Recurring concern

Inadequate safety assessment of ward environments

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First reported 21 Aug 2017•Latest report 26 May 2022

Definition

What this concern includes

Includes failures to assess, inspect or formally assure the physical configuration and safety of wards, healthcare units or their cells where the deficiency can leave patients or prisoners exposed to environmental risks; include the anchor's absent risk assessment, unsafe ward-layout assessments and incomplete or uncoordinated cell-inspection processes.

Not included

  • Excludes generic clinical, staffing, training or governance deficiencies unless they directly concern assessment or assurance of the ward environment.
  • Excludes condition-specific safety systems, such as ligature-point controls, CCTV, patient observation or fire detection, when that named system is the more specific unsafe concern.
  • Excludes ordinary building maintenance or isolated physical defects where no failure of ward-environment assessment or assurance is identified.
  • Excludes non-ward premises, public spaces and general workplace risk assessments without a supported ward or healthcare-unit context.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2017–2022

First to latest report issue date

Stated actions
4

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.

Birmingham and Solihull Mental Health NHS Foundation Trust1
Care Quality Commission1
Ministry of Justice1
NHS England1
The Priory Hospital Roehampton1

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. Birmingham and Solihull

    AI-generated summary

    SAIFUR RAHMAN · 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

    Saifur Rahman was found in cardiac arrest in his cell at HMP Birmingham on 20 January 2021, was taken to hospital after resuscitation, and died on 23 January 2021. The post-mortem recorded hypoxic/ischaemic encephalopathy associated with external neck compression, and the jury found that his intention was to commit suicide. The report raised concerns about delayed emergency calls, inadequate records of cell history, insufficient cell risk assessments, and the lack of a formal process for prison and mental health staff to inspect and act on cell risks.

    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 a formal process for complete visual inspection of ward cells

    Wider context from the report

    “3. NHS annual ████████ risk assessment: the evidence revealed that the mental health trust assessors had historically only dip-sampled a selection of the 15 x 2 cells on health care ward 2 (physical health) and ward 3 (mental health). They did not record which cells had been visually checked and relied in part on second-hand information from the prison about cell fabric and design. There had not been effective communication between the prison and health care staff. Generally, the trust had 140+ buildings across its entire estate to assess, this was done by two members of the health and safety team, and the assessment of the health care unit at HMP Birmingham was expected to be completed over several hours on one day. I was provided with a verbal undertaking that the trust would now visually inspect all 15 x 2 cells annually. However, this relies exclusively on the co-operation of the prison who have competing tensions given the operationally dynamic and challenging environment, especially if cells are occupied during the assessment. My ongoing concern is that there is no formalised process between the prison and mental health trust to visually inspect each cell. It is recognised prisoners housed on ward 2 and 3 are at a much greater risk of suicide than the general prison population, and general public as a whole, and will spend a great deal of time unobserved in the 15 x 2 cells. Therefore, in my view, visually inspecting 30 cells is not disproportionate to the level of risk and is not comparable to assessing an outpatient building in the community. The dynamic and challenging environment means it is likely all cells cannot be inspected on one visit. Visually inspecting each cell therefore needs to be properly planned and resourced by both the prison and mental health trust and consideration needs to be given to a formal process. ”

    Source location

    SAIFUR RAHMAN · Prevention of Future Deaths report
    Page 3 · 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

    Update the ligature risk assessment model to cover more cells over time and maintain an audit trail of previously viewed cells.

    Verbatim wording from the response

    “NHS Annual Risk Assessment The Trust had already identified the sampling of cells under the Ligature Risk Assessment as an area for improvement and prior to the inquest had provided evidence that the assessment model had already been updated to enable greater coverage of cells from year to year and to generate an audit trail for those cells which had been viewed in previous years.”

    Source location

    Response from BSMHFT
    Page 1 · response
    Published 26 May 2022

    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

    View every prison cell during the annual ligature risk assessment, subject to the prison providing assessor access.

    Verbatim wording from the response

    “on accessing any particular cell. Having received this assurance the Trust were able to reconsider the proportionality of the assessment and confirm to you that in future years the Ligature Risk Assessment would view all cells provided that the prison provided access.”

    Source location

    Response from BSMHFT
    Page 2 · response
    Published 26 May 2022

    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

    Formalise the risk-assessment process with the prison by placing it on the Local Delivery Board meeting agenda.

    Verbatim wording from the response

    “In order for this reassurance to be given, the Trust did consider future planning and resourcing to ensure that this would be completed. This takes place each year and the risk assessments for the prison are part of the Audit schedule for the Trust. In respect of formalising the process with the prison, the Trust’s Head of Healthcare at HMP Birmingham has emailed the Local delivery Board to ask that this matter is placed on the agenda for the meeting on 16th June 2022. This will ensure that the process is formalised. Commissioners will also be present at this meeting.”

    Source location

    Response from BSMHFT
    Page 2 · response
    Published 26 May 2022

    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

    Introduce a formalised cell ligature-risk assessment process with the Health and Safety team and NHS.

    Verbatim wording from the response

    “Finally, you have queried the process for cell ligature risk assessments following evidence heard at the inquest. This process has since been reviewed internally and the introduction of a formalised process is currently underway with the Health and Safety team, in partnership with the NHS. The prison will be accountable for visiting the cell six months after the NHS assessment to confirm that any obvious ligature points are identified and minimised as best as possible.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 26 May 2022

    Open published response

  2. Inner West London

    AI-generated summary

    Francesca Whyatt · 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

    Francesca Whyatt, who was at known risk from ligatures, was found unconscious with tights around her neck at the Priory Hospital on 25 September 2013 and died in hospital on 28 September 2013. The report identifies concerns about the ward’s four-floor configuration, observation arrangements, control of ligature items, staffing and training, and the lack of clear criteria for investigating ligature and other self-harming incidents as serious untoward incidents.

    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 risk assessment of the East Wing ward configuration over four floors

    Wider context from the report

    “(1) There has been no risk assessment of the configuration of the East Wing ward over four floors. ”

    Source location

    Francesca Whyatt · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
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Data last updated 7 September 2026