018. It was apparent from the evidence that due to staff turnover, a lack of trainers qualified and available to provide such training and other priorities, targets for SASH training are failing to be met and if anything the ratio of prison staff with the appropriate skills is reducing rather than increasing. This means that the risk of prisoners at risk of self harm and suicide may not be recognised by staff who have had no such training with whom they come into contact. ”
Source location
Sean Patrick Plumstead · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to train all prisoner-facing Carillion staff in self-harm and suicide prevention
Wider context from the report
“2. Training of All Prisoner-facing Staff The investigation into the death of Sean Plumstead, including evidence heard during the inquest, has highlighted matters of concern relating to Carillion’s past and present operations at HMP Winchester and possibly at other establishments nationally. The evidence showed that in the 18 months before Mr Plumstead’s death in September 2016, at least two Carillion staff were employed in prisoner-facing roles at the prison (in the Clothing Exchange Store) without any training in self-harm/suicide prevention (in apparent contradiction to the national policy - the Prison Service Instruction 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm/suicide prevention. It remains unclear whether the (Carillion) Works Manager and other Carillion supervisors (at a local and national level) are aware of the issue. The prison have since assumed the responsibility for the training of all staff in prisoner-facing roles but there is, as yet, no clarity on the obligations and assumptions which Ministry of Justice and Carillion were operating at the material time (2015-2016) nor indeed what arrangements will pertain in the future. Indeed, I have also heard evidence that the prison do not hold training records for Carillion staff. There is therefore some division of responsibility between the prison and Carillion and a risk that training of staff is missed because of the absence of such records. I consider there is a risk arising from my investigation that there was and continues to be a gap in training which Carillion is either unaware of or unconcerned with - a gap that may continue here and elsewhere. I understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but I cannot identify any requirement for self-harm/suicide management training, nor any commitment by Carillion to make staff available for such training by the prison as necessary. The apparent ambiguities in the arrangement could compromise the safety of prisoners that Carillion personnel are dealing with. I am also concerned of a risk in other prisons, where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. I invited Carillion to be an Interested Party to the inquest, a request which they declined to take up. Nevertheless, following the evidence in the inquest, the prima facie concerns have hardened. I consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of Justice both can address these concerns and clarify responsibilities. ”
Source location
Sean Patrick Plumstead · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver SASH suicide and self-harm prevention training to new prisoner-facing staff and roll out refresher training to existing staff.

Verbatim wording from the response
“The Introduction to Safer Custody course to which this refers was replaced by the Introduction to Suicide and Self-Harm Prevention course, known as SASH, in May 2017. Like its predecessor courses, the SASH course is being delivered to all new prison officers as part of their entry level training, and to all new staff in other prisoner-facing roles. It has also been developed in modular form so that it can be delivered as refresher training to existing staff.”

Source location
2017-0316-Response-by-HM-Prison-Probation-Services.2-1
Page 2 · response
Published 3 December 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Train additional staff as SASH trainers to increase capacity for course delivery.

Verbatim wording from the response
“The targets for the programme of refresher training have been revised to reflect the fact that the new training takes much longer to complete. This, together with the resourcing challenges that the Prison faced during the summer months, and the lack of availability of trainers equipped to deliver the new course means that it is now projected that the new course will have been delivered to all existing staff who have contact with prisoners by the end of September 2018. Additional staff will be trained as trainers in early 2018 in order to facilitate this.”

Source location
2017-0316-Response-by-HM-Prison-Probation-Services.2-1
Page 2 · response
Published 3 December 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Train prisoner-facing Carillion staff and maintain training records for all staff, including directly employed and contracted staff.

Verbatim wording from the response
“I can confirm that a number of Carillion staff in prisoner-facing roles at HMP Winchester have been trained, and that records of training delivered to all staff, including those who are not directly employed, are now held. These records do not, however, include information about the internal training programmes of other employers.”

Source location
2017-0316-Response-by-HM-Prison-Probation-Services.2-1
Page 3 · response
Published 3 December 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Issue a Service Manager’s Instruction notifying contractors of suicide and self-harm prevention training requirements and contractual obligations.

Verbatim wording from the response
“I accept that the requirement for prisoner-facing staff to undertake suicide and self-harm prevention training was not specifically brought to the attention of Carillion when their contract began, and I can confirm that a Service Manager’s Instruction will be issued imminently to ensure that Carillion, and our other contractors, are made aware of the requirement and their contractual obligation to comply with it. Both HMPPS and Carillion are committed to ensuring that all relevant staff are trained as soon as possible.”

Source location
2017-0316-Response-by-HM-Prison-Probation-Services.2-1
Page 3 · response
Published 3 December 2017
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Requested HMPPS issue a formal instruction identifying prisoner-facing staff required to complete SASH training.

Verbatim wording from the response
“4. We have proposed to them that they provide us with a formal instruction under the contractual arrangements for our staff to undergo SASH training and confirm which categories of staff should undergo training. Our client has confirmed this week that it considers all Carillion prisoner facing staff should be required to undergo training.”

Source location
2017-0316-Response-by-Carillion
Page 2 · response
Published 3 December 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Refresher-training figures do not mean prisoner-facing staff have never been trained or are deployed unable to recognise suicide and self-harm risk.

Verbatim wording from the response
“Crucially, this does not mean that untrained staff who are unable to recognise prisoners at risk are being deployed in the prison. The training targets relate to the completion of the local refresher training. So, whilst the figures that you quote show a temporary reduction in the proportion of staff who are “in date” in terms of the local requirement to have undertaken such training within the last three years, this does not mean that there are staff in prisoner-facing roles who have never been trained. Moreover, the refresher training that the staff are now undertaking is much more extensive, and contains more detailed information about risk, than the ACCT training that was previously available. For this reason I am confident that the changes that have been made to the training programme will have the effect of improving staff awareness and capacity to identify and address risk.”

Source location
2017-0316-Response-by-HM-Prison-Probation-Services.2-1
Page 2 · response
Published 3 December 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Refresher-training completion was delayed because the longer course, resourcing challenges and limited availability of qualified trainers constrained delivery.

Verbatim wording from the response
“The targets for the programme of refresher training have been revised to reflect the fact that the new training takes much longer to complete. This, together with the resourcing challenges that the Prison faced during the summer months, and the lack of availability of trainers equipped to deliver the new course means that it is now projected that the new course will have been delivered to all existing staff who have contact with prisoners by the end of September 2018. Additional staff will be trained as trainers in early 2018 in order to facilitate this.”

Source location
2017-0316-Response-by-HM-Prison-Probation-Services.2-1
Page 2 · response
Published 3 December 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Carillion disputes that its HMPPS contracts require Carillion staff to undergo self-harm and suicide prevention training.

Verbatim wording from the response
“CARILLION’S CONTRACTS WITH HMPPS I wish to clarify an apparent misunderstanding about our contractual obligations that you appear to be under following evidence that you heard during the inquest. By contract, Carillion provides a range of hard and soft facilities management services to HMPPS in public prisons throughout the country. However, having carefully reviewed our contracts with HMPPS, and contrary to the view that you formed during the inquest, there is in fact no contractual requirement upon Carillion and its staff to undergo SASH training, either as a business requirement, key deliverable or at all. Accordingly, prior to the inquest touching the death of Mr Plumstead, Carillion was unaware of the requirement for its staff to undergo SASH training.”

Source location
2017-0316-Response-by-Carillion
Page 2 · response
Published 3 December 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
HMPPS is responsible for training all prison-facing staff, including Carillion staff, in self-harm and suicide prevention.

Verbatim wording from the response
“We are accordingly grateful for having had this issue drawn to our attention and immediately upon receipt of your Regulation 28 report set about investigating the matter and how we might work with HMPPS on it, the obligation to train all prison facing staff, being theirs.”

Source location
2017-0316-Response-by-Carillion
Page 2 · response
Published 3 December 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Carillion cannot provide self-harm and suicide prevention training because it is highly specialist and specific to custodial settings.

Verbatim wording from the response
“2. We have identified that SASH training is highly specialist and specific to a custodial setting and as such is not job specific in terms of the training we would ordinarily expect our staff to undertake within facilities management. Accordingly, it is not training that we are able to provide to our staff as employers.”

Source location
2017-0316-Response-by-Carillion
Page 2 · response
Published 3 December 2017
Open published response
8 Apr2015
Manchester West
Concerns raised1
1. Failure of training for professionals working with young people to support recognition and discovery of self-harm
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Aleysha Martine Karla McLoughlin · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Aleysha Martine Karla McLoughlin, aged 16, died by hanging at her foster home on 3 April 2014 after a history of self-harm, overdoses and assessed ongoing risk of impulsive self-harm. The concerns included training for professionals to recognise self-harm, systems for sharing information when young people self-harm, urgent multi-agency discussions including mental health services, and a formal support pathway for young people who resist engagement.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of training for professionals working with young people to support recognition and discovery of self-harm
Wider context from the report
“(1) That it should be considered that the system of training for those working with young people, including teachers, school nurses, foster carers, social workers, mental health workers and medical nurses and doctors should be reviewed so as to ensure that these professionals should be alert for signs of self harm and should take opportunities to discover themselves so that those harming themselves can be offered help and support. By way of example evidence was given at the Inquest that the annual health check offered to looked after children did not include a blood pressure check. If a blood pressure check was included this would provide an opportunity for signs of self harm to be revealed. ”
Source location
Aleysha Martine Karla McLoughlin · Prevention of Future Deaths report
Page 4 · concerns
Open source report
13 Feb2014
Inner West London
Concerns raised1
1. Lack of training or experience to recognise the importance of information about patients’ suicidal intention
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Lisa Marie Inkin · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Lisa Marie Inkin, who had severe anorexia nervosa and was on home leave from an eating disorders unit, took her own life by diving in front of a train at Victoria Station on 9 April 2013. The report raised concerns about the lack of local specialist inpatient eating disorder services, communication between local and out-of-area providers, inadequate escalation of information about suicidal intent, possible failures to record or answer calls, and the proposed lack of overnight supervision and transport difficulties in Kent.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of training or experience to recognise the importance of information about patients’ suicidal intention
Wider context from the report
“8. Possible lack of training or experience on the part of Cygnet ward staff to understand the importance of receiving information about suicidal intention of one of their patients. ”
Source location
Lisa Marie Inkin · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide suicide intervention training to all frontline police staff

Concerns raised1

Lack of training and information for security staff on self-harm and suicide risk

Concerns raised1

Failure of support workers to complete suicide prevention training

Concerns raised1

Lack of self-harm training for frontline staff encountering patients with self-inflicted injuries

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised2

Failure to provide ACCT training to all relevant prison staff

Failure to train all prisoner-facing Carillion staff in self-harm and suicide prevention

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised1

Failure of training for professionals working with young people to support recognition and discovery of self-harm

Concerns raised1

Lack of training or experience to recognise the importance of information about patients’ suicidal intention

Actions described in response 1

Actions described in response 5

Respondent positions 5