Recurring concern

Inadequate control of access to means of self-harm

First to latest report 6 Jan 2014 — 20 Mar 2026

Reports that mention this concern
22
Times this concern has been raised
27
Stated actions linked to this concern
50

What this concern includes

Includes failures of controls specifically intended to identify, restrict, monitor, remove or otherwise prevent access to materials or objects that a person at risk of self-harm may use to harm themselves, including plastic bags, razor blades, cutlery and comparable means across healthcare, care, custodial and domestic settings.

What is not included
  • Excludes general suicide or self-harm risk-assessment, observation, supervision or treatment failures where access to a specific self-harm means is not the unsafe condition.
  • Excludes generic environmental checks, searches or access-control deficiencies unless they directly concern preventing access to an identified self-harm means.
  • Excludes ordinary availability of objects or materials where no self-harm risk or dedicated access-control failure is identified.
  • Excludes the existing narrower inpatient concern when an assertion is limited to the operation of inpatient controls and does not support the broader cross-setting access-to-means condition.

Reports and published responses 22 reports

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

  1. 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 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

  2. South Yorkshire (Eastern)

    AI-generated summary

    DANIEL 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

    Daniel Williams, who had psychiatric problems following a diagnosis of diabetes and was admitted to hospital after an insulin overdose, died by hanging in his hospital room on 15 June 2013. The concerns included inadequate staff training, record keeping and communication; insufficient exploration of suicidal thoughts and intent; unclear guidance on checking rooms and patients for potential self-harm items; and the absence of a single summary of key risks and incidents in the notes.

    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

    Absence of clear guidance for checking patients and rooms for potential self-harm items

    Wider context from the report

    “(3) The absence of clear guidance for checking patients and their rooms for potential self harm items both in the rooms themselves and for items brought into the hospital. ”

    Source location

    DANIEL WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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