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.
Trends
Reports over time
Reports mentioning this concern, 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
NHS trust10
Executive non-departmental public body2
Clinical commissioning group1
Health and social care service regulator1
Health professional body1
Integrated care board1
Ministerial department1
Reports and published responses 11 reports
See individual reports that have raised this concern, and the actions taken in response
Essex
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.
Linked response
Mid and South Essex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Mid and South Essex NHS Foundation Trust
Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.
Mid and South Essex NHS Foundation Trust
Require ligature risk assessments, including consideration of clothing as ligature material, with documented rationale and mitigating actions where items remain.
Mid and South Essex NHS Foundation Trust
Perform environmental risk assessments for clinical and non-clinical areas before placing potentially at-risk patients there.
Essex
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.
Linked response
Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Essex Partnership University NHS Foundation Trust
Improve CAMHS incident learning through ABC-format Datix records, staff training, action recording and ligature-risk categorisation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Essex Partnership University NHS Foundation Trust
Environmental risks cannot be eliminated entirely, so safety work is limited to minimising risks without introducing restrictive practice.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
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.
Linked response
NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
NHS England
Cygnet’s Ligature Risk Reduction Policy and Ligature Audit Tool are outside NHS England’s remit.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Cygnet is responsible for addressing its Ligature Risk Reduction Policy and Ligature Audit Tool.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Buckinghamshire
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Yorkshire Eastern
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.
Linked response
Leeds and York Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Leeds and York Partnership NHS Foundation Trust
Scope alternative wound-covering options and contact other mental health trusts to capture and share relevant practice.
Brighton and Hove
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Buckinghamshire
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.
Linked response
Oxford Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Oxford Health NHS Foundation Trust
Review and update the policy governing searches of patients and their belongings, including risk-based search guidance and training access.
Oxfordshire
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.
Linked response
Oxford Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Oxford Health NHS Foundation Trust
Issue and enforce guidance requiring staff to remove plastic bags at reception or supervise their removal and disposal.
Oxford Health NHS Foundation Trust
Record restricted-item advice and handover confirmations in visitors’ signing-in books and monitor completion weekly.
Oxford Health NHS Foundation Trust
Provide paper bags on wards as a safe alternative for transporting items.
Oxford Health NHS Foundation Trust
Add restricted-item advice to admission packs and staff checklists, with monthly matron audits.
Oxford Health NHS Foundation Trust
Implement a standard operating procedure and weekly management review for recording daily environmental checks.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Oxford Health NHS Foundation Trust
The Trust does not record every item entering or leaving patient lockers because doing so would be extremely labour intensive.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
South London
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South and East Cumbria
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.
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
The Cumbria Partnership NHS Foundation Trust is responsible for addressing the four concerns relating to events on the Dova Unit.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.