Recurring concern

Unreliable access to ligature cutters for frontline responders

First to latest report 21 May 2014 — 10 Apr 2024

Reports that mention this concern
6
Times this concern has been raised
7
Stated actions linked to this concern
6

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.

What is 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 and published responses 6 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Somerset

    AI-generated summary

    Cariss Lucy Stone · 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

    Cariss Lucy Stone was detained in a Psychiatric Intensive Care Unit and self-harmed on multiple occasions, including by attaching a ligature around her neck. During an interval in observations, she applied a ligature with fatal effect, and the healthcare assistant who found her did not have a ligature cutter. The concerns identified were possible inadequate understanding and training regarding observation requirements, including for agency staff, and the lack of routine access to ligature cutters for staff conducting observations.

    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 routinely supply staff conducting patient observations with ligature cutters

    Wider context from the report

    “(2) In a ward where self-harm including use of a ligature was not uncommon there was concern that members of staff and in particular those involved in carrying out observations on patients were not routinely supplied with ligature cutters. ”

    Source location

    Cariss Lucy Stone · 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

    Review whether staff should carry ligature cutters during level 2 and 3 observations and assess available cutters for the safest option.

    Verbatim wording from the response

    “Consideration and discussion is underway to consider staff holding a ligature cutter whilst carrying out level 2 and 3 observations for patients who present with a risk of self-harm/suicide. This would be alongside a further review of the types of ligature cutters that are available on the market, to ensure they have the safest option. Once agreed we will seek to roll this out across all the MH wards and update our Observation policy to provide greater detail on the process.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 4 · response
    Published 29 April 2024

    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

    The balance of patient and staff safety risks does not support staff routinely carrying ligature cutters on wards with increased violence and aggression risks.

    Verbatim wording from the response

    “We considered the potential risks of supplying staff on wards like Holford (PICU) and Ash ward (low secure inpatient rehabilitation and recovery unit for male adults with mental health difficulties) where there is an increased risk of violence and aggression with ligature cutters. This required careful consideration of both the risks to patients, who present with self-harm and suicide versus the risk of patients who present with high levels of violence and aggression or with a documented forensic history. Our conclusion from this review with the ward teams and senior leaders is that the balance of risk would not support staff routinely carrying ligature cutters.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 4 · response
    Published 29 April 2024

    Open published response

  2. East London

    AI-generated summary

    Winbourne Gregory Charles · 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

    Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.

    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

    Unavailability of a ligature cutter for prompt emergency use

    Wider context from the report

    “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include; a. A ward emergency bell was not sounded, b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles. c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination, d. Duty doctors were not called promptly, e. Oxygen administration was delayed, f. An on-site defibrillator was not used by staff g. Staff could or would not provide a clear and relevant history to paramedics. ”

    Source location

    Winbourne Gregory Charles · 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

    Conduct monthly resuscitation drills covering emergency alarms, equipment, oxygen, defibrillation, clinical handover and cardiac-checklist use.

    Verbatim wording from the response

    “4. Risk management (shortcomings in responding to the emergency) – the Coroner found that the Trust did not respond to the | 5. | Resus drills which include all of these elements are taking place monthly. | 1. Resus drills to take place monthly”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 4 · response
    Published 5 May 2023

    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

    Refresh staff training on ligature-cutter locations and use.

    Verbatim wording from the response

    “a. [continued] 5. Refresh staff as part of the above on whereabouts of Ligature cutters (2 on each ward)”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 5 · response
    Published 5 May 2023

    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

    Concerns about care provision and coordination are mainly for the NHS Trust to address.

    Verbatim wording from the response

    “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 5 May 2023

    Open published response

  3. South Wales Central

    AI-generated summary

    John Henry WHITE · 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 Henry White suspended himself on 20 October 2019 and was transferred to Royal Glamorgan Hospital, where he died on 23 October 2019. The inquest jury concluded that the failure to release the ligature sooner possibly contributed to his chances of survival. The principal concerns were the incomplete distribution of ligature cutters to frontline officers and the availability of bespoke training for officers responding to similar incidents.

    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

    Incomplete distribution of ligature cutters to frontline officers

    Wider context from the report

    “1. In June 2020 the Independent Office for Police Complaints recommended that all response vehicles be equipped with a ligature cutter or similar. That recommendation was accepted by Chief Superintendent Clare Evans on behalf of South Wales Police in July 2020. I received evidence from Chief Inspector ████████ that in 2020 South Wales Police had determined to widen the scope of the recommendation to all frontline officers. She informed me that ligature cutters were delivered to the force in July 2022. As at the 4th of October 2022, approximately 25% of those had been distributed to frontline officers. She was unable to assist the court with the timeline for the remaining distribution other than in relation to her own force division - a target date of the 22nd of October 2022. She candidly accepted in her evidence that the incomplete distribution to all frontline officers at this time meant that the scenario faced by the response officers attending upon Mr White on the 20th of October 2019 was still patent & the opportunity to release a suspended individual currently dependent upon whether there had been distribution to the tasked response officers. That is the concern that I have and wish you to consider and address. ”

    Source location

    John Henry WHITE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. South Yorkshire (Western)

    AI-generated summary

    Chelsea Blue Louise Mooney · 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

    Chelsea Blue Louise Mooney died two days after tying two non-fixed ligatures while in hospital, following inadequate observations and delays in the emergency response. Principal concerns included insufficient review of her diagnosis, inadequate exploration of allegations and information-sharing decisions, a failure to learn from previous ligature incidents, uncertainty among staff about responding to her, and delays and poor coordination during the final emergency response.

    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

    Unpractised and delayed ligature identification and knife response

    Wider context from the report

    “7. The approach of three members of staff checking Chelsea before the ligature knife was brought and used led to avoidable delay. I am aware from the evidence that there are practise exercises involving the 'Red Bag' however I am not clear that the same is practised in relation to the check, identification of a ligature and obtaining and using the ligature knife in these situations. ”

    Source location

    Chelsea Blue Louise Mooney · Prevention of Future Deaths report
    Page 4 · 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

    Pilot clinical skills stations covering observations, ligature awareness and removal, and response to patient deterioration.

    Verbatim wording from the response

    “36. The organisation is also piloting a programme called clinical skills stations which looks to enhance the training of nurses with practical simulation and these will cover observations and engagement, ligature awareness and removal and responding to a physical deterioration of a patient.”

    Source location

    Response from Cygnet Health Care
    Page 10 · response
    Published 3 October 2022

    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

    Roll out the clinical skills stations programme across the organisation after piloting it at three sites.

    Verbatim wording from the response

    “73. As per previous aspect. The organisation is piloting clinical skills stations, these will cover three aspects such as observation and engagement, ligature awareness and removal and responding to a deteriorating patient. This will be piloted on three sites and then will be rolled out across the organisation.”

    Source location

    Response from Cygnet Health Care
    Page 18 · response
    Published 3 October 2022

    Open published response

  5. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Kesia Blaine Waller · 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

    Kesia Blaine Waller, aged 17, was found suspended from a ligature at her residential housing unit on 20 January 2020 and died in hospital on 25 January 2020 after life-sustaining treatment was withdrawn following a catastrophic hypoxic brain injury. The concerns included inadequate staff training and equipment to respond to a young person suspended from a ligature, and ineffective communication and implementation of policies and 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 to provide staff with effective tools and implements for immediate life-saving action

    Wider context from the report

    “At Kesia’s Inquest I heard that her place of residence, City Road in Winchester, was a residential housing unit for vulnerable young people aged 16-21. The facility meets a housing need only for the young persons placed there. It was found on the evidence that A2 Dominion employees did not have sufficient training or tools (i.e. implements) in place to prepare staff for the situation that they faced on the 20th January 2020 when they found Kesia hanging in her room, nor could they carry out any physical actions to assist her (i.e. cut her down). There appeared to be no prior appreciation of the risk(s) of self-harm, overdose or attempted suicide of residents, and so on discovering Kesia suspended in her room, the staff were inadequately prepared on multiple levels. (a) I heard that whilst there has been additional training for the staff on areas of risk such as self-harm, overdose and/or suicide, there have been no physical changes in terms of the provision of tools and implements that staff could use should they be confronted by a young person in distress and/or in need of life-saving attention. It appears to me that without multi-factorial changes there remains a real and significant risk that staff at the residential units will remain unable to take any immediate and potentially life-saving action. The only tools and equipment that remain supplied is a standard home-style first aid kit which is entirely ineffective if a young person has suspended themselves from a ligature. (b) Although additional training and courses have been added to both the induction training and on-going professional development of staff within the residential units similar to City Road, I remain concerned by the way in which key policies and training are communicated and implemented as this does not appear to have changed. It was clear from the evidence that updates to policies are emailed to employees with a request that the employee responds to the email to confirm receipt. This proved to be wholly ineffective as what appeared to be expected by the company was that the employee would read, digest and understand the policy, and confirm when he/she had done so. The employee on duty on the 20th January 2020 was clearly unfamiliar with the appropriate policies and had only confirmed that he had received the email (which appeared to be all that was required) and not that he had actually read, digested and understood the appropriate policy/policies; how to apply them in practice and what was reasonably expected of him. Although enhanced risk training is now place, it appears to me that without any enhanced diligence to ensure that policies are actually read and understood by those working face-to-face with the vulnerable young adults then the overall effectiveness of risk training and identification is severely flawed. ”

    Source location

    Kesia Blaine Waller · 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

    Provide ligature-cutting kits with safety knives and quick guides in every care and support office, with content included in audits.

    Verbatim wording from the response

    “Additionally, we are providing ligature cutting kits in every office that provides any form of care and support provision and this will be fully rolled out by the end of July 2021. The kit includes a big fish safety knife which is recommended for ligature cutting. These kits will also have quick guides within them and are included in our audits for checking content.”

    Source location

    2021-0187-Response-from-A2Dominion_Published
    Page 1 · response
    Published 4 June 2021

    Open published response

  6. Manchester North

    AI-generated summary

    Mark Darren Bartholomew · 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 Darren Bartholomew, who had a longstanding diagnosis of paranoid schizophrenia and was detained in hospital after transfer from prison, died by hanging on 25 July 2013 during a routine observation check. Concerns included an inadequate response to emergency services, the absence of the ligature cutter needed to release him promptly, and insufficient detail in observation records.

    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 detailed guidance on access to and type of ligature cutters

    Wider context from the report

    “2. Ligature Cutters – The Consultant Forensic Pathologist, ████████ confirmed in evidence that time was very much of the essence. Specifically he stated ‘following application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes’ The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a bag attached to a hook on the wall in the secure clinic. The ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking, the absence had gone unnoticed. The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later. To the credit of the Trust, the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift. Although alerted to Department of Health guidance from 2007, I can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in a pouch by Custody Sergeants within the Custody Office of designated Police Stations. The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement, the ligature would have been released within a matter of seconds rather than minutes. ”

    Source location

    Mark Darren Bartholomew · 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 ensure immediately available ligature cutters in the secure clinic

    Wider context from the report

    “2. Ligature Cutters – The Consultant Forensic Pathologist, ████████ confirmed in evidence that time was very much of the essence. Specifically he stated ‘following application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes’ The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a bag attached to a hook on the wall in the secure clinic. The ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking, the absence had gone unnoticed. The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later. To the credit of the Trust, the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift. Although alerted to Department of Health guidance from 2007, I can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in a pouch by Custody Sergeants within the Custody Office of designated Police Stations. The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement, the ligature would have been released within a matter of seconds rather than minutes. ”

    Source location

    Mark Darren Bartholomew · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026