Recurring concern

Inadequate control of self-harm items in inpatient settings

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First reported 6 Jan 2014•Latest report 27 May 2026

Definition

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

Distinct published reports

Individual concerns
11

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
11

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.

Oxford Health NHS Foundation Trust3
NHS England2
Care Quality Commission1
Department of Health and Social Care1
Essex Partnership University NHS Foundation Trust1
Leeds and York Partnership NHS Foundation Trust1
Mid and South Essex NHS Foundation Trust1
NHS Cumbria Clinical Commissioning Group1
NHS Surrey and Sussex Integrated Care Board1
North Cumbria Integrated Care NHS Foundation Trust1
Resuscitation Council UK1
Rotherham Doncaster and South Humber NHS Foundation Trust1
South London and Maudsley NHS Foundation Trust1
Sussex Partnership NHS Foundation Trust1

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 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