20 Mar 2026 Luke Owen ASHCROFT · Prevention of Future Deaths report Greater Lincolnshire
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Concerns raised 1
Unsafe provision of corded telephones in cells occupied by prisoners who may self-harm View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
HM Prison and Probation Service
Review current telephony arrangements within the Care and Separation Unit.
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HM Prison and Probation Service
Develop a formal business case assessing the feasibility, proportionality and risks of relocating telephone sockets within cells.
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HM Prison and Probation Service
Modify Care and Separation Unit cell doors to route telephone cables securely beneath the doors.
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HM Prison and Probation Service
Enable telephones to be fixed to internal cell walls to minimise excess cable slack.
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HM Prison and Probation Service
Install fixed, non-weight-bearing handset cradles in cells using appropriate attachments.
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HM Prison and Probation Service
Review current Care and Separation Unit telephony arrangements.
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HM Prison and Probation Service
Develop a formal business case assessing the feasibility, proportionality and risks of relocating telephone sockets within cells.
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HM Prison and Probation Service
Modify Care and Separation Unit cell doors to route telephone cables securely beneath them.
View source
HM Prison and Probation Service
Install fixed wall-mounted telephone fittings and non-weight-bearing handset cradles to minimise cable slack and enable safe handset storage.
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HM Prison and Probation Service
Monitor implementation and effectiveness of the telephony safety measures through safety and assurance frameworks and ongoing review.
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Luke Owen ASHCROFT · Prevention of Future Deaths report
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Report summary
Luke Ashcroft was admitted to Lincoln County Hospital from HMP Lincoln after being found unconscious in his cell in the Care and Separation Unit. His death was confirmed on 1 July 2020, with the post-mortem finding hypoxic brain injury consistent with ligature application. The inquest identified concerns about missed healthcare opportunities, inadequate information sharing and risk mitigations, shortcomings in the ACCT plan, and failures to carry out required observations; it also raised concerns about the safety and availability of corded telephone access in the unit.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsafe provision of corded telephones in cells occupied by prisoners who may self-harm
Wider context from the report “My concerns are twofold.
Firstly, whilst not directly relevant to the death of Luke Ashcroft, I am concerned about the clear and obvious risks of self harm posed by the provision of a corded telephone, secured at one end, suspended at head height in a cell commonly occupied by prisoners, who may seek to self harm . I was told that the cell J109 had no ligature points and that the door was fitted with anti ligature fittings. As a consequence, that was the only method of securing telephone access. That same issue may extend to other cells in the CSU. Whether at head height or otherwise, the provision of a corded phone may well be an issue in potential cases of self harm and appears incongruous in comparison with other steps taken to ensure safety within that cell. The risks of an inmate utilising that cord in an act of self harm are self evident.
Secondly, the mechanism of provision of telephone access on CSU appears to require a prisoner requesting such provision before the cells are locked down. Thereafter, whilst a request can be made by a prisoner, telephone provision may depend upon the availability of additional officers to attend whilst the cell is unlocked and the telephone provided. That is not certain to take place. Given the proper availability to prisoners in crisis of freephone access to Samaritans and similar services, the possible absence of a handset to access such services is a matter of concern.
” Source location Luke Owen ASHCROFT · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review current telephony arrangements within the Care and Separation Unit.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a formal business case assessing the feasibility, proportionality and risks of relocating telephone sockets within cells.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Modify Care and Separation Unit cell doors to route telephone cables securely beneath the doors.
Verbatim wording from the response “In the interim, a number of risk reduction measures are being implemented including work to modify the CSU cell doors to enable telephone cables to be routed securely beneath the door. This adjustment will remove the requirement for cables to pass over the top of cell doors, thereby reducing the identified ligature risk.” Source location Response from HM Prison and Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable telephones to be fixed to internal cell walls to minimise excess cable slack.
Verbatim wording from the response “In addition, telephones will have the ability to be fixed to the internal wall to minimise excess slack and restrict the potential for inappropriate use. A fixed, non-weight bearing handset cradle will also be installed within cells using appropriate attachments, ensuring that the handset can be safely stored without the need for prisoners to maintain tension on the cable during use.” Source location Response from HM Prison and Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install fixed, non-weight-bearing handset cradles in cells using appropriate attachments.
Verbatim wording from the response “In addition, telephones will have the ability to be fixed to the internal wall to minimise excess slack and restrict the potential for inappropriate use. A fixed, non-weight bearing handset cradle will also be installed within cells using appropriate attachments, ensuring that the handset can be safely stored without the need for prisoners to maintain tension on the cable during use.” Source location Response from HM Prison and Probation Service
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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 current Care and Separation Unit telephony arrangements.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
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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 Develop a formal business case assessing the feasibility, proportionality and risks of relocating telephone sockets within cells.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
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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 Modify Care and Separation Unit cell doors to route telephone cables securely beneath them.
Verbatim wording from the response “In the interim, a number of risk reduction measures are being implemented including work to modify the CSU cell doors to enable telephone cables to be routed securely beneath the door. This adjustment will remove the requirement for cables to pass over the top of cell doors, thereby reducing the identified ligature risk.” Source location Response from HM Prison and Probation Service
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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 Install fixed wall-mounted telephone fittings and non-weight-bearing handset cradles to minimise cable slack and enable safe handset storage.
Verbatim wording from the response “In addition, telephones will have the ability to be fixed to the internal wall to minimise excess slack and restrict the potential for inappropriate use. A fixed, non-weight bearing handset cradle will also be installed within cells using appropriate attachments, ensuring that the handset can be safely stored without the need for prisoners to maintain tension on the cable during use.” Source location Response from HM Prison and Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor implementation and effectiveness of the telephony safety measures through safety and assurance frameworks and ongoing review.
Verbatim wording from the response “The implementation and effectiveness of these measures will be monitored through the establishment’s safety and assurance frameworks. The controls introduced will be subject to ongoing review to ensure that they remain effective, proportionate, and responsive to any emerging risks or learning.” Source location Response from HM Prison and Probation Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Immediate relocation of CSU telephone sockets is not undertaken because it requires significant structural alteration and capital investment.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relocation of CSU telephone sockets is not currently being implemented because it requires significant structural alteration and capital investment, pending feasibility assessment.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
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3 Mar 2026 Mujahid Adam · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to maintain special cells in a condition that prevents access to ligature-making material View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mujahid Adam · 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
Mujahid Adam died by suicide after being found hanging in his prison cell on 15 March 2025; he was declared dead on 21 March 2025 at University College Hospital. The concerns included inadequate and non-contemporaneous recording of 15-minute observations, no clear definition of what constituted an observation, delays in calling Code Blue and cutting him down, and disrepair in the cell that allowed access to ligature material.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain special cells in a condition that prevents access to ligature-making material
Wider context from the report “(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made . Despite daily AFCs, that disrepair was not noted although this was a special cell.
” Source location Mujahid Adam · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit a bid to upgrade constant supervision cells to ligature-resistant specifications and address disrepair.
Verbatim wording from the response “In response to concerns about the condition of constant supervision cells at HMP Pentonville, I can confirm that a bid has been submitted to upgrade these cells to ligature resistant specifications. This work will address any disrepair and reduce opportunities for prisoners to use the fabric of the accommodation to ligature. In addition, staff at HMP Pentonville have been reminded of their responsibility to complete daily accommodation fabric checks. These are physical checks of all prisoner living areas, including cells, to ensure that the area is clean, decent and fit for purpose. They are also valuable opportunities for staff to identify anything that raises suspicion, including items that can be used to ligature.” Source location 2026-0125 - Response from HMPPS
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8 Feb 2026 Elise Kay Louise Sebastian · Prevention of Future Deaths report Essex
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Concerns raised 2
Unsecured ligature-risk items in the presence of high-risk patients View source Failure to hand over vital self-harm and ligature information at shift change View source
This report raised 29 other concerns. They are not shown here because they do not form part of this recurring concern.
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Elise Kay Louise Sebastian · 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
Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsecured ligature-risk items in the presence of high-risk patients
Wider context from the report “6. Detained patients including Elise were not kept under observations by trained staff and mealtimes were chaotic with patients moving between areas without the required supervision. On 17 April the activity co-ordinator left a box of mobile phone chargers and headphones that posed a ligature risk, with a member of ward staff in a communal area, asking that she look after this whilst he collected some takeaway food that had been ordered by patients from the ward entrance. On his return, the box was unattended in the presence of patients with a high risk of ligature and suicide , with no member of ward staff present to keep patients who required level 2 and level 3 observations. This was not reported to the nurse in charge, and no incident report was completed. Evidence was that there were many new staff and that breaches of procedure were a regular occurrence. This left patients at risk. Evidence was heard that patients are still being left without the required observations since this death.
” Source location Elise Kay Louise Sebastian · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to hand over vital self-harm and ligature information at shift change
Wider context from the report “3. There was poor communication between ward staff and vital information about self-harm and ligaturing was not handed over on shift change. It was undisputed that Elise tied 12 Ligatures between 7ᵗʰ and 14ᵗʰ April and ████████ on 15 April. The Datix incident recording gave minimal details and only the ligatures from the 13ᵗʰ and 14ᵗʰ were recorded on the whiteboard in the nurse’s office.
” Source location Elise Kay Louise Sebastian · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve CAMHS incident learning through ABC-format Datix records, staff training, action recording and ligature-risk categorisation.
Verbatim wording from the response “▪ Training with preceptor nurses as part of induction” Source location 2026-0078 - Response from Essex University Partnership Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement electronic SBAR handovers to improve communication of patient safety information between shifts.
Verbatim wording from the response “The Trust has also implemented changes to handover process using SBAR – an electronic handover system.” Source location 2026-0078 - Response from Essex University Partnership Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Environmental risks cannot be eliminated entirely, so safety work is limited to minimising risks without introducing restrictive practice.
Verbatim wording from the response “There are a range of potential environmental risks on all wards. The Trust has a set of Environmental Standards to minimise risks and utilise reduced ligature products but it is not possible to eliminate all risks. Part of environmental risk mitigation is the observation level assigned to each person, based on that individual persons risks. Observation is about having a presence and engaging with patients and to empower staff to be curious and knowledgeable of the risks and mindful of the complexities of each individual patient.” Source location 2026-0078 - Response from Essex University Partnership Trust
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12 Jan 2026 STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to cost structural mitigation of accessible window-bar ligature points View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
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STUART CHRISTOPHER JAMES BERRY · 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
STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to cost structural mitigation of accessible window-bar ligature points
Wider context from the report “CONCERN: A further concern raised by the evidence relates to the lack of any attempt to cost structural cell improvements to mitigate , at least in some cells on each wing, the most obvious of ligature points in the Victorian Prison estates’ cells, namely the readily accessible fixed bars at the windows. Whilst other less obvious ligature points are potentially available in cells, all the (multiple) self-inflicted ligature related deaths at HMP Chelmsford in recent years have exclusively involved the use of the window bars.
The HMPPS Prison Group Director for Hertfordshire, Essex and Suffolk prisons undertook, following his evidence that such costings had not even been sought to date, to now ensure that such an exercise is undertaken. However, the concern remains that this is a national issue in relation to all Victorian or equivalent prisons and that absent even a costing exercise, steps to mitigate this serious, obvious and continuing risk will not be addressed .
” Source location STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit a local business case to upgrade HMP Chelmsford Victorian-style windows to anti-ligature designs.
Verbatim wording from the response “Nationally, we recognise that older cells can contain multiple potential ligature fixtures—including plumbing, furniture, and electrical fittings. HMP Chelmsford have submitted a local business case seeking to upgrade Victorian-style windows to anti-ligature designs.” Source location Response from HM Prison & Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete conversion of 50 cells across 13 locations to a ligature-resistant standard.
Verbatim wording from the response “The long-term solution is the redevelopment of cells to a fully ligature-resistant (LR) standard. Although newer prisons and refurbished wings are built to this specification, much of the estate predates the LR standard and does not currently include extensive LR provision. We are concluding a project to convert 50 cells across 13 locations, prioritised according to assessed levels of risk. This includes HMP Chelmsford, where four LR cells were completed in 2025. While LR cells are valuable, they are not always appropriate for individuals requiring constant supervision. In such cases, purpose-built constant-supervision cells offer greater visibility for staff, are the safer alternative, and several are already available at HMP Chelmsford. Subject to funding, we aim to increase the provision of LR cells nationally in the coming financial year.” Source location Response from HM Prison & Probation Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National provision of ligature-resistant cells will increase subject to funding.
Verbatim wording from the response “The long-term solution is the redevelopment of cells to a fully ligature-resistant (LR) standard. Although newer prisons and refurbished wings are built to this specification, much of the estate predates the LR standard and does not currently include extensive LR provision. We are concluding a project to convert 50 cells across 13 locations, prioritised according to assessed levels of risk. This includes HMP Chelmsford, where four LR cells were completed in 2025. While LR cells are valuable, they are not always appropriate for individuals requiring constant supervision. In such cases, purpose-built constant-supervision cells offer greater visibility for staff, are the safer alternative, and several are already available at HMP Chelmsford. Subject to funding, we aim to increase the provision of LR cells nationally in the coming financial year.” Source location Response from HM Prison & Probation Service
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24 Sep 2025 Steven HART · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1
Failure to ensure observation panels cannot be opened from inside to create ligature opportunities View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Steven HART · 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
Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.
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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 observation panels cannot be opened from inside to create ligature opportunities
Wider context from the report “1. Failure to Adequately Monitor and Audit Cells for Ligature Points
Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself.
Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk.
The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm . Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately.
2. Failure to Effectively Communicate Risk and Incidents
There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk.
3. Failure to Carry Out Appropriate Observations
Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials.
The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners.
” Source location Steven HART · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Restore ligature-resistant cells to serviceable condition using approved lockable observation hatches.
Verbatim wording from the response “I can confirm that interim measures have been put in place at HMP Bedford to ensure that the ligature-resistant (LR) cells are now serviceable. The LR cell observation panels have temporarily been replaced with an approved lockable observation hatch. A full review of all LR doors has been completed, alongside an urgent assessment of the current door and observation panel design. Additionally, Government Facilities Services Limited has undertaken a further review of the locking mechanism within the LR cell observation panels to ensure they remain fully serviceable. In the longer term, a proposal to replace the existing LR cell observation panels with a model that meets current safety specifications – designed to reduce the risk of prisoners from opening them inside the cell - has been issued for tender.” Source location Response from HM Prison & Probation Service
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a full review of ligature-resistant doors and an urgent assessment of the door and observation-panel design.
Verbatim wording from the response “I can confirm that interim measures have been put in place at HMP Bedford to ensure that the ligature-resistant (LR) cells are now serviceable. The LR cell observation panels have temporarily been replaced with an approved lockable observation hatch. A full review of all LR doors has been completed, alongside an urgent assessment of the current door and observation panel design. Additionally, Government Facilities Services Limited has undertaken a further review of the locking mechanism within the LR cell observation panels to ensure they remain fully serviceable. In the longer term, a proposal to replace the existing LR cell observation panels with a model that meets current safety specifications – designed to reduce the risk of prisoners from opening them inside the cell - has been issued for tender.” Source location Response from HM Prison & Probation Service
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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 tender proposal to replace ligature-resistant observation panels with a model meeting current safety specifications.
Verbatim wording from the response “I can confirm that interim measures have been put in place at HMP Bedford to ensure that the ligature-resistant (LR) cells are now serviceable. The LR cell observation panels have temporarily been replaced with an approved lockable observation hatch. A full review of all LR doors has been completed, alongside an urgent assessment of the current door and observation panel design. Additionally, Government Facilities Services Limited has undertaken a further review of the locking mechanism within the LR cell observation panels to ensure they remain fully serviceable. In the longer term, a proposal to replace the existing LR cell observation panels with a model that meets current safety specifications – designed to reduce the risk of prisoners from opening them inside the cell - has been issued for tender.” Source location Response from HM Prison & Probation Service
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29 Jul 2025 Azroy Dawes-Clarke · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1
Failure to provide bedding materials resistant to being ripped into ligatures View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Azroy Dawes-Clarke · 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
Azroy Dawes-Clarke died in hospital on 10 November 2021 after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and treatment. The substantive concerns included inadequate communication and healthcare involvement, disproportionate and prolonged restraint, delays in recognising the arrest and starting CPR, unsuitable ligature-resistant materials, and gaps in staff training on ACCT procedures, first aid, basic life support, and the legal framework for medical emergencies.
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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 bedding materials resistant to being ripped into ligatures
Wider context from the report “(1) Despite being in a safer cell, dressed in an anti-ligature gown, Mr Dawes-Clarke was able to make a ligature from the bedding material in his cell. The material from which the mattress and pillow cover are made, permit strips to be ripped from them.
” Source location Azroy Dawes-Clarke · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a cell design review to assess alternative materials meeting fire-safety and anti-ligature requirements for bedding.
Verbatim wording from the response “HMPPS are currently undertaking a cell design review which is looking at all aspects of cell design, including furniture and fittings, to ensure it takes account of developments in how prisoners are accommodated and improvements in what is currently available on the market. As part of this review, we will explore the possibility of using different materials which meet the stringent fire safety requirements and can also function as anti-ligature for bedding. The review is expected to conclude at the end of 2026.” Source location Response from HM Prison and Probation Service
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6 Mar 2025 Henok Zaid GEBRSSLASIE · Prevention of Future Deaths report Coventry
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Concerns raised 1
Ligature risks at the tops of patient bedroom doors in unobserved areas View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Henok Zaid GEBRSSLASIE · 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
Henok Zaid GEBRSSLASIE, who was detained under the Mental Health Act at the Caludon Centre, was found partially suspended by a ligature in his bedroom on Sherbourne Ward on 12 August 2021, nearly three hours after his last observation. The report identifies continuing concern about the known high risk posed by bedroom door tops as ligature anchor points and notes that door-top alarms had not been installed on the ward by March 2025.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Ligature risks at the tops of patient bedroom doors in unobserved areas
Wider context from the report “ii. It is known (and has been known for some years by the Coventry and Warwickshire Partnership NHS Trust) that the top of a door is a “high risk area” for ligatures in particular patients bedroom which have doors that may be locked by patients from the inside and thereby an unobserved patient area .
iii. The circumstances of this inquest touching upon the death of Henok GEBRSSLASIE in August 2021 accentuated this point.
iv. Such risks carrying with it a clear risk of death .
v. Since the incident it was known that door top alarms is “the way forward” as an environmental change that would mitigate such risk and referred to in a serious investigation report in April 2023, this “way forward” expressed in evidence during the inquest.
vi. There remains (now 42 months post Mr GEBRSSLASIEs death) no door top alarms on the patient bedroom doors at Sherbourne Ward, the Psychiatric Intensive Care Unit, at the Caludon Centre.
vii. The cumulative effect (there ‘seemingly’ no expediency to physically better mitigate this known environmental high-risk issue) is such that a concern as to future deaths exists as of March 2025.
” Source location Henok Zaid GEBRSSLASIE · Prevention of Future Deaths report
Open source report
20 Jun 2024 Yasmin Louise ADAMS · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 1
Presence of fixed shower rails creating ligature points in prisoner-accessible shower areas View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Yasmin Louise ADAMS · 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
Yasmin Louise ADAMS, who had emotionally unstable personality disorder and a history of self-harm, was found suspended and unconscious in her prison cell on 12 November 2016 and died in hospital the next day. Concerns included a 29-minute gap in observation checks, fixed shower rails presenting ligature risks, uncertainty about staff training on personality disorder and learning disability, and the use of cellular confinement for a prisoner on an ACCT.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Presence of fixed shower rails creating ligature points in prisoner-accessible shower areas
Wider context from the report “2. The inquest heard that HMP Foston Hall no longer has fixed shower rails in prisoner’s cell bathroom areas. It could not be confirmed to the court that other prisons across the prion estate do not have fixed shower rails in prisoner’s cell bathroom areas, or other shower areas where prisoners may be out of view of staff. Although potential ligature points are multiple within prisons, and cannot totally be eliminated, fixed shower rails present particular and clear risk of use as ligature points .
” Source location Yasmin Louise ADAMS · Prevention of Future Deaths report
Open source report
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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 Convert cells in older prisons to ligature-resistant standards through the estate-wide programme.
Verbatim wording from the response “A ligature-resistant (LR) cell is one from which as many ligature points as possible have been removed, through the design and installation of furniture and fittings. This includes the door and window, electrical, heating and sanitary fittings, and other features such as shower curtain rails. Our long-term aim is to ensure that LR cells are available as an option for staff managing prisoners in crisis, and that they retain those features in full working order and do not deviate from the standard over time. All new prisons and major additions, such as new wings, are usually” Source location Response from HMPPS
Open published response
31 May 2024 Frazer Charlie Williams · Prevention of Future Deaths report Dorset
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Concerns raised 1
Camouflaging similarity between cell-door and bedsheet colours View source
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Guys Marsh Prison
Explore and, where appropriate, resolve the cell-door and bedsheet colour camouflage issue.
View source
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AI-generated summary
Frazer Charlie Williams · 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
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Camouflaging similarity between cell-door and bedsheet colours
Wider context from the report “xi. The colour of the cell doors and bedsheets at HMP Guys Marsh, and possibly at other prisons nationally, being very similar can camouflage ligatures .
” Source location Frazer Charlie Williams · Prevention of Future Deaths report
Open source report
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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 Explore and, where appropriate, resolve the cell-door and bedsheet colour camouflage issue.
Verbatim wording from the response “This has been escalated for exploration of the issue and, if appropriate, resolution/action, is ongoing.” Source location Response from HMPPS / HMP Guys Marsh
Open published response
5 Feb 2024 Georgia Dehaney-Perkins · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure of an assisted-bathroom anti-ligature safety mechanism View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Georgia Dehaney-Perkins · 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
Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow, after a history of mental health difficulties, self-harm and suicidal ideation. The medical cause of death was recorded as combined alcohol and drug toxicity. Concerns included the suitability and safety of her ward bathroom, incomplete risk assessment and incident recording, insufficient documentation and communication about medication and alcohol risks, and a lack of action after family raised concerns about her leaving home with medication.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of an assisted-bathroom anti-ligature safety mechanism
Wider context from the report “(1) On 28 August Ms Dehaney-Perkins was agitated and distressed on return to the ward from leave and had consumed alcohol that was known to increase her risk of self-harm. ████████. Staff found Ms Dehaney-Perkins and removed the ligature.
a. Ms Dehaney-Perkins was admitted to a room with an assisted bathroom (this was not a requirement for her) with a fault in the anti-ligature safety mechanism meant that the safety feature could not be implemented .
b. There was no risk assessment about the suitability of this room for Ms Dehaney-Perkins a patient with a self-harming history at the time of the admission.
c. The fixed-point ligature was not appropriately updated in the risk assessment and was not discussed at a discharge planning meeting.
d. The Trust Datix Report was incomplete
” Source location Georgia Dehaney-Perkins · Prevention of Future Deaths report
Open source report
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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 Check assisted-bathroom handrail mechanisms every shift and conduct management, fixture, and ligature audits.
Verbatim wording from the response “There is a prompt on the handover sheet to ensure that the Nurse In-Charge checks the handrails mechanism remains in a locked and upright position. This is checked and signed for every shift. Regular audit and assurance are completed by the Ward Manager and Ward Clerk to check that this is being completed. Regular inspections of all room fixtures including handrails are done as part of Ligature audits to ensure compliance with EPUT safety protocols.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.