Recurring concern

Unreliable controls for restricting dangerous items in inpatient care

First to latest report 6 Jun 2014 — 21 Apr 2023

Reports that mention this concern
7
Times this concern has been raised
8
Stated actions linked to this concern
3

What this concern includes

Includes inpatient-care controls for identifying, recording, removing, restricting, tracking or checking dangerous or banned items, including responsibility at admission, environmental or room checks, monitoring of removed items and verification that restrictions remain effective.

What is not included
  • Excludes generic staffing, training, documentation or risk-assessment deficiencies unless they directly impair controls for restricting dangerous items in inpatient care.
  • Excludes ordinary property management and non-safety-related belongings controls.
  • Excludes medication-security concerns, ligature-point controls and self-harm prevention processes when the assertion does not specifically concern identifying or restricting dangerous items in inpatient care.
  • Excludes care-home, custodial or domestic item-control concerns unless the assertion explicitly supports the same inpatient-care process.

Reports and published responses 7 reports

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

  1. Surrey

    AI-generated summary

    Amy Henderson · 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

    Amy Henderson, who had been diagnosed with post-partum depression and admitted to Priory Hospital, Woking after expressing suicidal thoughts and plans, died there on 21 March 2022 after taking her own life by suspension in a disabled toilet. Concerns included risk assessments and observations not being completed in line with policy, therapy notes indicating deterioration not being acted upon, incomplete information about her suicide risk, and ineffective management of the disabled toilet as a high-risk area.

    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

    Lack of clarity about responsibility for identifying and removing banned and restricted items at admission

    Wider context from the report

    “2. The Priory Woking has a policy in relation to the removal of banned and restricted items but there was a lack of clarity and confusion among the clinicians as to who was responsible for ensuring that such items are identified and removed from the patient at admission. ”

    Source location

    Amy Henderson · Prevention of Future Deaths report
    Page 3 · 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

    Clarifying responsibility for identifying and removing banned or restricted items at admission is outside NHS England’s remit.

    Verbatim wording from the response

    “Regarding your second concern that at The Priory Woking there was a lack of clarity and confusion among clinicians as to who was responsible for ensuring that banned and restricted items are identified and removed from a patient at admission, this is outside of NHS England’s remit and I note that you have also addressed your Report to Priory Group who are the appropriate organisation to respond to this concern.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 27 April 2023

    Open published response

    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

    Priory Group is identified as the appropriate organisation to address responsibility for removing banned or restricted items at admission.

    Verbatim wording from the response

    “Regarding your second concern that at The Priory Woking there was a lack of clarity and confusion among clinicians as to who was responsible for ensuring that banned and restricted items are identified and removed from a patient at admission, this is outside of NHS England’s remit and I note that you have also addressed your Report to Priory Group who are the appropriate organisation to respond to this concern.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 27 April 2023

    Open published response

  2. Norfolk

    AI-generated summary

    Tracy Dawn WOOD · 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

    Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident report.

    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 recover and check restricted items when patients return to the ward

    Wider context from the report

    “4. Part of the Risk Assessment for giving a ████████ to Tracy was that she was to hand the ████████ back on her return to the ward. Tracy did not return the ████████ and was not asked to return the ████████. That Tracy had been given an ████████ was overlooked on her return. ”

    Source location

    Tracy Dawn WOOD · Prevention of Future Deaths report
    Page 2 · 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

    Ambiguous scope of restrictions on giving hazardous items to patients

    Wider context from the report

    “3. Tracy ████████ on 30 March 2021 and a note was placed on her SBAR records in red and bold “Do not give Tracy ████████”. On 1 June 2021 Tracy was given a ████████, at her request, before leaving the ward for a community visit. Evidence was heard that following a “risk assessment” it was acceptable for this decision to be made by a Band 6 Nurse when the ████████ was used off the ward and not on the ward where the original incident had occurred. The instruction not to give the ████████ did not specify whether this applied on or off the ward. There was no discussion with a Doctor or any other clinical staff when making this decision. There was no record of the ████████ being given to Tracy in the written records and no record of the rationale for the decision being made ”

    Source location

    Tracy Dawn WOOD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. East London

    AI-generated summary

    Rohan Dayal Singh · 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

    Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.

    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 of searches to detect and remove dangerous contraband

    Wider context from the report

    “1. Rohan Singh died on a mental health ward, following his death he was found to be in possession of number of prohibited items including controlled drugs and a bracelet consisting of a ligature and a blade. Before admission into hospital, Rohan had been subject to a personal search by police officers when the bracelet was seized. During Rohan’s admission his property was subjected to a search and later he himself was searched for contraband, despite these steps he retained dangerous contraband. ”

    Source location

    Rohan Dayal Singh · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Revise the search policy to govern search-information handover and review, and the disposal or storage of seized items, then disseminate the changes.

    Verbatim wording from the response

    “In order to address the issue of contraband being handed back to Mr Dayal Singh, the Trust is revising its search policy to explicitly include guidance on:”

    Source location

    2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 5 May 2021

    Open published response

    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

    Create and deliver a search training course, record completion in ESR, provide it at induction and every two years, and monitor compliance.

    Verbatim wording from the response

    “To ensure that nursing staff are equipped to carry out robust searches the Trust’s Director of Nursing and the Learning and Development Team are creating a ‘search’ training course. The course will reflect the Trust’s updated policy. Completion of the course will be monitored using the Trust’s Electronic Staff Record (ESR) data base.”

    Source location

    2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 5 May 2021

    Open published response

  4. Shropshire, Telford and Wrekin

    AI-generated summary

    Lee William Davies · 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 William Davies, a detained patient, absconded from a mental health ward on 17 June 2019 and was found unconscious the following day after an out-of-hospital cardiac arrest. He died in hospital on 18 June 2019 after treatment was withdrawn; the inquest recorded a brain injury caused by illicit drug use. Concerns included the reduction of his observation levels despite his risk of absconding to obtain drugs, and ward-garden planting and monitoring arrangements that could allow drugs or other items to be concealed.

    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 maintain garden planting that prevents concealment of dangerous and contraband items

    Wider context from the report

    “(1) During the course of the inquest I heard evidence that it was likely that Mr Davies had absconded on 17/6/19 by scaling a perimeter fence in the garden of Laurel Ward. The Jury was told that patients had unrestricted access to the garden except when the doors were locked overnight between 10.30 pm – 7.30 am; (2) The inquest heard that on 5/6/19 Mr Davies attempted to climb over the fence with a chair; (3) Mr Davies had absconded from Laurel Ward on 2 occasions since he was detained under s3 MHA on 24/5/19 and on 15/6/19 and used drugs. On the latter occasion he was reported by a peer to have climbed over the fence. (4) On 16/6/19 Mr Davies attempted to abscond again by trying to climb over the fence and was stopped by staff. He was observed to be arranging items to help him climb over the fence namely a bin and a chair. (5) The deceased was admitted to the Centre with a known substance abuse problem; (6) The jury was told by the Responsible Clinician that the deceased was also at risk of obtaining drugs from within the ward itself as the ward was not secure; (7) I also received evidence during the investigation that when Mr Davies’s personal belongings were collected following his death, these included a crushed metal can likely to have been used for narcotic use; (8) The inquest heard evidence that the fence of Laurel Ward garden was approximately 3100 mm in height having been increased in 2015. (9) The inquest was provided with two photographs of the fence taken on the morning of the third day of inquest being 8/10/20 that showed a wooden panelled fence with a metal mesh/wire upper level behind a paved pathway with a shrubbery filled with green foliage and plants; (10) The photographs showed that some of the shrubbery plants were almost as high as the wooden part of the fence and very dense to the extent the fence could not be seen behind them and nor could the ground beneath due to ground level foliage; (11) I heard evidence at the conclusion of the inquest in the absence of the Jury that the shrubbery was not considered to be dense enough by the head of security to conceal any items and that after an incidents of absconding a anti climb review was undertaken; (12) My concern is that it is not sufficient to carry out a search of the area after a patient has absconded. The current planting arrangements based on the most recent photographs, do appear to provide ample ground coverage for ANY item to be concealed including drugs, drug paraphernalia, weapons, items that could be used as weapons and items in connection with absconding. (13) There was no evidence that the garden was searched on a regular basis, patients were not observed in the garden unless their level of observation included eyesight observations, and there was no CCTV covering the garden area. (14) My view is that circumstances of the current planting arrangements in the shrubbery present a risk of deaths which will continue to exist. This also extends to a risk of injury to staff on Laurel Ward and other patients. ”

    Source location

    Lee William Davies · Prevention of Future Deaths report
    Page 2 · 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 garden foliage is considered sufficient because it balances concealment risk and reduces access to the fence.

    Verbatim wording from the response

    “Following our review on the 2nd November, we are satisfied that the garden is maintained in such a way that it is therapeutic to service users and balances the risk of being able to conceal objects as any objects hidden by service user’s would have to be brought through the ward first. This review found that the presence of the foliage impedes service user’s access to the fence thus reducing the ability to scale it.”

    Source location

    2020-0261-Response-from-Midlands-Partnership-NHS-Foundation-Trust_Redacted.pdf
    Page 2 · response
    Published 31 December 2020

    Open published response

  5. Brighton and Hove

    AI-generated summary

    Bethany Tengquist · 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

    Bethany Tengquist hanged herself on 29 December 2018 after two telephone charging cables had been removed from her room but her dressing gown cord remained available. The report raises concerns that room checks and the removal of dangerous items were incomplete and flawed, and that staff may not have been properly trained.

    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

    Incomplete and flawed checks and removal of dangerous items from patient rooms

    Wider context from the report

    “During the course of the Pre-Inquest reviews it has become apparent that vulnerable patients are continuing to self-harm. The checks which are made and the removal of items which are considered dangerous to patients is clearly incomplete and flawed. The example with regard to Bethany Tengquist concerns the fact that on the 29th December 2018 when she hanged herself – a short time before she was found, two telephone charging cables were removed from her room and yet her dressing gown cord was left available for her to use to hang herself. Clearly the system in place to carry out these room checks is unsatisfactory and/or staff are not properly trained to do them. Please tell me precisely how you are going to put this right. ”

    Source location

    Bethany Tengquist · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. South Wales Central

    AI-generated summary

    Deidre Harvey · 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

    Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.

    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

    Lack of effective tracking of items taken from and returned to patients

    Wider context from the report

    “Secretary of State for Health 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Minister for Health, Welsh Assembly Government 1. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 2. The inquest heard that an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months, with staff having to “manage” the risk. The Coroner is concerned that there should be an expedited process for rectifying obvious ligature points on Mental Health Units Chief Executive – Cwm Taf University Health Board 1. The inquest heard of the Pod system on the Mental Health Unit in which items of danger to patients were deposited (and then possibly returned to the patient). There was no evidence of any effective system to identify who had what item, and when. The Coroner is concerned that there should be an effective system to check on what is taken from a patient and then later returned to a patient. 2. The inquest heard that patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the unit or may not even know they are there. In this inquest the consultant psychiatrist treating Deidre was not aware of the potentially toxic effects of the drug for her lupus. The Coroner is concerned that outside consultants should have a more active input into the care of the mental health patient on a Mental Health Unit, in order that their expertise and knowledge is available to the treating consultant psychiatrist. 3. The inquest heard that there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk for a patient admitted on the Mental Health Unit, with the result that responsibility for a risk assessment might not be recognised. The Coroner is concerned that there should be proper management and dissemination of risk management policies to frontline staff to avoid any confusion Editor British National Formulary Hydroxychloroquine 1. The expert evidence given was that Hydroxychloroquine (HCQ) is not contra-indicated in Appendix 1 of the BNF for anti-epileptic drugs. The manufacturer’s leaflet however does contain a caution against using HCQ alongside anti-epileptic drugs. It is acknowledged that the text of the BNF does indicate that HCQ should not be used in case of neurological disorders (including epilepsy) but this does not catch patients like Dee who was on an anti-epileptic drug (Lamotrigine) for her bipolar condition but was not epileptic. The coroner is concerned that the BNF might not fully describe the risk to patients taking Lamotrigine (or drugs of similar class or composition) alongside Hydroxychloroquine. Royal College of Psychiatrists Hydroxychloroquine 1. The evidence in the inquest showed that the psychiatrists treating Deidre were largely unaware of the potential side-effects of Hydroxychloroquine which Deidre was received for her Systemic Lupus Erythematosus. These include mental changes and psychosis. The Coroner is concerned that consultants treating other mental patients who are receiving this drug should be aware of these side-effects, and is concerned that there should be proper liaison with the consultant dermatologist over its toxic and potential mental health side-effects. In General the Coroner is concerned that the psychiatrists treating a patient in a Mental Health Unit should have the benefit of specialist advice from outside consultants who may be treating the patient for a physical condition British Association of Dermatologists Hydroxychloroquine 1. The expert evidence received in this inquest revealed that Hydroxychloroquine could build up to toxic levels even with normal dosage. ████████ of the Dept of Toxicology, Birmingham Heartlands Hospital reported that there is a clear cross-over between apparently toxic concentrations and apparently therapeutic concentrations. Deidre at the time of her death had a concentration of approximately 25 mg/L and fatalities at 7.5 mg/L. The Coroner is concerned that this drug should not be prescribed to a patient suffering from Lupus (which in itself is not life-threatening) without an awareness that toxic levels can build up even at the recommended dose. The Coroner is concerned that the dermatologist prescribing this drug should liaise with other consultants treating the patient for other conditions (in Deidre’s case for her mental health problems) so that specialist knowledge about the toxic effects of this drug can be shared. CEO Alerts NHS Hydroxychloroquine 1. The evidence in this inquest is that Deidre (who was a detained patient under Section 3 MHA) was being given a drug for a physical condition (Lupus) which can build up to toxic levels even at normal doses. The inquest heard that there is no routine checking of Hydroxychloroquine levels at clinical level, even though ████████ said he thought that clinical monitoring of this drug might be important. The Coroner is concerned that there may be other dependent persons suffering from lupus (or other conditions for which Hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of Hydroxychloroquine in their system unbeknown to their carers. ”

    Source location

    Deidre Harvey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Implement a safe system for recording items stored in and removed from patient PODS.

    Verbatim wording from the response

    “A safe system of work has been implemented to ensure that staff are recording items stored in and taken from patient PODS.”

    Source location

    2018-0266-Response-by-University-Health-Board
    Page 1 · response
    Published 20 July 2017

    Open published response

    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

    Responsibility for NHS matters in Wales is devolved and falls outside the scope of this England policy response.

    Verbatim wording from the response

    “Your report directs two matters of concern to the Secretary of State for Health which I will address in turn giving the policy position in England. You will appreciate that responsibility for the NHS in Wales is a devolved matter.”

    Source location

    2018-0266-Response-by-Department-of-Health-Social-Care
    Page 1 · response
    Published 20 July 2017

    Open published response

  7. South and East Cumbria

    AI-generated summary

    James Edward Boylan · 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

    James Edward Boylan, who had a history of anxiety and was admitted to a mental health unit, died by hanging using a phone charger cord and a bathroom rail. The concerns included removable bathroom rails creating a ligature point, insufficient searching of patients’ property, access to a cord, and failures in recognising and communicating the escalation of his condition.

    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

    Insufficient searching of patients’ property for concealed dangerous items

    Wider context from the report

    “(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion, and so again Mr Boylan had access to something which he could use to hang himself with. ”

    Source location

    James Edward Boylan · Prevention of Future Deaths report
    Page 2 · 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

    The Cumbria Partnership NHS Foundation Trust is responsible for addressing the four concerns relating to events on the Dova Unit.

    Verbatim wording from the response

    “I note that you have also addressed your report to the Cumbria Partnership NHS Foundation Trust and I would expect them to properly address the four concerns relating to events during Mr Boylan’s time on the Dova Unit at Furness General Hospital.”

    Source location

    2014-0253-Response-by-Department-of-Health
    Page 2 · response
    Published 6 June 2014

    Open published response

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