Recurring concern

Inadequate control of self-harm items in inpatient settings

First to latest report 6 Jan 2014 — 27 May 2026

Reports that mention this concern
11
Times this concern has been raised
11
Stated actions linked to this concern
11

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.

What is 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 and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026