Recurring concern
Inadequate control of self-harm items in inpatient settings
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Request correctionFirst reported 6 Jan 2014•Latest report 27 May 2026
What this concern includes
Includes deficiencies in dedicated inpatient controls for self-harm items, including room and belongings checks, searches after leave, seizure or removal, and restrictions on hazardous items or materials.
Not included
- Excludes failures of patient observation or supervision that are not specifically about controlling self-harm items.
- Excludes clinical risk assessment, care planning or communication failures unless they directly concern control of self-harm items.
- Excludes generic staff training, staffing or documentation deficiencies not specifically tied to this item-control system.
- Excludes hazards unrelated to self-harm items.
- Reports
- 11
- Individual concerns
- 11
- Date range
- 2014–2026
- Stated actions
- 11
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 raised1
Failure to prevent access to ligature materials
This report raised 7 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
Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Require ligature risk assessments, including consideration of clothing as ligature material, with documented rationale and mitigating actions where items remain.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Perform environmental risk assessments for clinical and non-clinical areas before placing potentially at-risk patients there.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Unsecured ligature-risk items in the presence of high-risk patients
This report raised 30 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
Improve CAMHS incident learning through ABC-format Datix records, staff training, action recording and ligature-risk categorisation.
Stated by Essex Partnership University 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
Environmental risks cannot be eliminated entirely, so safety work is limited to minimising risks without introducing restrictive practice.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Lack of guidance for identifying and minimising potential ligatures, including hazardous clothing
This report raised 1 other concern. 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.
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
Cygnet’s Ligature Risk Reduction Policy and Ligature Audit Tool are outside NHS England’s remit.
Stated by NHS England
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Position
Cygnet is responsible for addressing its Ligature Risk Reduction Policy and Ligature Audit Tool.
Stated by NHS England
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Concerns raised1
Failure to conduct effective bedroom searches for prohibited self-harm items
This report raised 1 other concern. 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 raised1
Availability of wound-dressing materials usable for self-harm
This report raised 9 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
Incomplete and flawed checks and removal of dangerous items from patient rooms
This report raised 10 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 raised1
Failure of searching and seizure processes to prevent introduction of self-harm materials after unescorted leave
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
Review and update the policy governing searches of patients and their belongings, including risk-based search guidance and training access.
Stated by Oxford Health NHS Foundation Trust
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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
Lack of adequate policy or guidance for assessing and managing self-harm risks from items on adolescent psychiatric units
This report raised 1 other concern. 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 raised1
Failure to remove removable bathroom rails except when required
This report raised 5 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.
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 Cumbria Partnership NHS Foundation Trust is responsible for addressing the four concerns relating to events on the Dova Unit.
Stated by Department of Health and Social Care
Data last updated 7 September 2026