Recurring concern

Failure to control ligature risks in inpatient and custodial environments

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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
Individual concerns: 32
Date range: 2014–2026
Stated actions: 32

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation 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

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.

24 Mar2015
Peterborough
Concerns raised2
1. Allowing cell door keys to be carried around the neck on tied shoelaces
2. Failure to retrofit cell doors with anti-ligature strips
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Stuart Megginson BAUMBER · 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 Megginson BAUMBER died by hanging in his cell at HMP Peterborough between 22:30 on 14 November 2013 and 04:10 on 15 November 2013, after being remanded in custody for arson. The jury found that occasions existed when the ACCT process should have been initiated and that inadequate understanding and training contributed to this not happening. The report also raised concerns about ligature points on cell doors, healthcare screening that did not mention section 136 detentions, and items available to prisoners that could facilitate suicide.

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
Allowing cell door keys to be carried around the neck on tied shoelaces
Wider context from the report
“12. Some prisoners at HMP Peterborough are allowed to carry their cell door key which is placed on shoelaces tied together and placed around the neck of the prisoner which clearly creates a self-made ligature for those who may be at risk. ”
Source location
Stuart Megginson BAUMBER · Prevention of Future Deaths report
Page 3 · 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 retrofit cell doors with anti-ligature strips
Wider context from the report
“3. However, whilst the current specification for cell door design now incorporates an anti-ligature strip, there is no retrofit programme in operation and thus, there are significant numbers of cell doors that do not meet the current standard. ”
Source location
Stuart Megginson BAUMBER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Oct2014
Surrey
Concerns raised1
1. Open and accessible ligature points within prisoner cells
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.
Respondent positions 1
1. Position
  The Ministry of Justice Estate Directorate is responsible for delivering prison construction and refurbishment projects addressing accessible ligature points.
  Stated by HM Prison and Probation ServiceRedirects responsibility
AI-generated summary

Chrylin Angela Maria Norrell-Goldsmith · 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

Chrylin Angela Maria Norrell-Goldsmith was found shortly before midnight on 26 July 2013, partially suspended by a ligature in her cell at HMP Downview. CPR and subsequent paramedic efforts were unsuccessful, and the jury concluded that she took her own life. The principal concerns included exposed pipework in the cell, multidisciplinary input at ACCT reviews, retention of primary source data in the Phoenix Programme, and recording significant medical events in records accessible to prison discipline staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Open and accessible ligature points within prisoner cells
Wider context from the report
“1. Open pipe work within the cell Whilst it may not be possible to remove all potential ligature points within a cell, removal of easily accessible and obvious ligature points may serve to reduce the risk of self harm and suicide to vulnerable prisoners. ”
Source location
Chrylin Angela Maria Norrell-Goldsmith · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 Ministry of Justice Estate Directorate is responsible for delivering prison construction and refurbishment projects addressing accessible ligature points.

Verbatim wording from the response
“The Ministry of Justice Estate Directorate (MoJ ED) are responsible for the delivery of prison and construction projects. MoJ ED now routinely provide ‘safer cells’ in all new prison construction projects. “Safer cells” are specifically designed to remove known ligature points thereby reducing the opportunities for a prisoner to self-harm by means of ligature. MoJ ED also routinely provide “safer cells” when refurbishing existing accommodation wherever it is physically possible to do so. The programme of new construction and planned refurbishments means that the numbers of safer cells are increasing across the prison estate.”

Source location
2014-0470-Response-by-NOMS
Page 1 · response
Published 27 October 2014
Open published response
30 Jun2014
Manchester West
Concerns raised1
1. Use of cells containing ligature points for detainees at risk of self-harm or suicide
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Jake Reginald Hardy · 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

Jake Reginald Hardy, a 17-year-old detained at HM YOI Hindley, died on 20 January 2012 after being found partially suspended by a ligature in his cell. The report describes failures to identify, record and respond to his vulnerabilities, self-harm risk and reports of verbal bullying, including failures in safeguarding, ACCT care planning, supervision and overnight risk assessment. Concerns also included ligature points in cells, inadequate personal officer support, staff training and communication systems, and limited access to family telephone support.

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
Use of cells containing ligature points for detainees at risk of self-harm or suicide
Wider context from the report
“3. Cells containing ligature points (such as window bars) are still in use at HM YOI Hindley for detainees who have been assessed to be at risk of self-harm or suicide. This concern may be of relevance to other Young Offender Institutes also. ”
Source location
Jake Reginald Hardy · Prevention of Future Deaths report
Page 4 · concerns
Open source report
6 Jun2014
South and East Cumbria
Concerns raised2
1. Failure to remove removable bathroom rails except when required
2. Failure to keep ligature-capable cords centrally so that patients cannot directly access them
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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The Cumbria Partnership NHS Foundation Trust is responsible for addressing the four concerns relating to events on the Dova Unit.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

James Edward Boylan · 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

James Edward Boylan, who had a history of anxiety and was admitted to a mental health unit, died by hanging using a phone charger cord and a bathroom rail. The concerns included removable bathroom rails creating a ligature point, insufficient searching of patients’ property, access to a cord, and failures in recognising and communicating the escalation of his condition.

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 remove removable bathroom rails except when required
Wider context from the report
“(1) Removable rails in a bathroom designed for use by disabled people had been left inadvertently ever since the unit was opened. No one seemed to be aware that these rails were removable and certainly nobody had removed them. This provided a ligature point which would otherwise have been absent in a unit which was specifically designed to have as few ligature points as possible. The Coroner is concerned that this same situation may apply in other units and people need to be aware that ligature points in mental health units should be limited as far as humanly possible, and specifically that removable rails should be removed except when actually required. ”
Source location
James Edward Boylan · 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 keep ligature-capable cords centrally so that patients cannot directly access them
Wider context from the report
“(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion, and so again Mr Boylan had access to something which he could use to hang himself with. ”
Source location
James Edward Boylan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 Cumbria Partnership NHS Foundation Trust is responsible for addressing the four concerns relating to events on the Dova Unit.

Verbatim wording from the response
“I note that you have also addressed your report to the Cumbria Partnership NHS Foundation Trust and I would expect them to properly address the four concerns relating to events during Mr Boylan’s time on the Dova Unit at Furness General Hospital.”

Source location
2014-0253-Response-by-Department-of-Health
Page 2 · response
Published 6 June 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Allowing cell door keys to be carried around the neck on tied shoelaces

Failure to retrofit cell doors with anti-ligature strips

Concerns raised1

Open and accessible ligature points within prisoner cells

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Use of cells containing ligature points for detainees at risk of self-harm or suicide

Concerns raised2

Failure to remove removable bathroom rails except when required

Failure to keep ligature-capable cords centrally so that patients cannot directly access them

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Respondent positions 1

Respondent positions 1