Recurring concern

Unreliable controls for patient-specific restricted items

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First reported 9 Sep 2021•Latest report 17 Jun 2022

Definition

What this concern includes

Includes dedicated controls for identifying, risk-assessing, communicating, authorising, restricting and preventing access to items designated as restricted for a particular patient or resident in mental-health wards, care homes or comparable care settings, including informing families and visitors and maintaining documented fail-safe prevention arrangements.

Not included

  • Excludes generic dangerous-item, contraband or ward-security concerns where no patient-specific restricted-item regime is identified.
  • Excludes the existing broader inpatient concern concerning dangerous-item restriction when the assertion does not specifically concern patient-specific restricted-item controls.
  • Excludes generic family communication, care planning or visitor-information failures unrelated to restricted items.
  • Excludes ordinary medication-security, self-harm-means and prohibited-item searches unless the assertion specifically concerns a patient-specific restricted-item decision and its controls.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2021–2022

First to latest report issue date

Stated actions
1

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.

Blackpool Teaching Hospitals NHS Foundation Trust1
Department of Health and Social Care1
Hellesdon Hospital1
Lancashire County Council1
Lancashire & South Cumbria NHS Foundation Trust1
Nightingales Care Limited1
Norfolk and Suffolk NHS Foundation Trust1
Zion Care Limited1

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. Blackpool and the Fylde

    AI-generated summary

    Margaret Florence Joyce Stringer · 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

    Margaret Florence Joyce Stringer died by suicide between 18.35 and 19.00 on 10 October 2020 in the bathroom adjoining her room at Nightingales Nursing Home. The inquest found that appropriate precautions were not taken, including the return of an item used as a ligature, and that information about her suicide risk was incomplete and insufficiently recognised. Concerns included the absence of a fail-safe system to restrict access to dangerous items and weaknesses in the collation and transfer of information about suicide risk between services.

    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 fail-safe, documented system preventing residents’ access to restricted items

    Wider context from the report

    “1) (Addressed to Nightingales Care Limited and Zion Care Limited, referred to collectively as ‘Nightingales’) Whereas the court heard evidence that Nightingales would not accept another patient with an equivalent medical profile/history and that, should a resident within one of Nightingales’ homes require access to items to be restricted, they would be given 1:1 support pending a mental health assessment and discharge to a more appropriate facility, it was not possible for the home concerned to advise the court as to how and by whom the lead in question had been returned to Mrs Stringer. The concern arises that, in the case of a resident whose care requires access to items to be restricted, there should be a fail-safe, documented system, known to and implemented by staff, by which access to those items by the resident is prevented. In the circumstances that the possibility of a resident requiring such care may still arise, this concern exists notwithstanding the decisions now made. ”

    Source location

    Margaret Florence Joyce Stringer · 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

    Existing admission restrictions, one-to-one care and urgent referral or discharge arrangements address risks for unsuitable residents.

    Verbatim wording from the response

    “1. As per the evidence of ████████, Nightingale’s is not a secure unit and a resident with a similar history to that of Ms Stringer would no longer be admitted to the Home. Should there be a concern in relation to a resident who was already admitted at the home, a system of 1:1 care would be implemented which would restrict access to any items. An urgent referral would therefore be arranged for assessment of the resident and the resident would be discharged to a more suitable placement/acute hospital. The concern raised should therefore not eventuate.”

    Source location

    Response from DAC Beachcroft
    Page 1 · response
    Published 21 September 2022

    Open published response

  2. Suffolk

    AI-generated summary

    Joshua SAHOTA · 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

    Joshua Sahota, a 25-year-old man, died on 9 September 2019 after being found with a plastic carrier bag over his head and a bed sheet around his neck while an inpatient on a mental health ward. The report raised concerns about ineffective communication to families and friends regarding items classified as restricted, including plastic carrier bags, and the inquest identified concerns including insufficient staffing, insufficient observations and one-to-one support, inadequate documentation, no psychologist availability, and an unclear restricted-items policy.

    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 communicate patient-specific restricted items to families and friends before ward visits

    Wider context from the report

    “relate to the communication of what are ‘restricted and contraband items’ to the family and friends of a patient, before those family and friends visit the mental health ward. This would be particularly important for a family or friends first visit to the ward. The court was told that there are signs up at the entrance of the ward detailing items that are ‘contraband’. These items are not allowed onto the ward in any circumstances. This makes it clear to all visitors what cannot be taken onto the ward in any circumstances. However, the court was told that a ‘restricted item’ regime also exists, under which patients are risk assessed, with some being allowed particular items (such as mobile phone charger leads, laptop leads, belts and lighters), whilst others are not. From the evidence we heard in this case, we know that Josh’s clothes were taken onto the ward in a plastic carrier bag, which at the time was a restricted item. We heard that the bag was emptied, the contents were searched, re-packed and then taken to Josh’s room. From the investigation into this matter, it is apparent that firstly, that had the family known that a plastic carrier bag was a restricted item, it would not have been taken to the hospital in the first instance. Secondly, that had the family been aware that a plastic carrier bag was a restricted item, even though they may have used one to deliver Josh’s clothes, they would have drawn staff attention to the bag when it was subsequently taken and left in Josh’s room. During the evidence no clear system or procedure was identified, for a family to be notified of any particular items that have been deemed ‘restricted’ items for their loved one to have in their possession. There was therefore no effective communication with the family regarding what items were, and what items were not, allowed onto the ward in Josh’s case. I am therefore concerned that families and friends of current in-patients, may still inadvertently take a particular item onto ward, or be aware that their loved one has a particular item in their possession, yet be totally unaware that that particular item has been risk assessed as a restricted item for their loved one. It is known that families and friends of in-patients can play a vital role in their care, treatment and recovery. However, without knowing what have been deemed ‘restricted items’ for their loved one, the ability to assist in keeping their loved one safe whilst an in-patient, is effectively removed from those family and friends. ”

    Source location

    Joshua SAHOTA · 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

    Improve visitor and service-user communications about the ban on plastic bags through updated letters, external messaging and ward signage.

    Verbatim wording from the response

    “This item is a completely “banned” item across all inpatient units save our rehabilitation unit. Improvements have been made to our external messaging to families and carers on this subject plus a number of safeguards have been put in place to disrupt the passage of restricted items including plastic bags. For example on entering the main Wedgwood reception visitors are asked to show what items they have brought to the unit, if these are within or contain a plastic bag a paper one will be given as a replacement. Likewise for any service user going out on leave, on return they will be given an alternative type of bag either paper or canvas. When advancing to the ward reception there are posters and a “sandwich board” which highlight various pieces of information including restrictions on items coming in to the ward namely plastic bags.”

    Source location

    2021-0301-Response-from-Hellesdon-Hospital_Published
    Page 1 · response
    Published 17 September 2021

    Open published response
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Data last updated 7 September 2026