Recurring concern
Inadequate control of access to means of self-harm
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Request correctionFirst reported 6 Jan 2014•Latest report 20 Mar 2026
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.
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
- 22
- Individual concerns
- 27
- Date range
- 2014–2026
- Stated actions
- 50
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
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.
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Concerns raised2
Patient access to ligatures and other objects usable for self-harm or against others
Failure to prevent repeated access to and use of ligatures
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to review wound-dressing materials before ground leave
Availability of wound-dressing materials usable for self-harm
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Scope alternative wound-covering options and contact other mental health trusts to capture and share relevant practice.
Stated by Leeds and York Partnership NHS Foundation Trust
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Concerns raised1
Failure to prevent access to plastic bags for a person at risk of self-harm
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.4
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Action
Remove plastic bags from residents’ bedrooms.
Stated by Belgravia Care Home -
Action
Secure all plastic bags in locked kitchen and cleaning cupboards accessible only to management and senior carers.
Stated by Belgravia Care Home -
Action
Remove, cut up and safely dispose of bags brought back from shops, bags used during personal care, and all other used bags in a locked external commercial bin.
Stated by Belgravia Care Home
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Action
Implement individual robust risk assessments for residents at risk of suicidal tendencies.
Stated by Belgravia Care Home
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Concerns raised1
Failure to monitor the handing out and proper return of plastic cutlery used at mealtimes
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Identify and consider more break-resistant alternatives to plastic spoons for patients at risk of self-harm.
Stated by Oxford Health NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
It is not practically possible to monitor every plastic spoon on the ward, although alternative, more break-resistant cutlery is being considered.
Stated by Oxford Health NHS Foundation Trust
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Concerns raised1
Failure to remove palliative opiate medication from a bereaved person’s possession
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to prevent access to razor blades
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Issue a learning bulletin reinforcing razor-blade risks and providing guidance on managing access to disposable razors.
Stated by HM Prison and Probation Service -
Action
Pilot a revised ACCT case-management process with documentation prompting case managers to assess razor-blade risks and consider access restrictions during reviews.
Stated by HM Prison and Probation Service -
Action
Consider options for managing disposable-razor risks, including further access controls and safer alternatives.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to prevent access to plastic bags as restricted items on the ward
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 concernsEach statement is shown once, even when linked to more than one concern.
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.5
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Action
Issue and enforce guidance requiring staff to remove plastic bags at reception or supervise their removal and disposal.
Stated by Oxford Health NHS Foundation Trust -
Action
Record restricted-item advice and handover confirmations in visitors’ signing-in books and monitor completion weekly.
Stated by Oxford Health NHS Foundation Trust -
Action
Provide paper bags on wards as a safe alternative for transporting items.
Stated by Oxford Health NHS Foundation Trust
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Action
Add restricted-item advice to admission packs and staff checklists, with monthly matron audits.
Stated by Oxford Health NHS Foundation Trust -
Action
Implement a standard operating procedure and weekly management review for recording daily environmental checks.
Stated by Oxford Health NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Trust does not record every item entering or leaving patient lockers because doing so would be extremely labour intensive.
Stated by Oxford Health NHS Foundation Trust
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Concerns raised1
Failure to maintain restrictions on plastic bags
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.2
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Action
Review the reducing restrictive practice policy using relevant Care Quality Commission guidance.
Stated by CAS Behavioural Health -
Action
Restrict plastic bags across all hospitals under a blanket policy and maintain the ban.
Stated by CAS Behavioural Health
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The blanket ban on plastic bags in all hospitals fully addresses the concerns, so no additional responsive work is identified.
Stated by CAS Behavioural Health
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Concerns raised1
Lack of strict controls over access to pentobarbital
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to control access to available medication for a person at risk of overdose
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Take action to manage the medicines-policy breach.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Issue a formal practice alert reinforcing suicide-risk, medicines-management and safe-medication-administration requirements, with staff acknowledgement.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Review the Medicines Code and supporting staff guidance to address medication-administration and risk-assessment issues, and report through internal governance.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The Trust is responsible for addressing concerns about medication access, risk assessment and staff recognition of available drugs.
Stated by Department of Health and Social Care
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Position
Medication checks and removal of excessive medicines are limited by service users’ capacity and willingness to disclose information and permit searches.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
Data last updated 7 September 2026