20 Mar 2026 Luke Owen ASHCROFT · Prevention of Future Deaths report Greater Lincolnshire
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Concerns raised 1
Unsafe provision of corded telephones in cells occupied by prisoners who may self-harm View source
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 concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Luke Owen ASHCROFT · 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
Luke Ashcroft was admitted to Lincoln County Hospital from HMP Lincoln after being found unconscious in his cell in the Care and Separation Unit. His death was confirmed on 1 July 2020, with the post-mortem finding hypoxic brain injury consistent with ligature application. The inquest identified concerns about missed healthcare opportunities, inadequate information sharing and risk mitigations, shortcomings in the ACCT plan, and failures to carry out required observations; it also raised concerns about the safety and availability of corded telephone access in the unit.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unsafe provision of corded telephones in cells occupied by prisoners who may self-harm
Wider context from the report “My concerns are twofold.
Firstly, whilst not directly relevant to the death of Luke Ashcroft, I am concerned about the clear and obvious risks of self harm posed by the provision of a corded telephone, secured at one end, suspended at head height in a cell commonly occupied by prisoners, who may seek to self harm . I was told that the cell J109 had no ligature points and that the door was fitted with anti ligature fittings. As a consequence, that was the only method of securing telephone access. That same issue may extend to other cells in the CSU. Whether at head height or otherwise, the provision of a corded phone may well be an issue in potential cases of self harm and appears incongruous in comparison with other steps taken to ensure safety within that cell. The risks of an inmate utilising that cord in an act of self harm are self evident.
Secondly, the mechanism of provision of telephone access on CSU appears to require a prisoner requesting such provision before the cells are locked down. Thereafter, whilst a request can be made by a prisoner, telephone provision may depend upon the availability of additional officers to attend whilst the cell is unlocked and the telephone provided. That is not certain to take place. Given the proper availability to prisoners in crisis of freephone access to Samaritans and similar services, the possible absence of a handset to access such services is a matter of concern.
” Source location Luke Owen ASHCROFT · Prevention of Future Deaths report
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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 Review current telephony arrangements within the Care and Separation Unit.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
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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 Develop a formal business case assessing the feasibility, proportionality and risks of relocating telephone sockets within cells.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
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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 Modify Care and Separation Unit cell doors to route telephone cables securely beneath the doors.
Verbatim wording from the response “In the interim, a number of risk reduction measures are being implemented including work to modify the CSU cell doors to enable telephone cables to be routed securely beneath the door. This adjustment will remove the requirement for cables to pass over the top of cell doors, thereby reducing the identified ligature risk.” Source location Response from HM Prison and Probation Service
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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 Enable telephones to be fixed to internal cell walls to minimise excess cable slack.
Verbatim wording from the response “In addition, telephones will have the ability to be fixed to the internal wall to minimise excess slack and restrict the potential for inappropriate use. A fixed, non-weight bearing handset cradle will also be installed within cells using appropriate attachments, ensuring that the handset can be safely stored without the need for prisoners to maintain tension on the cable during use.” Source location Response from HM Prison and Probation Service
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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 Install fixed, non-weight-bearing handset cradles in cells using appropriate attachments.
Verbatim wording from the response “In addition, telephones will have the ability to be fixed to the internal wall to minimise excess slack and restrict the potential for inappropriate use. A fixed, non-weight bearing handset cradle will also be installed within cells using appropriate attachments, ensuring that the handset can be safely stored without the need for prisoners to maintain tension on the cable during use.” Source location Response from HM Prison and Probation Service
Open published response
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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 Review current Care and Separation Unit telephony arrangements.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
Open published response
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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 Develop a formal business case assessing the feasibility, proportionality and risks of relocating telephone sockets within cells.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
Open published response
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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 Modify Care and Separation Unit cell doors to route telephone cables securely beneath them.
Verbatim wording from the response “In the interim, a number of risk reduction measures are being implemented including work to modify the CSU cell doors to enable telephone cables to be routed securely beneath the door. This adjustment will remove the requirement for cables to pass over the top of cell doors, thereby reducing the identified ligature risk.” Source location Response from HM Prison and Probation Service
Open published response
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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 Install fixed wall-mounted telephone fittings and non-weight-bearing handset cradles to minimise cable slack and enable safe handset storage.
Verbatim wording from the response “In addition, telephones will have the ability to be fixed to the internal wall to minimise excess slack and restrict the potential for inappropriate use. A fixed, non-weight bearing handset cradle will also be installed within cells using appropriate attachments, ensuring that the handset can be safely stored without the need for prisoners to maintain tension on the cable during use.” Source location Response from HM Prison and Probation Service
Open published response
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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 Monitor implementation and effectiveness of the telephony safety measures through safety and assurance frameworks and ongoing review.
Verbatim wording from the response “The implementation and effectiveness of these measures will be monitored through the establishment’s safety and assurance frameworks. The controls introduced will be subject to ongoing review to ensure that they remain effective, proportionate, and responsive to any emerging risks or learning.” Source location Response from HM Prison and Probation Service
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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 Immediate relocation of CSU telephone sockets is not undertaken because it requires significant structural alteration and capital investment.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
Open published response
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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 Relocation of CSU telephone sockets is not currently being implemented because it requires significant structural alteration and capital investment, pending feasibility assessment.
Verbatim wording from the response “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.” Source location Response from HM Prison and Probation Service
Open published response
29 Jul 2025 Azroy Dawes-Clarke · Prevention of Future Deaths report Kent and Medway
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Concerns raised 1
Failure to provide bedding materials resistant to being ripped into ligatures View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Azroy Dawes-Clarke · 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
Azroy Dawes-Clarke died in hospital on 10 November 2021 after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and treatment. The substantive concerns included inadequate communication and healthcare involvement, disproportionate and prolonged restraint, delays in recognising the arrest and starting CPR, unsuitable ligature-resistant materials, and gaps in staff training on ACCT procedures, first aid, basic life support, and the legal framework for medical emergencies.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide bedding materials resistant to being ripped into ligatures
Wider context from the report “(1) Despite being in a safer cell, dressed in an anti-ligature gown, Mr Dawes-Clarke was able to make a ligature from the bedding material in his cell. The material from which the mattress and pillow cover are made, permit strips to be ripped from them.
” Source location Azroy Dawes-Clarke · Prevention of Future Deaths report
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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 Conduct a cell design review to assess alternative materials meeting fire-safety and anti-ligature requirements for bedding.
Verbatim wording from the response “HMPPS are currently undertaking a cell design review which is looking at all aspects of cell design, including furniture and fittings, to ensure it takes account of developments in how prisoners are accommodated and improvements in what is currently available on the market. As part of this review, we will explore the possibility of using different materials which meet the stringent fire safety requirements and can also function as anti-ligature for bedding. The review is expected to conclude at the end of 2026.” Source location Response from HM Prison and Probation Service
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23 May 2025 Matthew Joseph O’Reilly · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Failure to evaluate small-quantity purchases for possible self-harm View source
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Matthew Joseph O’Reilly · 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
Matthew Joseph O’Reilly was found collapsed and unresponsive in his locked student accommodation room on 25 September 2020 and was pronounced dead after attempted resuscitation. Postmortem testing found recently ingested, significant and fatally toxic levels of a substance, and the inquest concluded that he died following deliberate self-ingestion, although his intentions remained unclear. The report raised concerns about gaps in guidance and oversight for the sale of a reportable poison, particularly through online marketplaces, and about public access to websites promoting poison-based suicide methods.
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× 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 evaluate small-quantity purchases for possible self-harm
Wider context from the report “1. ████████ is a reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that:
a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public.
b. The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training for sellers, particularly ████████ acquired by members of the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harm.
c. Whilst there is a legal duty on persons selling this substance to report “suspicious” transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life .
d. The current Home Office guidance and supporting video, leaflet and posters do not reference ████████ as a specific example of concern and focuses on the phenomenon of ‘malicious’ misuse and not deliberate misuse in the sense of suicide/self-harm.
” Source location Matthew Joseph O’Reilly · Prevention of Future Deaths report
Open source report
23 May 2025 Mathew Anthony Price · Prevention of Future Deaths report Manchester West
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Concerns raised 2
Failure to evaluate small-quantity purchases for suicide or self-harm indicators View source Failure of Home Office guidance materials to address deliberate suicide or self-harm misuse of the substance View source
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mathew Anthony Price · 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
On 28 June 2021, Mathew Anthony Price was found collapsed and unresponsive at his residence after consuming a significant and fatally toxic quantity of a substance. The report identifies concerns about the sale and purchase of the substance, including inadequate guidance for sellers and the failure to recognise small-quantity purchases as potential self-harm risks. It also describes online access to information about poisons and methods of suicide.
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× 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 evaluate small-quantity purchases for suicide or self-harm indicators
Wider context from the report “1. ████████ is a reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that:
a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public.
b. The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training to sellers, particularly ████████ acquired by members of the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ basis of the means of self-harming.
c. Whilst there is a legal duty on persons selling this substance to report “suspicious” transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life .
d. The current Home Office guidance and supporting video, leaflet and posters do not reference ████████ as a specific example of concern and focuses on the phenomenon of ‘malicious’ misuse and not deliberate misuse in the sense of suicide/self-harm.
” Source location Mathew Anthony Price · Prevention of Future Deaths report
Open source report × 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 of Home Office guidance materials to address deliberate suicide or self-harm misuse of the substance
Wider context from the report “1. ████████ is a reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that:
a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public.
b. The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training to sellers, particularly ████████ acquired by members of the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ basis of the means of self-harming.
c. Whilst there is a legal duty on persons selling this substance to report “suspicious” transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life.
d. The current Home Office guidance and supporting video, leaflet and posters do not reference ████████ as a specific example of concern and focuses on the phenomenon of ‘malicious’ misuse and not deliberate misuse in the sense of suicide/self-harm .
” Source location Mathew Anthony Price · Prevention of Future Deaths report
Open source report
23 May 2025 Kelly Michelle Walsh · Prevention of Future Deaths report Manchester West
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Concerns raised 2
Failure to evaluate small-quantity purchases for deliberate self-harm View source Failure of Home Office guidance materials to address deliberate misuse for suicide or self-harm View source
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Kelly Michelle Walsh · 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
Kelly Michelle Walsh was discovered dead at her residence on 27 February 2021 after ingesting a fatally toxic substance obtained from an internet-based supplier. The report raised concerns about insufficient guidance for online sellers and the failure to identify suspicious small-quantity purchases that may be intended for self-harm. It also identified online access to information about obtaining and using poisons to end life.
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 evaluate small-quantity purchases for deliberate self-harm
Wider context from the report “1. ████████ is a reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that:
a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public.
b. The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training to sellers, particularly ████████ acquired by members of the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harming.
c. Whilst there is a legal duty on persons selling this substance to report “suspicious” transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life.
d. The current Home Office guidance and supporting video, leaflet and posters do not reference ████████ as a specific example of concern and focuses on the phenomenon of ‘malicious’ misuse and not deliberate misuse in the sense of suicide/self-harm.
” Source location Kelly Michelle Walsh · Prevention of Future Deaths report
Open source report × 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 of Home Office guidance materials to address deliberate misuse for suicide or self-harm
Wider context from the report “1. ████████ is a reportable poison as well as a reportable explosives precursor within the terms, meaning and effect of Part 4 of Schedule 1A of the Poisons Act 1972 with the consequence that:
a. The Poisons Act 1972 sets out the legal obligations in relation to the sale, purchase, and use of these chemicals for suppliers, professional users and members of the public.
b. The published Guidance (commenced in 2014 and updated in August 2024) does not give specific guidance or suggested training to sellers, particularly ████████ acquired by members of the public, particularly over ‘online marketplaces’ in circumstances of the purchase on a ‘one off’ basis for the means of self-harming.
c. Whilst there is a legal duty on persons selling this substance to report “suspicious” transactions within 24 hours to the Home Office, the purchase of small quantities is being presumed to be connected to the many legitimate uses of the substance (such as food preservation, fertilizer etc) rather than in fact, being evaluated as a member of the public seeking purchase of modest quantities used as their chosen means by which to end life.
d. The current Home Office guidance and supporting video, leaflet and posters do not reference ████████ as a specific example of concern and focuses on the phenomenon of ‘malicious’ misuse and not deliberate misuse in the sense of suicide/self-harm.
” Source location Kelly Michelle Walsh · Prevention of Future Deaths report
Open source report
14 Nov 2024 Hannah Mary AITKEN · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2
Unrestricted domestic sale of the substances View source Unrestricted import of the substances View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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. 11
Action
Strengthen controls on reportable poisons, including suspicious-transaction reporting, online-marketplace obligations, and supplier personnel awareness requirements.
Stated by Home OfficeStated completedThe respondent said that this action was complete when they made their response on 14 November 2024. View source
Action
Improve retailer awareness of legal reporting duties and engage online platforms to encourage removal of pure-form sales and use of declarations of intended use.
Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2024. View source
Action
Continue work to ensure suppliers meet their obligations under the Poisons Act.
Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2024. View source
Action
Operate the Concerning Methods Working Group to develop and deliver targeted actions reducing public access to emerging suicide methods.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2024. View source
Action
Work with businesses, online suppliers and manufacturers to reduce non-legitimate purchasing and raise safeguarding awareness.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 November 2024. View source
Action
Work with online platforms to remove the substance from sale to individuals in its pure form.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 November 2024. View source
Action
Continue operational work with organisations to reduce access to concerning methods.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2024. View source
Action
Introduce Border Force guidance on responding to detected goods potentially intended to assist suicide.
Stated by Home OfficeStated completedThe respondent said that this action was complete when they made their response on 14 November 2024. View source
Action
Monitor Border Force policies, explore improvements to operational responses, and support frontline staff to identify and respond to relevant items.
Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2024. View source
Action
Work with the Department of Health and Social Care and relevant stakeholders to assess the benefits and proportionality of further regulation addressing overseas sales, purity, and quantities.
Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2024. View source
Action
Consider working with Border Force, using existing legal provisions, to detect potentially suicide-related packages sent to vulnerable individuals.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2024. View source See 8 more actions
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AI-generated summary
Hannah Mary AITKEN · 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
Hannah Mary Aitken died at her supported accommodation on 14 September 2023 after taking an overdose of a poisonous substance obtained with the intention of ending her life. The report raises concerns about the unrestricted domestic and international availability of the substance, the quantities and purity in which it is sold, and the lack of central monitoring or clear responsibility for regulating its use in relation to self-harm.
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 Unrestricted domestic sale of the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad.
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions ;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Source location Hannah Mary AITKEN · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unrestricted import of the substances
Wider context from the report “The Court heard anecdotal evidence from three Emergency Medical Consultants and others witnesses that in their direct experience, the use of ████████ for self-harm is increasing. However, none were aware of a central monitoring system which is able to record incidents of ████████ poisoning.
████████ are reportable substances under the Poisons Act 1972. The only obligation under this legislation is that domestic sellers must report reasonable grounds for believing transactions are suspicious. There are no restrictions on the import of ████████ from abroad .
Since 2020, the Home Office has received at least five Prevention of Future Death Reports relating to ████████ The Home Secretary has recently provided reassurance in response to the Regulation 28 report relating to the death of Dr Jonathan Shaw that “the Home Office is actively exploring legislative and policy options, including working with or alongside officials of other Government Departments as appropriate, for the control of ████████ (and other similar substances)”.
The Home Office has clarified in evidence during this inquest that the policy objective of the Poisons Act 1972 is to control access to explosives precursors and poisons and to detect terrorist use of these substances to illicitly manufacture explosives or to cause harm to third parties. Prevention of suicide/self-harm is not a policy objective of the Home Office under this Act, and this falls under the remit of the Department for Health and Social Care. No evidence was provided that there is active consideration of controlling access to these substances to the general public, whether under the remit of the Home Office or any other Government department.
Whilst these substances have legitimate uses, including ████████ ████████ there does not appear to have been consideration as to whether the purity can be diluted, or any other measures taken, to reduce the risk posed by the quantities in which these substances are currently sold, against the risk to life that they can pose.
- ████████ can be purchased domestically with no restrictions save a duty on sellers to report suspicious transactions;
- ████████ can be purchased from abroad and imported to Great Britain with no restrictions ;
████████
████████
- The quantities and purity in which ████████ are sold do not appear to be those required for their legitimate use, for example in ████████
- It does not appear there is any consideration of regulating/monitoring the use of ████████ outside the limited provisions of the Poisons Act 1972, and it is not clear which Government department would be responsible for this.
Consideration should be given to whether any steps can be taken to address the above concerns.
” Source location Hannah Mary AITKEN · Prevention of Future Deaths report
Open source report
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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 Strengthen controls on reportable poisons, including suspicious-transaction reporting, online-marketplace obligations, and supplier personnel awareness requirements.
Verbatim wording from the response “The substance described in your report is a “reportable” poison listed in Part 4 of Schedule 1A of the Poisons Act. For the avoidance of doubt, this means that whilst it can be bought by members of the public, suspicious transactions need to be reported by retailers if there are questionable grounds for suspecting it is intended for any illicit use. The Poisons Act was amended in October 2023 to strengthen controls, and enhance our suspicious activity reporting requirements, including new obligations for online marketplaces. As well as the requirement to report suspicious transactions, economic operators supplying any reportable substances must now demonstrate that their personnel are aware about which of their products contain listed substances, and are instructed on their obligations.” Source location Response from the Home Office
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve retailer awareness of legal reporting duties and engage online platforms to encourage removal of pure-form sales and use of declarations of intended use.
Verbatim wording from the response “As your report captures, the Home Office is aware of the issues relating to this substance. My officials have been undertaking work across Government to both reduce access to this substance, and raise awareness to suppliers of the dangers of this substance. To this end, the Homeland Security Group (HSG) have been working to improve retailer awareness of their legal obligation to report suspicious activity for regulated and reportable substances.” Source location Response from the Home Office
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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 Continue work to ensure suppliers meet their obligations under the Poisons Act.
Verbatim wording from the response “Specifically, HSG have engaged with online platforms to encourage them to voluntarily remove the sale to individuals in its pure form. Government expertise in relation to substances of concern is also shared to inform retailer sales practices. This includes encouraging suppliers to use declaration of use forms for sales of such substances. This work will continue to ensure suppliers are meeting their requirements under the Poisons Act. Furthermore, if during the processing of suspicious activity reports a safeguarding concern is identified by Counter Terrorism Policing, consideration will be given to disseminating this intelligence to police forces to consider a welfare check.” Source location Response from the Home Office
Open published response
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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 Operate the Concerning Methods Working Group to develop and deliver targeted actions reducing public access to emerging suicide methods.
Verbatim wording from the response “On methods of suicide specifically, Government departments have taken steps to reduce access to, and awareness of, this substance. DHSC leads a Concerning Methods Working Group to raise awareness of and tackle access to substances such as this one. The working group involves representatives from the voluntary, community and social enterprise sector, police, academics and the NHS, as well as Government departments including Department of Science, Innovation and Technology and the Home Office. The group develops and delivers rapid targeted actions to collectively reduce public access to emerging methods, including this one. Over 30 of the actions identified and implemented by the group have been to tackle this substance specifically.” Source location Response from DHSC
Open published response
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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 Work with businesses, online suppliers and manufacturers to reduce non-legitimate purchasing and raise safeguarding awareness.
Verbatim wording from the response “The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.” Source location Response from DHSC
Open published response
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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 Work with online platforms to remove the substance from sale to individuals in its pure form.
Verbatim wording from the response “The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.” Source location Response from DHSC
Open published response
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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 Continue operational work with organisations to reduce access to concerning methods.
Verbatim wording from the response “The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.” Source location Response from DHSC
Open published response
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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 Border Force guidance on responding to detected goods potentially intended to assist suicide.
Verbatim wording from the response “Similarly, Border Force has introduced guidance for its officers (operating within its existing legal provisions). This guidance provides instructions on the action they can take if they are in receipt of information, in any form or manner, that leads to a detection of goods at the border containing an item that may be intended to assist with suicide. This of course relies on Border Force working closely with police forces and other relevant agencies to safeguard vulnerable individuals to the full extent possible. This work is complex, and Border Force will continue to monitor its policies, exploring opportunities to improve its ability to take action. Where possible, Border Force will also continue to ensure that frontline staff who may encounter these items know what action to take, and are supported on a case-by-case basis when required.” Source location Response from the Home Office
Open published response
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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 Monitor Border Force policies, explore improvements to operational responses, and support frontline staff to identify and respond to relevant items.
Verbatim wording from the response “Similarly, Border Force has introduced guidance for its officers (operating within its existing legal provisions). This guidance provides instructions on the action they can take if they are in receipt of information, in any form or manner, that leads to a detection of goods at the border containing an item that may be intended to assist with suicide. This of course relies on Border Force working closely with police forces and other relevant agencies to safeguard vulnerable individuals to the full extent possible. This work is complex, and Border Force will continue to monitor its policies, exploring opportunities to improve its ability to take action. Where possible, Border Force will also continue to ensure that frontline staff who may encounter these items know what action to take, and are supported on a case-by-case basis when required.” Source location Response from the Home Office
Open published response
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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 Work with the Department of Health and Social Care and relevant stakeholders to assess the benefits and proportionality of further regulation addressing overseas sales, purity, and quantities.
Verbatim wording from the response “On the issue of further regulation, an aspect of the concern you have raised relates to individuals based in Great Britain, purchasing this substance from overseas retailers. As the Poisons Act only applies to Great Britain (i.e. England, Scotland, and Wales), there is no obligation for retailers based outside the specified jurisdiction to report transactions which they believe to be suspicious. The Department is seeking to address this, as well as” Source location Response from the Home Office
Open published response
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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 Consider working with Border Force, using existing legal provisions, to detect potentially suicide-related packages sent to vulnerable individuals.
Verbatim wording from the response “The group has worked with businesses, including online suppliers and manufacturers of the substance, to reduce people’s ability to purchase it for non-legitimate purposes including suicide, and to raise awareness around safeguarding concerns with businesses where required. Government departments have also previously worked with manufacturers to reduce the lethality of the substance if ingested. This included work with online platforms to remove it from sale to individuals in its pure form. The group continues to work operationally with a range of organisations, and we are actively considering opportunities to work with the Border Force, using existing legal provisions, to help detect packages at the border which may be linked to vulnerable individuals and intended for suicide. The group’s actions are kept under review.” Source location Response from DHSC
Open published response
23 Jun 2023 Stephen Kurt Beadman · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Failure to restrict access to potentially harmful male-grooming equipment for prisoners with an identified history of self-harming View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Stephen Kurt Beadman · 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
Stephen Kurt Beadman was a 34-year-old serving prisoner at HMP Wakefield who was found unresponsive after applying a ligature to his neck and died in hospital the following day. The Inquest found that he committed suicide having been bullied by other prisoners. The principal concern was that the prison’s limited consultant psychiatrist resource was insufficient for the complex mental health needs of its prisoner population, creating concern that other deaths may occur.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to restrict access to potentially harmful male-grooming equipment for prisoners with an identified history of self-harming
Wider context from the report “1) Mr Beadman had a history of self-harming ████████. Nonetheless, he was permitted ████████ in his possession when alone in his cell.
2) For the avoidance of doubt, Mr Beadman took his own life later in the afternoon of 7th April 2021 by applying a ligature to his neck, ████████ to take his own life.
3) The issue of ████████ gives rise to a foreseeable risk.
4) Only six weeks before the 7th April 2021 incident, another prisoner, Carl Shaun Langdell had used a similar type of ████████ to inflict a fatal wound to his neck. A Prevention of Future Death Report dated 21.10.22 was made in that case. A copy is attached, along with the response received from ████████ dated 23.12.22.
5) Evidence was taken at the Inquest in which several people working at the prison expressed support for such ████████ to be withdrawn from use in the prison.
6) It is acknowledged that consideration has been given within the prison service nationally to the withdrawal of ████████ of this type and that this work (including various pilot projects) is ongoing. It is further acknowledged that the difficulties in identifying a workable alternative system of male grooming are considerable. This does not, however, obviate the need to remove a clear source of potential harm from those with an identified history of self-harming.
” Source location Stephen Kurt Beadman · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to eliminate or reduce ligature points in cells used for prisoners at risk of self-harm View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Thomas Victor HUNTLEY · 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
Thomas Victor Huntley died in HMP Winchester after he was found unresponsive in his cell on 28 May 2020, following a planned act intended to end his life. The inquest identified concerns about missing and inadequately recorded risk information, failures in ACCT documentation and risk assessment, inadequate observations, information sharing between prison and healthcare staff, and ligature risks in cells.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to eliminate or reduce ligature points in cells used for prisoners at risk of self-harm
Wider context from the report “Cells
At HMP Winchester within the area, considered and referred to by most healthcare and prison staff, as the ‘mental health’ cells there are 2 cells which are not equipped in a way to reduce the amount of available ligature points.
It was clear from the evidence of the healthcare staff at the MDT meeting on the 28/05/2020 that they did not consider the contents of the cell when deciding to move Mr Huntley to the ‘mental health cells’ simply due to the fact he was on an ACCT. I heard evidence that the policy of CNWL has now changed and that a cell move risk assessment must now be carried out and that there is now a revised ligature audit process. HMP Winchester informed me that there is now an annual ligature audit carried out in conjunction with the new healthcare provider at that establishment. In addition I was informed that all telephone points in the ‘mental health cells’ at HMP Winchester have now been removed and placed outside the cells. These are welcome developments.
However at inquest those representing the HMPPS could not inform me whether all telephone points within cells designed for use by those at risk of self harm across the prison estate had been removed. Nor was any evidence available as to what consideration had been given to reducing the risk of the telephone points by design of the points themselves or the manner of their installation. Those representing were invited to provide this information after the hearing but have not done so.
I am concerned that telephone points which provide a ligature point may remain within cells which prison and health care staff consider to be suitable for use by those at risk of self harm .
” Source location Thomas Victor HUNTLEY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review ligature-resistant cell standards and their use in supporting prisoners in crisis.
Verbatim wording from the response “The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible. The review has included the cell build standards and how they are used to support prisoners in crisis. Our aim is to ensure that cells that are fitted with ligature-resistant features are available as an option for staff managing prisoners in crisis, and that they retain those features in full working order and do not deviate from the standard over time. At this point it is too early to say what new rules may be introduced, such as setting the frequency of maintenance, although we do recognise that cells are subject to constant wear and tear and need frequent attention to keep them up to standard.” Source location Response from HM Prison and Probation Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is currently too early to determine whether new ligature-resistant cell maintenance rules should be introduced.
Verbatim wording from the response “The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible. The review has included the cell build standards and how they are used to support prisoners in crisis. Our aim is to ensure that cells that are fitted with ligature-resistant features are available as an option for staff managing prisoners in crisis, and that they retain those features in full working order and do not deviate from the standard over time. At this point it is too early to say what new rules may be introduced, such as setting the frequency of maintenance, although we do recognise that cells are subject to constant wear and tear and need frequent attention to keep them up to standard.” Source location Response from HM Prison and Probation Service
Open published response
28 Nov 2022 Susan Jane PERRY · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure to secure medication cupboard keys View source
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 concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Susan Jane PERRY · 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
Susan Jane PERRY had a chronic complex mental ill health condition and was receiving long-term care and support at supported accommodation. She was found deceased in her room on 23 October 2020, and the inquest found that COVID-19 infection and elevated levels of prescription medication contributed to her death. The principal concern was that medication cupboard keys were kept nearby in unsecured locations, creating a risk that a service user could access medication; no evidence was received that practices and procedures across similar accommodation addressed this risk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to secure medication cupboard keys
Wider context from the report “(1) I received evidence from her support workers that service user's medications were kept in locked cupboards on the ground floor. However, the keys to the same were kept either in an unlocked drawer nearby, or in a pot on an adjacent, or nearby work surface . I sought clarification upon this and evidence to determine if this arrangement was still in place today. Whilst I did not receive any evidence per se on this matter, the indication I received from counsel for MIRUS Wales did not satisfy me, that arrangements for access to this cupboard had been altered or revised since Susan Perry’s death on 23.10.20.
(2) My concern is simply that these arrangements give rise to a risk that a service user could access medication (their own, or other service users) from the locked cupboards by opening the same using the nearby keys, defeating the purpose of securing the medication . Deliberate, or inadvertent administration of such medication could well lead to the death of that individual.
(3) I believe that MIRUS Wales operate several similar supported accommodation concerns across South Wales, and I received no evidence to satisfy me that practices & procedures were in place across these concerns to address this risk of self-harm.
” Source location Susan Jane PERRY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the medication policy and revise key-holder requirements so medication keys remain on the nominated key holder’s person.
Verbatim wording from the response “• mirus has reviewed its medication policy, procedures, and practice in relation to the handling of keys. (Action completed 5th December 2022)” Source location Response from MIRUS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update medication training for staff and managers to strengthen key-handling and prevent unauthorised access to medication.
Verbatim wording from the response “• The content of the medication training for staff and managers has been updated to strengthen the additional measures for handling of keys to ensure safe storage and prevent unauthorised access to medication. (Action taken 5th December 2022)” Source location Response from MIRUS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement additional quality-assurance measures to verify that the medication-key and training actions have been implemented.
Verbatim wording from the response “• Additional quality assurance measures will follow to ensure that the above actions have been implemented. (Action by end of February 2023)” Source location Response from MIRUS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Subject the medication-safety measures to scrutiny at leadership meetings and the March 2023 Board of Trustees meeting.
Verbatim wording from the response “The above measures will be subject to full scrutiny at our leadership meetings and at the next full Board of Trustee meeting in March 2023.” Source location Response from MIRUS
Open published response
21 Oct 2022 Carl Shaun Langdell · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Failure to prevent prisoners at known chronic risk of suicide or self-harm from possessing items when alone in locked cells overnight View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Carl Shaun Langdell · 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
Carl Shaun Langdell was discovered in his locked, single-occupancy prison cell with a significant neck wound and died after suffering cardiac arrest despite emergency treatment. The concerns included his identified chronic risk of suicide or self-harm, recent bizarre and agitated behaviour after refusing medication, and his being permitted to possess an unspecified item while alone in his cell overnight. The inquest recorded a finding of suicide and attributed the death to haemorrhage from a neck incision.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to prevent prisoners at known chronic risk of suicide or self-harm from possessing items when alone in locked cells overnight
Wider context from the report “(2) He had been identified by a consultant psychiatrist as at “chronic risk of suicide attempts/self-harm attempts which is likely to remain due to the nature of his personality disorder” .
(3) In January 2021 he was observed to be acting in a bizarre and agitated manner after refusing his prescribed medication for the previous month.
(4) Despite this history and the known risk he was permitted under the prevailing ████████ rules at HMP Wakefield to be in possession of ████████ when alone in his locked cell overnight.
” Source location Carl Shaun Langdell · Prevention of Future Deaths report
Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the prison’s local policy governing the issue and return of the relevant hygiene items, including risk assessment and blade checks.
Verbatim wording from the response “During the inquest, you heard evidence that following Mr Langdell’s death, the Governor ordered a review of the prison’s local ████████ policy and confirmed that it sets out the action that must be taken when staff issue ████████, which includes a risk assessment and staff ensuring they check that the blades are present when the razor is returned.” Source location Response from HM Prison and Probation Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct estate-wide pilots testing alternatives to current wet-shave provision and associated control measures to identify improvements.
Verbatim wording from the response “At a national level, we recognise the risks associated with the current ████████ provision and are actively seeking to identify improvements to the current provision. Throughout this year we have conducted several pilots across the prison estate, testing alternatives to the current wet shave provision and control measures in establishments. These pilots are due to conclude in the spring of 2023, at which time they will be evaluated” Source location Response from HM Prison and Probation Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate the pilots, including concerns, issues, and effects on violence and self-harm.
Verbatim wording from the response “At a national level, we recognise the risks associated with the current ████████ provision and are actively seeking to identify improvements to the current provision. Throughout this year we have conducted several pilots across the prison estate, testing alternatives to the current wet shave provision and control measures in establishments. These pilots are due to conclude in the spring of 2023, at which time they will be evaluated” Source location Response from HM Prison and Probation Services
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make informed recommendations on future shaving provision in prison establishments based on the pilot evaluation.
Verbatim wording from the response “to consider any concerns or issues which may have arisen and measured against the impact they have had on violence and self-harm. This evaluation will enable us to make informed recommendations on future shaving provision in prison establishments.” Source location Response from HM Prison and Probation Services
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Includes failures of controls specifically intended to identify, restrict, monitor, remove or otherwise prevent access to materials or objects that a person at risk of self-harm may use to harm themselves, including plastic bags, razor blades, cutlery and comparable means across healthcare, care, custodial and domestic settings.
