First reported 6 Jun 2014•Latest report 20 Mar 2026
Definition
What this concern includes
Includes physical design, fixture, room-stripping, risk-assessment and information controls directly concerned with preventing access to ligature opportunities in inpatient or custodial settings.
Not included
General suicide or self-harm risk management without a ligature control
Observation failures where no ligature hazard is identified
Community or public-location fall hazards
Reports
24
Distinct published reports
Individual concerns
32
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
32
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.
HM Prison and Probation Service10
Ministry of Justice9
Bedford Prison3
Department of Health and Social Care3
Essex Partnership University NHS Foundation Trust3
NHS England3
Care Quality Commission2
Central and North West London NHS Foundation Trust1
Coventry and Warwickshire Partnership NHS Trust1
Downview Prison and Young Offender Institution1
Garth Prison1
GeoAmey PECS Limited1
Glangwili General Hospital1
Grendon Prison1
Guys Marsh Prison1
Ministerial department11
Prison or young offender institution11
Executive agency10
NHS trust8
Executive non-departmental public body4
Private limited company4
Health and social care service regulator2
Clinical commissioning group1
Healthcare site1
Justice inspectorate1
Police force1
Prison operator1
Sub-organisation1
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.
Greater Lincolnshire
Concerns raised1
Unsafe provision of corded telephones in cells occupied by prisoners who may self-harm
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 concerns
Each 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.10
Action
Review current telephony arrangements within the Care and Separation Unit.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Develop a formal business case assessing the feasibility, proportionality and risks of relocating telephone sockets within cells.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Modify Care and Separation Unit cell doors to route telephone cables securely beneath the doors.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Enable telephones to be fixed to internal cell walls to minimise excess cable slack.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Install fixed, non-weight-bearing handset cradles in cells using appropriate attachments.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Review current Care and Separation Unit telephony arrangements.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Develop a formal business case assessing the feasibility, proportionality and risks of relocating telephone sockets within cells.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Modify Care and Separation Unit cell doors to route telephone cables securely beneath them.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Install fixed wall-mounted telephone fittings and non-weight-bearing handset cradles to minimise cable slack and enable safe handset storage.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Monitor implementation and effectiveness of the telephony safety measures through safety and assurance frameworks and ongoing review.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Immediate relocation of CSU telephone sockets is not undertaken because it requires significant structural alteration and capital investment.
Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Relocation of CSU telephone sockets is not currently being implemented because it requires significant structural alteration and capital investment, pending feasibility assessment.
Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to maintain special cells in a condition that prevents access to ligature-making material
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Submit a bid to upgrade constant supervision cells to ligature-resistant specifications and address disrepair.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.
Essex
Concerns raised2
Unsecured ligature-risk items in the presence of high-risk patients
Failure to hand over vital self-harm and ligature information at shift change
This report raised 29 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Improve CAMHS incident learning through ABC-format Datix records, staff training, action recording and ligature-risk categorisation.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Implement electronic SBAR handovers to improve communication of patient safety information between shifts.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Environmental risks cannot be eliminated entirely, so safety work is limited to minimising risks without introducing restrictive practice.
Stated by Essex Partnership University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised1
Failure to cost structural mitigation of accessible window-bar ligature points
This report raised 13 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Submit a local business case to upgrade HMP Chelmsford Victorian-style windows to anti-ligature designs.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Complete conversion of 50 cells across 13 locations to a ligature-resistant standard.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
National provision of ligature-resistant cells will increase subject to funding.
Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Bedfordshire and Luton
Concerns raised1
Failure to ensure observation panels cannot be opened from inside to create ligature opportunities
This report raised 6 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Restore ligature-resistant cells to serviceable condition using approved lockable observation hatches.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 October 2025.
Action
Complete a full review of ligature-resistant doors and an urgent assessment of the door and observation-panel design.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 October 2025.
Action
Issue a tender proposal to replace ligature-resistant observation panels with a model meeting current safety specifications.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 October 2025.
Kent and Medway
Concerns raised1
Failure to provide bedding materials resistant to being ripped into ligatures
This report raised 6 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Conduct a cell design review to assess alternative materials meeting fire-safety and anti-ligature requirements for bedding.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2025.
Coventry
Concerns raised1
Ligature risks at the tops of patient bedroom doors in unobserved areas
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 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.
Derby and Derbyshire
Concerns raised1
Presence of fixed shower rails creating ligature points in prisoner-accessible shower areas
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Convert cells in older prisons to ligature-resistant standards through the estate-wide programme.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 26 June 2024.
Dorset
Concerns raised1
Camouflaging similarity between cell-door and bedsheet colours
This report raised 16 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Explore and, where appropriate, resolve the cell-door and bedsheet colour camouflage issue.
Stated by Guys Marsh PrisonStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Essex
Concerns raised1
Failure of an assisted-bathroom anti-ligature safety mechanism
This report raised 8 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Check assisted-bathroom handrail mechanisms every shift and conduct management, fixture, and ligature audits.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 February 2024.
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Includes physical design, fixture, room-stripping, risk-assessment and information controls directly concerned with preventing access to ligature opportunities in inpatient or custodial settings.
