Recurring concern
Inadequate control of access to means of self-harm
- 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 22 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- Leeds and York Partnership NHS Foundation Trust
Stated actions 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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Leeds and York Partnership NHS Foundation Trust
Scope alternative wound-covering options and contact other mental health trusts to capture and share relevant practice.
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Concerns raised1
Failure to prevent access to plastic bags for a person at risk of self-harm
Linked response
- Belgravia Care Home
Stated actions 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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Belgravia Care Home
Remove plastic bags from residents’ bedrooms.
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Belgravia Care Home
Secure all plastic bags in locked kitchen and cleaning cupboards accessible only to management and senior carers.
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Belgravia Care Home
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.
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Belgravia Care Home
Implement individual robust risk assessments for residents at risk of suicidal tendencies.
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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.
Linked response
- Oxford Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Oxford Health NHS Foundation Trust
Identify and consider more break-resistant alternatives to plastic spoons for patients at risk of self-harm.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Oxford Health NHS Foundation Trust
It is not practically possible to monitor every plastic spoon on the ward, although alternative, more break-resistant cutlery is being considered.
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Concerns raised1
Failure to remove palliative opiate medication from a bereaved person’s possession
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to prevent access to razor blades
Linked response
- HM Prison and Probation Service
Stated actions 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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HM Prison and Probation Service
Issue a learning bulletin reinforcing razor-blade risks and providing guidance on managing access to disposable razors.
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HM Prison and Probation Service
Pilot a revised ACCT case-management process with documentation prompting case managers to assess razor-blade risks and consider access restrictions during reviews.
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HM Prison and Probation Service
Consider options for managing disposable-razor risks, including further access controls and safer alternatives.
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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.
Linked response
- Oxford Health NHS Foundation Trust
Stated actions 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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Oxford Health NHS Foundation Trust
Issue and enforce guidance requiring staff to remove plastic bags at reception or supervise their removal and disposal.
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Oxford Health NHS Foundation Trust
Record restricted-item advice and handover confirmations in visitors’ signing-in books and monitor completion weekly.
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Oxford Health NHS Foundation Trust
Provide paper bags on wards as a safe alternative for transporting items.
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Oxford Health NHS Foundation Trust
Add restricted-item advice to admission packs and staff checklists, with monthly matron audits.
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Oxford Health NHS Foundation Trust
Implement a standard operating procedure and weekly management review for recording daily environmental checks.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Oxford Health NHS Foundation Trust
The Trust does not record every item entering or leaving patient lockers because doing so would be extremely labour intensive.
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Concerns raised1
Failure to maintain restrictions on plastic bags
Linked response
- CAS Behavioural Health
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
CAS Behavioural Health
Review the reducing restrictive practice policy using relevant Care Quality Commission guidance.
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CAS Behavioural Health
Restrict plastic bags across all hospitals under a blanket policy and maintain the ban.
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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CAS Behavioural Health
The blanket ban on plastic bags in all hospitals fully addresses the concerns, so no additional responsive work is identified.
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Concerns raised1
Lack of strict controls over access to pentobarbital
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.
Linked responses
- Birmingham and Solihull Mental Health NHS Foundation Trust
- Department of Health and Social Care
Stated actions 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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Birmingham and Solihull Mental Health NHS Foundation Trust
Take action to manage the medicines-policy breach.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Issue a formal practice alert reinforcing suicide-risk, medicines-management and safe-medication-administration requirements, with staff acknowledgement.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Review the Medicines Code and supporting staff guidance to address medication-administration and risk-assessment issues, and report through internal governance.
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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Department of Health and Social Care
The Trust is responsible for addressing concerns about medication access, risk assessment and staff recognition of available drugs.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Medication checks and removal of excessive medicines are limited by service users’ capacity and willingness to disclose information and permit searches.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026