Recurring concern

Failure to control ligature risks in inpatient and custodial environments

First to latest report 6 Jun 2014 — 20 Mar 2026

Reports that mention this concern
24
Times this concern has been raised
32
Stated actions linked to this concern
32

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.

What is 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 and published responses 24 reports

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

  1. Peterborough

    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

  2. Surrey

    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

  3. Manchester West

    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

  4. South and East Cumbria

    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

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

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Data last updated 7 September 2026