Recurring concern

Inadequate control of access to means of self-harm

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First reported 6 Jan 2014•Latest report 20 Mar 2026

Definition

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

Distinct published reports

Individual concerns
27

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
50

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.

Home Office4
Ministry of Justice4
Department of Health and Social Care3
NHS England3
Care Quality Commission2
HM Prison and Probation Service2
Oxford Health NHS Foundation Trust2
Wakefield Prison2
Advisory Council on the Misuse of Drugs1
Alternative Futures Group Limited1
Belgravia Care Home1
Belgravia Care Home Limited1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Cygnet Behavioural Health Limited1
Elmley 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.

  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
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Data last updated 7 September 2026