Recurring concern

Unreliable checking of prolonged occupied toilets

First to latest report 11 Nov 2014 — 29 Sep 2015

Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
0

What this concern includes

Includes failures in arrangements for monitoring, checking and escalating prolonged or unexplained toilet occupancy in care, residential or custodial settings, including unclear thresholds, missed checks, delayed entry or failure to obtain assistance when an occupant may be in distress.

What is not included
  • Excludes general welfare checks, resident supervision or patient observation where prolonged toilet occupancy is not the material safety condition.
  • Excludes routine toilet checks for concealed items or contraband where the concern is security screening rather than the welfare of an occupant.
  • Excludes toilet design, door-access and physical environment deficiencies unless they directly impair the process for checking a prolonged occupied toilet.
  • Excludes failures occurring after an occupant has been promptly checked and their condition established.

Reports and published responses 2 reports

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

  1. Milton Keynes

    AI-generated summary

    Lee Anthony Boden · 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

    Lee Anthony Boden was released from prison to an approved premises in Milton Keynes on 13 February 2015 and was found unresponsive in a bathroom later that night, where drugs and drug paraphernalia were found. He was confirmed dead at 12.10am on 14 February 2015; the stated cause of death was central respiratory depression associated with illicit heroin use. Concerns included limited advance notice of his placement, lack of forward planning, insufficient recognition of his vulnerability, the length of time before he was discovered, and an apparent absence of a protocol for monitoring vulnerable new arrivals.

    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

    Resident remaining undiscovered in bathroom for almost four hours

    Wider context from the report

    “(3) That he had been in the bathroom for almost four hours before he was discovered. ”

    Source location

    Lee Anthony Boden · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Existing walk-around, curfew and scheduled self-harm checks were considered adequate to assure residents’ well-being as far as possible.

    Verbatim wording from the response

    “Measures are in place to assure, as far as possible, the well-being of residents at the AP. The regime includes two “walk-around” checks during the day (the last at 5.30pm), as well as a curfew check of all residents at 11pm. Residents with earlier curfews are checked at their curfew time (as was the case with Mr Boden) and those subject to self-harm monitoring procedures are checked in accordance with a monitoring schedule set out in their self-harm management plan.”

    Source location

    2015-0394-Response-by-NOMS
    Page 2 · response
    Published 29 September 2015

    Open published response

  2. Coventry

    AI-generated summary

    Amar MAJID · 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

    Amar Majid was found dead in a disabled toilet at the Public Library, Coventry, with a syringe in his hand and material believed to be heroin. The principal concern was that no one checked on his well-being for over five hours despite evidence that the toilets were cleaned hourly; the report also noted possible confusion about procedures for checking a toilet occupied for a considerable period.

    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 check the well-being of people occupying toilets for prolonged periods

    Wider context from the report

    “I heard evidence from ████████ (Business Improvement Manager) of Coventry City Council (CCC) that the disabled toilets in the library are used by individuals abusing drugs. Mr Majid was present in the toilet from 10.00am and heard to be making noises. I was concerned that no-one checked on his well-being for over 5 hours, despite what I understand to be hourly cleaning of the toilet. Earlier intervention may have prevented his death. ”

    Source location

    Amar MAJID · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Confusion about procedures for checking toilets occupied for considerable periods

    Wider context from the report

    “Also I invite you to review your procedures concerning checking the toilets as it seems there was confusion as to the correct procedure to follow when a toilet was occupied for a considerable period of time. Mr Majid was in the toilet from about 10.00am to the door being opened at about 3.00pm. That delay may have contributed to his death although I was unable to make firm findings on that point. ”

    Source location

    Amar MAJID · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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

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Data last updated 7 September 2026