Recurring concern

Failure to control ligature risks in inpatient and custodial environments

Get email alerts

Request correction

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.

21 Dec2023
Nottinghamshire
Concerns raised2
1. Unavailability of in-cell ligature point maps to staff
2. Lack of in-cell ligature point risk assessments
This report raised 2 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
  Existing observation escalation and gated-cell relocation are relied on to manage high-risk prisoners.
  Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
AI-generated summary

Wyndham Richard Thomas · 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

Wyndham Richard Thomas was a serving prisoner who was found unconscious in his cell after ligating on 4 November 2018 and died in hospital on 6 November 2018. The substantive concerns were the absence of in-cell ligature-point risk assessments and maps, and the lack of designated safer cells at HMP Nottingham, which reduced opportunities to mitigate the risk of self-harm and death by ligature asphyxiation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of in-cell ligature point maps to staff
Wider context from the report
“1. There is a lack of local and national system of in-cell ligature point risk assessments, and no ligature point maps available to staff. The Prison Staff caring for Wyndham were not aware of the location of known ligature points within the cell. This meant that suspicion was not drawn when Wyndham was seen positioned in an area which had access to a ligature point. ”
Source location
Wyndham Richard Thomas · Prevention of Future Deaths report
Page 2 · 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
Lack of in-cell ligature point risk assessments
Wider context from the report
“1. There is a lack of local and national system of in-cell ligature point risk assessments, and no ligature point maps available to staff. The Prison Staff caring for Wyndham were not aware of the location of known ligature points within the cell. This meant that suspicion was not drawn when Wyndham was seen positioned in an area which had access to a ligature point. ”
Source location
Wyndham Richard Thomas · 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
Existing observation escalation and gated-cell relocation are relied on to manage high-risk prisoners.

Verbatim wording from the response
“With regards to your concerns pertaining to in-cell ligature point risk assessments and the availability of ligature point maps, we expect staff to be aware of the potential for a prisoner to be equally at risk of ligaturing at any position in the cell, as well as to the possibility that a ligature point may not be used in all circumstances that require immediate action to preserve life. Prisoners assessed as high risk of suicide should either have their observation level increased or they should be relocated into a gated cell, if doing so would not be detrimental to the prisoner’s welfare.”

Source location
Response from HM Prison and Probation Service
Page 2 · response
Published 29 December 2023
Open published response
14 May2023
Hampshire, Portsmouth and Southampton
Concerns raised2
1. Lack of certified Safer Cells for managing ligature risk
2. Failure to eliminate or reduce ligature points in cells used for prisoners at risk of self-harm
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 1
1. Action
  Review ligature-resistant cell standards and their use in supporting prisoners in crisis.
  Stated by HM Prison and Probation ServiceStated in progress
Respondent positions 1
1. Position
  It is currently too early to determine whether new ligature-resistant cell maintenance rules should be introduced.
  Stated by HM Prison and Probation ServiceUnable to act
AI-generated summary

Thomas Victor HUNTLEY · 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

Thomas Victor Huntley died in HMP Winchester after he was found unresponsive in his cell on 28 May 2020, following a planned act intended to end his life. The inquest identified concerns about missing and inadequately recorded risk information, failures in ACCT documentation and risk assessment, inadequate observations, information sharing between prison and healthcare staff, and ligature risks in cells.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of certified Safer Cells for managing ligature risk
Wider context from the report
“The final area of concern is the lack of certified Safer Cells at HMP Winchester. The inquest heard evidence that these had either never existed at HMP Winchester or had not done so for many years. The evidence from prison governors was that, generally speaking within the prison estate, they were not used or proved too hard to maintain to the certified standard. However certified Safer Cells is still referred to in PSI 64/2011 as a means of managing risk from ligatures. It was heard in evidence that HMP Winchester experience high levels of self-harm and suicide and yet it did not appear that consideration had been given recently to introducing these. Those representing the HMPSS at the were invited to provide information about the status and use of safer certified cells across the prison estate. No such information has been forthcoming. ”
Source location
Thomas Victor HUNTLEY · Prevention of Future Deaths report
Page 4 · 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 eliminate or reduce ligature points in cells used for prisoners at risk of self-harm
Wider context from the report
“Cells At HMP Winchester within the area, considered and referred to by most healthcare and prison staff, as the ‘mental health’ cells there are 2 cells which are not equipped in a way to reduce the amount of available ligature points. It was clear from the evidence of the healthcare staff at the MDT meeting on the 28/05/2020 that they did not consider the contents of the cell when deciding to move Mr Huntley to the ‘mental health cells’ simply due to the fact he was on an ACCT. I heard evidence that the policy of CNWL has now changed and that a cell move risk assessment must now be carried out and that there is now a revised ligature audit process. HMP Winchester informed me that there is now an annual ligature audit carried out in conjunction with the new healthcare provider at that establishment. In addition I was informed that all telephone points in the ‘mental health cells’ at HMP Winchester have now been removed and placed outside the cells. These are welcome developments. However at inquest those representing the HMPPS could not inform me whether all telephone points within cells designed for use by those at risk of self harm across the prison estate had been removed. Nor was any evidence available as to what consideration had been given to reducing the risk of the telephone points by design of the points themselves or the manner of their installation. Those representing were invited to provide this information after the hearing but have not done so. I am concerned that telephone points which provide a ligature point may remain within cells which prison and health care staff consider to be suitable for use by those at risk of self harm. ”
Source location
Thomas Victor HUNTLEY · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review ligature-resistant cell standards and their use in supporting prisoners in crisis.

Verbatim wording from the response
“The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible. The review has included the cell build standards and how they are used to support prisoners in crisis. Our aim is to ensure that cells that are fitted with ligature-resistant features 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. At this point it is too early to say what new rules may be introduced, such as setting the frequency of maintenance, although we do recognise that cells are subject to constant wear and tear and need frequent attention to keep them up to standard.”

Source location
Response from HM Prison and Probation Service
Page 2 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
It is currently too early to determine whether new ligature-resistant cell maintenance rules should be introduced.

Verbatim wording from the response
“The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible. The review has included the cell build standards and how they are used to support prisoners in crisis. Our aim is to ensure that cells that are fitted with ligature-resistant features 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. At this point it is too early to say what new rules may be introduced, such as setting the frequency of maintenance, although we do recognise that cells are subject to constant wear and tear and need frequent attention to keep them up to standard.”

Source location
Response from HM Prison and Probation Service
Page 2 · response
Published 22 November 2023
Open published response
19 Jul2022
Bedfordshire and Luton
Concerns raised1
1. Failure to design out injury and ligature points from prison cells
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

Ezra Mathew TAMIEM · 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

Ezra Mathew Tamiem was detained at HMP Bedford and held in the healthcare wing because of concerns about his mental state and suicide risk. He was found hanging in his cell on 15 July 2020 and was confirmed deceased by paramedics. The concerns included a ligature point in the cell and a serious failure of the required observation procedure, with only two of five recorded observations performed.

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 design out injury and ligature points from prison cells
Wider context from the report
“Mr Tamiem was housed in a cell on the healthcare wing. ████████ Head of Safety at HMP Bedford told the court that was for both security ████████ ████████ gave evidence that this device was in operation throughout the prison except in the refurbished cells and except in the “safer cell”. The safer cell did not have this ligature point. Safer cells are cells with injury and ligature points designed out. ████████ hanged himself and died as a result. ████████ told the court that there were no plans to remedy this and so the risk remains. ”
Source location
Ezra Mathew TAMIEM · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Apr2021
County Durham and Darlington
Concerns raised1
1. Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points
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 3
1. Position
  Operational processes for locally commissioned mental health services are the responsibility of local NHS providers and their commissioning partners.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Enforcement action was not required because the regulator concluded there was no ongoing risk to service users.
  Stated by Department of Health and Social CareNo action considered necessary
2. Position
  The environmental survey had included the deceased’s bedroom, contrary to the concern that it had not been inspected for ligature risks.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustDisputes the concern
AI-generated summary

Mina TOPLEY-BIRD · 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

Mina TOPLEY-BIRD, who had a severe and enduring mental illness and a history of suicide and self-harm attempts, was admitted to West Park Hospital after attempting to run into traffic and stab herself. On 8 May 2019, after being told that no bed was available for her in London, she said words to the effect of “I may as well kill myself”; she was later found hanging in her room and pronounced dead. Concerns included incomplete access to historic medical records, inability to print and share documents across NHS Trust systems, uncertainty about ligature-point assessments, limited bed-management coverage, and incomplete risk-assessment and safety-summary processes.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points
Wider context from the report
“3. The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given. One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points. ”
Source location
Mina TOPLEY-BIRD · Prevention of Future Deaths report
Page 5 · 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
Operational processes for locally commissioned mental health services are the responsibility of local NHS providers and their commissioning partners.

Verbatim wording from the response
“Mental health services provided by TEWV are locally commissioned and therefore operational processes, such as those described, are the responsibility of local NHS providers and their clinical commissioning group (CCG) system partners, which commission the services.”

Source location
2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 2 · response
Published 13 April 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Enforcement action was not required because the regulator concluded there was no ongoing risk to service users.

Verbatim wording from the response
“My officials also approached the Care Quality Commission (CQC). The CQC has sought assurances from the Trust in relation to its investigation and has concluded that there is no ongoing risk to service users and that enforcement action was not required.”

Source location
2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 3 · response
Published 13 April 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The environmental survey had included the deceased’s bedroom, contrary to the concern that it had not been inspected for ligature risks.

Verbatim wording from the response
“For completeness, MTB was in bedroom 4 (identifier 2.04 previously). The Suicide Prevention Environmental Survey and Risk Assessment, attached below, formed part of the documentary evidence made available to the Coroner. This demonstrated that the survey in place at the time of the incident had included bedroom 4 (2.04).”

Source location
2021-0100-Response-from-West-Park-Hospital-Redacted
Page 3 · response
Published 13 April 2021
Open published response
5 Oct2020
Lancashire and Blackburn with Darwen
Concerns raised1
1. Failure to remove redundant television brackets constituting ligature points
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review all HMP Garth cells and remove unused television brackets presenting ligature points.
  Stated by HM Prison and Probation ServiceStated in progress
2. Action
  Review equivalent accommodation and reported self-harm incidents across other prisons to identify and remove unused ligature-point brackets.
  Stated by HM Prison and Probation ServiceStated in progress
3. Action
  Alert Prison Group Directors and Governors to identify unused brackets and arrange their prompt removal.
  Stated by HM Prison and Probation ServiceStated planned
AI-generated summary

Wesley Dennis Rowlands · 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

Wesley Dennis Rowlands died by suicide through ligature hanging in his cell at HMP Garth, using a fixed television bracket. The principal concern was that redundant television brackets remained installed in cells, including his, creating gross and obvious ligature points until removed.

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 redundant television brackets constituting ligature points
Wider context from the report
“A number of cells at HMP Garth, including the deceased’s cell, have television brackets built into the structure of the cell walls. Although the brackets are now redundant, they remain in place and constitute a gross and obvious ligature point and will continue to do so until removed. ”
Source location
Wesley Dennis Rowlands · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review all HMP Garth cells and remove unused television brackets presenting ligature points.

Verbatim wording from the response
“During the inquest, evidence was given that a number of cells at HMP Garth have television brackets, which are no longer in use, built into the structure of the cells walls, and you have expressed concern that unless removed they will continue to present a potential ligature point.”

Source location
2020-0195-Response-from-HMP-Garth_Redacted.pdf
Page 1 · response
Published 27 November 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review equivalent accommodation and reported self-harm incidents across other prisons to identify and remove unused ligature-point brackets.

Verbatim wording from the response
“Please be assured that this is an issue that we take very seriously, and arrangements have already been made by our Prison Maintenance Group to review all cells at HMP Garth and to remove the brackets. This work was delayed by the restrictions that we implemented in response to the pandemic, but I can confirm that it will be completed by February 2021. We are seeking also to address any similar risks in other prisons by reviewing all accommodation of the same type, and looking back at reported self-harm incidents, so that we can identify and remove any other unused brackets that offer ligature points. We will also alert Prison Group Directors and Governors to the concerns that you have reported, so that they are aware of the importance of identifying unused brackets and taking prompt action to remove them.”

Source location
2020-0195-Response-from-HMP-Garth_Redacted.pdf
Page 1 · response
Published 27 November 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Alert Prison Group Directors and Governors to identify unused brackets and arrange their prompt removal.

Verbatim wording from the response
“Please be assured that this is an issue that we take very seriously, and arrangements have already been made by our Prison Maintenance Group to review all cells at HMP Garth and to remove the brackets. This work was delayed by the restrictions that we implemented in response to the pandemic, but I can confirm that it will be completed by February 2021. We are seeking also to address any similar risks in other prisons by reviewing all accommodation of the same type, and looking back at reported self-harm incidents, so that we can identify and remove any other unused brackets that offer ligature points. We will also alert Prison Group Directors and Governors to the concerns that you have reported, so that they are aware of the importance of identifying unused brackets and taking prompt action to remove them.”

Source location
2020-0195-Response-from-HMP-Garth_Redacted.pdf
Page 1 · response
Published 27 November 2020
Open published response
22 May2018
Bedfordshire and Luton
Concerns raised2
1. Failure of Healthcare Cell number 1 to meet reduced-risk cell design expectations
2. Inward-opening window providing an obvious ligature point in a cell
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

Michael 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

Michael BERRY was found hanging from a sheet in the Medical Wing of Bedford Prison on 10 March 2017 and later died after life-sustaining treatment was withdrawn following a hypoxic brain injury. The report raised concern that a cell described as a “Reduced Risk Cell” or “Safer Cell” contained an obvious ligature point at an inward-opening window, with possible design solutions to avoid this.

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 of Healthcare Cell number 1 to meet reduced-risk cell design expectations
Wider context from the report
“(1) Michael was in Healthcare Cell number 1 which throughout the Inquest was described variously as a “Reduced Risk Cell” or “Safer Cell”. It appears that in fact it is not a reduced risk cell but more a “Half Way House” in that the furniture is fixed to the floor. In the cell, however there was a very obvious ligature point that could be avoided, namely the window, which opens inwardly. On the face of it there would appear to be many design solutions that would overcome the need for an opening window that provides such an obvious ligature point. ”
Source location
Michael BERRY · Prevention of Future Deaths report
Page 2 · 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
Inward-opening window providing an obvious ligature point in a cell
Wider context from the report
“(1) Michael was in Healthcare Cell number 1 which throughout the Inquest was described variously as a “Reduced Risk Cell” or “Safer Cell”. It appears that in fact it is not a reduced risk cell but more a “Half Way House” in that the furniture is fixed to the floor. In the cell, however there was a very obvious ligature point that could be avoided, namely the window, which opens inwardly. On the face of it there would appear to be many design solutions that would overcome the need for an opening window that provides such an obvious ligature point. ”
Source location
Michael BERRY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jun2017
Central Hampshire
Concerns raised2
1. Cell safety features permitting door wedging and ligature use
2. Incomplete provision of anti-ligature protection on cell doors
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

Michael Folley · 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

Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.

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
Cell safety features permitting door wedging and ligature use
Wider context from the report
“I heard evidence that prisoners are issued with plastic mirrors that are frequently used as wedges in cell doors. This means officers are vigilant to ensure prisoners only have one mirror each and if there are more in a cell than necessary they will be removed. It was suggested that a thicker mirror could be issued or a mirror/reflective panel could be inserted into the wall. This was an ongoing process of replacement in the prison. Window design was also being considered and I was informed a trial had begun prison to roll out a new type of window but that this could take up to 2 years to complete. ”
Source location
Michael Folley · Prevention of Future Deaths report
Page 6 · 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
Incomplete provision of anti-ligature protection on cell doors
Wider context from the report
“I also heard that steps had been taken to fit anti-ligature strips in some but not all cell doors. All of these suggestions seemed eminently sensible yet the pace of these changes does need to be considered. ”
Source location
Michael Folley · Prevention of Future Deaths report
Page 7 · concerns
Open source report
4 Apr2017
Buckinghamshire
Concerns raised2
1. Unreduced accessibility of sanitation-room ligature points
2. Lack of specific audit of wing ligature points
This report raised 7 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

ARTHUR ALBERT MORLEY · 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

Arthur Albert Morley was a prisoner serving an indeterminate sentence at HMP Grendon when he was found hanging from a pipe in a sanitation area shortly after being told he would be returned to his previous prison. The report raised concerns about accessible ligature points, inadequate sanitation-room security and inspection arrangements, delays in reviewing procedures and incident learning, and insufficient communication and healthcare involvement in return-to-unit decisions.

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
Unreduced accessibility of sanitation-room ligature points
Wider context from the report
“(1) The death occurred in December 2015. Since then there does not appear to have been a specific audit of possible ligature points on the wings, particularly pipework in the sanitation rooms, which remain accessible at night to prisoners but are out of view of wing staff. There are no current proposals to undertake works to reduce accessibility of ligature points such as open pipes. ”
Source location
ARTHUR ALBERT MORLEY · 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
Lack of specific audit of wing ligature points
Wider context from the report
“(1) The death occurred in December 2015. Since then there does not appear to have been a specific audit of possible ligature points on the wings, particularly pipework in the sanitation rooms, which remain accessible at night to prisoners but are out of view of wing staff. There are no current proposals to undertake works to reduce accessibility of ligature points such as open pipes. ”
Source location
ARTHUR ALBERT MORLEY · Prevention of Future Deaths report
Page 1 · concerns
Open source report
6 Oct2016
East Riding and Hull
Concerns raised1
1. Failure to classify all identified ligature points as extreme risks requiring urgent elimination
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

Helen Louise MILLARD · 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

Helen Louise MILLARD hanged herself using bathroom taps at the Westlands Mental Health Unit, Hull, between 18:32 and 18:59 on 12 May 2015, and died at Hull Royal Infirmary at 01:28 on 13 May 2015. The principal concern was that the ligature-point classification system treated points one metre or less above the ground as amber, despite evidence that ligature risk was independent of height and that such points could cause death rapidly.

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 classify all identified ligature points as extreme risks requiring urgent elimination
Wider context from the report
“Evidence was heard that NHS England is undertaking an ongoing programme of work to eliminate ligature points in in-patient and other psychiatric facilities. It was established that a ‘traffic light’ system is in operation which prioritises the work once a ligature point has been identified in any particular facility. The Court heard that if a point is scored ‘red’ this equates with an extreme risk and mandates urgent elimination of the point. If, however, a risk is categorised as ‘amber’ this nevertheless represents a high risk. The classification according to this traffic light system is based upon the height of the ligature point from the ground. If a ligature point is one metre or less it is categorised as being ‘amber’, whereas if it is over one metre above the ground it is categorised as ‘red’. Expert evidence was adduced from a number of expert witnesses and Consultant Psychiatrists that at least 50% of deaths due to hanging in inpatient psychiatric facilities occur from ligature points which are one metre or less in height above the ground. Patients merely need to learn forward and tighten the ligature around their neck under their body weight and they collapse into unconsciousness within ten to twenty seconds and death can occur in as little as two to three minutes. This evidence was backed up by peer reviewed literature which was also read out during the course of the Inquest. My principal concern is that there is an obvious incongruity in the classification system as effectively all ligature points, no matter what their height, should be regarded as representing extreme risks. Evidence was heard that the risk is independent of height and consideration needs to be given to classifying all ligature points once identified as ‘red’ and their elimination tackled on an urgent basis. ”
Source location
Helen Louise MILLARD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 May2016
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Failure to provide ligature-free windows in service user areas
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Secure windows in areas identified as presenting potential ligature risks.
  Stated by Hywel Dda University LHBStated completed
2. Action
  Repeat point-of-ligature audits across all mental health and learning disability inpatient units in May or June 2016.
  Stated by Hywel Dda University LHBStated planned
3. Action
  Develop and prioritise a programme addressing window risks across inpatient units.
  Stated by Hywel Dda University LHBStated in progress
1. Action
  Submit prioritised recommendations for each unit to the 2016/17 Capital Programme for consideration.
  Stated by Hywel Dda University LHBStated planned
2. Action
  Issue an addendum to Health Building Note 35 requiring ligature-free design in new and existing acute mental health facilities, including CAMHS.
  Stated by Welsh GovernmentStated in progress
3. Action
  Undertake a formal review of Health Building Note 35 to assess whether substantial amendment or replacement by a revised HBN 03-01 is needed.
  Stated by Welsh GovernmentStated planned
Respondent positions 1
1. Position
  Window replacement was not prioritised because identified ligature risks were mitigated by securing windows and considering competing Health Board priorities.
  Stated by Hywel Dda University LHBExisting arrangements considered sufficient
AI-generated summary

Mihangel ap Dafydd · 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

Mihangel ap Dafydd was detained under the Mental Health Act and placed under 15-minute observations after being assessed as at risk of self-harm. On 16 February 2014 he was found hanging from a window using a bag strap; concerns included the incorrect removal of potentially harmful property and windows that had not been adapted to prevent their use as ligature points, which the jury found contributed to his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide ligature-free windows in service user areas
Wider context from the report
“The windows in service user areas at Morlais Ward are not ligature free and whilst it is intended to make them so following the death of Mr ap Dafydd this work has not yet been undertaken. ”
Source location
Mihangel ap Dafydd · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Secure windows in areas identified as presenting potential ligature risks.

Verbatim wording from the response
“I can confirm that the Health Board undertakes an annual point of ligature audit programme across all of its mental health and learning disability in-patient units, which includes an audit of Morlais Ward on the West Wales General Hospital site. The point of ligature audits undertaken following Mr. ap Dafydd's death identified potential point of ligature risks with windows on a number of the in-patient units, including Morlais Ward which were reported through the Health Board's Capital programme. The point of ligature programme is considered alongside all of the annual priorities across the Health Board, and the replacement of windows was not deemed to be the greatest priority, as following identification of the risk, steps were taken to mitigate the risk, including the securing of windows in some areas.”

Source location
2016-0169-Response-by-University-Health-Board
Page 1 · response
Published 3 May 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Repeat point-of-ligature audits across all mental health and learning disability inpatient units in May or June 2016.

Verbatim wording from the response
“The point of ligature audit programme plans to repeat the audit of all inpatient units across mental health and learning disabilities in May/June 2016. Following which a prioritised recommendations will be submitted for consideration by the 2016/17 Capital programme, for each unit considering”

Source location
2016-0169-Response-by-University-Health-Board
Page 1 · response
Published 3 May 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and prioritise a programme addressing window risks across inpatient units.

Verbatim wording from the response
“The point of ligature audit programme plans to repeat the audit of all inpatient units across mental health and learning disabilities in May/June 2016. Following which a prioritised recommendations will be submitted for consideration by the 2016/17 Capital programme, for each unit considering”

Source location
2016-0169-Response-by-University-Health-Board
Page 1 · response
Published 3 May 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Submit prioritised recommendations for each unit to the 2016/17 Capital Programme for consideration.

Verbatim wording from the response
“The point of ligature audit programme plans to repeat the audit of all inpatient units across mental health and learning disabilities in May/June 2016. Following which a prioritised recommendations will be submitted for consideration by the 2016/17 Capital programme, for each unit considering”

Source location
2016-0169-Response-by-University-Health-Board
Page 1 · response
Published 3 May 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Issue an addendum to Health Building Note 35 requiring ligature-free design in new and existing acute mental health facilities, including CAMHS.

Verbatim wording from the response
“I note your report and requested actions have been sent to the Chief Executive of Hywel Dda University Health Board. However, given that you have identified issues which are of relevance to all NHS organisations, I can confirm that we will be issuing an addendum to Health Building Note 35 – “Accommodation for People with Mental Illness Part 1: The Acute Unit Ligature Free Design”. This addendum will specifically highlight the requirement for ligature free design in both new and existing acute mental health unit facilities in Wales. The addendum to the Health Building Note will also widen the requirements to other facilities dealing with acute mental health in-patients including Children & Adolescent Mental Health Services (CAMHS). This document is in the process of being finalised by Welsh Government officials and our NHS estates advisors and will issue by the end of this month.”

Source location
2016-0169-Response-by-Welsh-Government
Page 1 · response
Published 3 May 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Undertake a formal review of Health Building Note 35 to assess whether substantial amendment or replacement by a revised HBN 03-01 is needed.

Verbatim wording from the response
“In addition to the above, I have also requested that NHS Shared Services Partnership – Specialist Estate Services (NWSSP-SES) undertake a formal review of HBN 35. This will consider if the HBN needs more substantial amendment or if it should be superseded by a revised HBN 03-01, amended, where required, to reflect further developments in Welsh Government policy and any specific needs of NHS Wales.”

Source location
2016-0169-Response-by-Welsh-Government
Page 1 · response
Published 3 May 2016
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Window replacement was not prioritised because identified ligature risks were mitigated by securing windows and considering competing Health Board priorities.

Verbatim wording from the response
“I can confirm that the Health Board undertakes an annual point of ligature audit programme across all of its mental health and learning disability in-patient units, which includes an audit of Morlais Ward on the West Wales General Hospital site. The point of ligature audits undertaken following Mr. ap Dafydd's death identified potential point of ligature risks with windows on a number of the in-patient units, including Morlais Ward which were reported through the Health Board's Capital programme. The point of ligature programme is considered alongside all of the annual priorities across the Health Board, and the replacement of windows was not deemed to be the greatest priority, as following identification of the risk, steps were taken to mitigate the risk, including the securing of windows in some areas.”

Source location
2016-0169-Response-by-University-Health-Board
Page 1 · response
Published 3 May 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Unavailability of in-cell ligature point maps to staff

Lack of in-cell ligature point risk assessments

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

Concerns raised2

Lack of certified Safer Cells for managing ligature risk

Failure to eliminate or reduce ligature points in cells used for prisoners at risk of self-harm

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

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

Concerns raised1

Failure to design out injury and ligature points from prison cells

Concerns raised1

Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to remove redundant television brackets constituting ligature points

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

Concerns raised2

Failure of Healthcare Cell number 1 to meet reduced-risk cell design expectations

Inward-opening window providing an obvious ligature point in a cell

Concerns raised2

Cell safety features permitting door wedging and ligature use

Incomplete provision of anti-ligature protection on cell doors

Concerns raised2

Unreduced accessibility of sanitation-room ligature points

Lack of specific audit of wing ligature points

Concerns raised1

Failure to classify all identified ligature points as extreme risks requiring urgent elimination

Respondent positions 1

Actions described in response 1

Respondent positions 1

Respondent positions 3

Actions described in response 3