Recurring concern
Unreliable access to ligature cutters for frontline responders
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Request correctionFirst reported 21 May 2014•Latest report 10 Apr 2024
What this concern includes
Includes failures of dedicated arrangements to provide, distribute, carry, store, access or promptly use ligature cutters for frontline police, healthcare, care or other responders who may encounter a ligature emergency.
Not included
- Excludes environmental ligature points, safer-cell design and other physical-hazard controls where the concern is not access to a ligature cutter.
- Excludes patient observation, self-harm risk assessment, incident classification, handover and training deficiencies unless they directly cause unreliable access to a ligature cutter.
- Excludes generic emergency equipment shortages not specifically involving ligature cutters.
- Excludes failures concerning the clinical response after a ligature cutter has been promptly accessed.
- Reports
- 6
- Individual concerns
- 7
- Date range
- 2014–2024
- Stated actions
- 6
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
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.
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Concerns raised1
Failure to routinely supply staff conducting patient observations with ligature cutters
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Review whether staff should carry ligature cutters during level 2 and 3 observations and assess available cutters for the safest option.
Stated by Somerset NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The balance of patient and staff safety risks does not support staff routinely carrying ligature cutters on wards with increased violence and aggression risks.
Stated by Somerset NHS Foundation Trust
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Concerns raised1
Unavailability of a ligature cutter for prompt emergency use
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.2
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Action
Conduct monthly resuscitation drills covering emergency alarms, equipment, oxygen, defibrillation, clinical handover and cardiac-checklist use.
Stated by North East London NHS Foundation Trust -
Action
Refresh staff training on ligature-cutter locations and use.
Stated by North East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social Care
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Concerns raised1
Incomplete distribution of ligature cutters to frontline officers
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Unpractised and delayed ligature identification and knife response
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 concernsEach statement is shown once, even when linked to more than one concern.
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.2
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Action
Pilot clinical skills stations covering observations, ligature awareness and removal, and response to patient deterioration.
Stated by Cygnet Health Care Limited -
Action
Roll out the clinical skills stations programme across the organisation after piloting it at three sites.
Stated by Cygnet Health Care Limited
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Concerns raised1
Failure to provide staff with effective tools and implements for immediate life-saving action
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Provide ligature-cutting kits with safety knives and quick guides in every care and support office, with content included in audits.
Stated by A2Dominion Housing Group Limited
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Concerns raised2
Lack of detailed guidance on access to and type of ligature cutters
Failure to ensure immediately available ligature cutters in the secure clinic
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026