21 May 2014 Mark Darren Bartholomew · Prevention of Future Deaths report Manchester North
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Concerns raised 6 Failure to retain and make essential observation documentation available View source Failure of communication in coordinating family notification of death View source Failure of observation records to specify and capture who and when observations are completed View source Lack of detailed guidance on access to and type of ligature cutters View source Failure to provide essential patient and emergency-equipment information to external emergency services View source Failure to ensure immediately available ligature cutters in the secure clinic View source See 3 more concerns
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AI-generated summary
Mark Darren Bartholomew · 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
Mark Darren Bartholomew, who had a longstanding diagnosis of paranoid schizophrenia and was detained in hospital after transfer from prison, died by hanging on 25 July 2013 during a routine observation check. Concerns included an inadequate response to emergency services, the absence of the ligature cutter needed to release him promptly, and insufficient detail in observation records.
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. The report was sent to Jackson Lees Group Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to retain and make essential observation documentation available
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jackson Lees Group Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of communication in coordinating family notification of death
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jackson Lees Group Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of observation records to specify and capture who and when observations are completed
Wider context from the report “3. The Trust has a documented Observation Policy. Whilst the Policy requires records to be contemporaneously recorded, it does not specify how this is to be achieved . The actual observation sheet apparently in use at present indicates a poor level of detail as to who and when it is completed and in its present format would not withstand a rigorous audit .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jackson Lees Group Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed guidance on access to and type of ligature cutters
Wider context from the report “2. Ligature Cutters – The Consultant Forensic Pathologist, ████████ confirmed in evidence that time was very much of the essence. Specifically he stated ‘following application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes’
The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a bag attached to a hook on the wall in the secure clinic. The ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking, the absence had gone unnoticed. The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later. To the credit of the Trust, the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift.
Although alerted to Department of Health guidance from 2007, I can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in a pouch by Custody Sergeants within the Custody Office of designated Police Stations. The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement, the ligature would have been released within a matter of seconds rather than minutes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jackson Lees Group Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide essential patient and emergency-equipment information to external emergency services
Wider context from the report “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate . More particularly:-
• The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available.
• Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest.
• Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Jackson Lees Group Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure immediately available ligature cutters in the secure clinic
Wider context from the report “2. Ligature Cutters – The Consultant Forensic Pathologist, ████████ confirmed in evidence that time was very much of the essence. Specifically he stated ‘following application, pressure through the ligature, and unconsciousness may ensue within a few seconds with death within minutes’
The registered nurse in charge of the ward ran to the scene, but then had to retrieve the ligature cutters which should have been in the front pocket of a bag attached to a hook on the wall in the secure clinic . The ligature cutter had in fact been used following an incident a week earlier and had not been returned. Despite a regime of daily checking, the absence had gone unnoticed. The Nurse-in-Charge immediately retrieved the ward scissors from a locked drawer and the ligature was subsequently released albeit approximately 2 minutes later . To the credit of the Trust, the practice of daily checks for equipment has now been superseded by a check at the commencement of each shift.
Although alerted to Department of Health guidance from 2007, I can find no detailed guidance with regard to either access to or the type of ligature cutter to be used. Evidence was given to the Inquest by the Senior Investigating Officer of Greater Manchester Police who made reference to the use of an implement carried in a pouch by Custody Sergeants within the Custody Office of designated Police Stations. The Senior Investigating Officer was not aware of any untoward incident arising from the use of such an implement which according to the Officer cannot be used to inflict harm on a third person. If the Security Nurse who had initially attended had been carrying such an implement, the ligature would have been released within a matter of seconds rather than minutes.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations