6 Jun 2014 James Edward Boylan · Prevention of Future Deaths report South and East Cumbria
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Concerns raised 6 Failure to remove removable bathroom rails except when required View source Failure to disseminate GRIST assessment information to staff View source Failure to rigorously complete GRIST assessments View source Failure to keep ligature-capable cords centrally so that patients cannot directly access them View source Failure to maintain an overall view of escalating patient risk View source Insufficient searching of patients’ property for concealed dangerous items View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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.
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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. The report was sent to NHS Cumbria Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to remove removable bathroom rails except when required
Wider context from the report “(1) Removable rails in a bathroom designed for use by disabled people had been left inadvertently ever since the unit was opened. No one seemed to be aware that these rails were removable and certainly nobody had removed them. This provided a ligature point which would otherwise have been absent in a unit which was specifically designed to have as few ligature points as possible. The Coroner is concerned that this same situation may apply in other units and people need to be aware that ligature points in mental health units should be limited as far as humanly possible, and specifically that removable rails should be removed except when actually required .
” 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 NHS Cumbria Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate GRIST assessment information to staff
Wider context from the report “(4) GRIST: Assessments should be more rigorously completed and disseminated so that staff are aware of their contents , because in relation to Mr Boylan this did not appear to have taken place so that an opportunity for communication of information was lost .
” 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 NHS Cumbria Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to rigorously complete GRIST assessments
Wider context from the report “(4) GRIST: Assessments should be more rigorously completed and disseminated so that staff are aware of their contents, because in relation to Mr Boylan this did not appear to have taken place so that an opportunity for communication of information was lost.
” 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 NHS Cumbria Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to keep ligature-capable cords centrally so that patients cannot directly access them
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 .
” 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 NHS Cumbria Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an overall view of escalating patient risk
Wider context from the report “(3) There were numerous events over the 7 days during which Mr Boylan was present on the ward for someone with an overall view to realise that his condition was escalating and that he might become a danger to himself, but because no one person had such knowledge of all the facts, this was not recognised . It is suggested that communication be improved in any way in which the Trust thinks possible.
” 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 NHS Cumbria Clinical Commissioning Group; that does not assign responsibility.
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.
” Open source report
3 Feb 2014 Amanda Jane Vickers · Prevention of Future Deaths report North and West Cumbria
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Concerns raised 1 Insufficient availability of crisis home beds 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
Amanda Jane Vickers · 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
Amanda Jane Vickers had a long history of depression and suicidal ideation and was found hanging at her home on 22 August 2013. She was awaiting admission to 81 Lowther Street Crisis Home, but no place was immediately available; the report raised concern that this six-bedded unit was the only facility of its type in the county and suggested reviewing the availability of beds.
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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. The report was sent to NHS Cumbria Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of crisis home beds
Wider context from the report “This lady died whilst awaiting a place at 81 Lowther Street Crisis Home. She had been there before and found it therapeutic. No space was available, and no date when one might arise was known. She died whilst waiting for admission. The evidence was that this 6-bedded unit is the only one of its type in the whole county . It is understood that the CCG is responsible for commissioning such facilities. On the balance of probability an admission would have made a difference in this case. A review of the facilities available is suggested with a view to the provision of a greater number of beds for patients such as the deceased.
” 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 Develop improved mental health pathways, including the configuration of community and bed-based crisis services across the county.
Verbatim wording from the response “The independent review of mental health is due to report back at the end of May 2014. This will inform the future provision of mental health and wellbeing strategy from 2014. This is with a view to developing a new Mental Health Strategy for our County and will have a significant impact on public/patient consultation. Both of these elements will have a significant impact in informing the development of improved mental health pathways which will include configuration of community and bed-based crisis services across the county.” Source location 2014-0052-Response-by-Cumbria-Clinical-Commissioning-Group
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations