Recipient

Safety Matters (Legal) Limited

First report 1 Jul 2022•Latest report 1 Jul 2022

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Company limited by guarantee. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Safety Matters (Legal) Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

1 Jul2022
Manchester City
Concerns raised14
1. Failure of serious incident investigations to obtain relevant information and make additional enquiries
2. Patient access to ligatures and other objects usable for self-harm or against others
3. Failure to prevent repeated access to and use of ligatures
1. Lack of appropriate contemporaneous clinical record keeping by support workers
2. Lack of appropriate clinical supervision of nurses and support workers
3. Lack of a clear clinical assessment and plan for repeated self-harm attempts
4. Lack of an auditing process for care plans and risk assessments
5. Inadequate communication of self-harm information, observation completion and records between nurses in charge and support workers
6. Failure to complete patient observations as directed
7. Failure to complete and update care plans and risk assessments after MDT meetings or ward rounds
8. Failure to keep accurate records of patient observations
9. Lack of appropriate contemporaneous clinical record keeping by nurses
10. Lack of regular training in automated external defibrillator use
11. Lack of regular training on applicable policies and procedures
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.
AI-generated summary

Shona Christine Michaela Campbell · 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

Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.

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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of serious incident investigations to obtain relevant information and make additional enquiries
Wider context from the report
“10. The opportunities missed by the Safety Matters Ltd Serious Incident Investigation report process to obtain other relevant information and/or make additional enquiries which could affect the overall findings and recommendations for learning, improving practice and procedures as well as patient safety. This will also help improve other investigations that the authors of the report may do in the future. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Patient access to ligatures and other objects usable for self-harm or against others
Wider context from the report
“5. That patients could obtain ligatures and other objects that could be used for self-harm/suicide and/or used against other patients and staff members. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to prevent repeated access to and use of ligatures
Wider context from the report
“9. The lack of a clear clinical assessment and plan to investigate and deal with repeated self-harm attempts that could result in serious injury or death as well as the repeated access to and use of ligatures. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of appropriate contemporaneous clinical record keeping by support workers
Wider context from the report
“2. The lack of appropriate contemporaneous clinical record keeping by the Support Workers. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of appropriate clinical supervision of nurses and support workers
Wider context from the report
“8. The need for appropriate clinical supervision of nurses and support workers. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of a clear clinical assessment and plan for repeated self-harm attempts
Wider context from the report
“9. The lack of a clear clinical assessment and plan to investigate and deal with repeated self-harm attempts that could result in serious injury or death as well as the repeated access to and use of ligatures. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of an auditing process for care plans and risk assessments
Wider context from the report
“7. Completion and updating of all care plans including risk assessments after MDT meetings/Ward rounds as well as an auditing process. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication of self-harm information, observation completion and records between nurses in charge and support workers
Wider context from the report
“4. There was inadequate communication between the Nurse in Charge and Support Workers about important clinical information relating to self-harm as well as completion of observations and the records. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete patient observations as directed
Wider context from the report
“3. Patient observations were not being completed as directed and accurate records were not being kept. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete and update care plans and risk assessments after MDT meetings or ward rounds
Wider context from the report
“7. Completion and updating of all care plans including risk assessments after MDT meetings/Ward rounds as well as an auditing process. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to keep accurate records of patient observations
Wider context from the report
“3. Patient observations were not being completed as directed and accurate records were not being kept. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of appropriate contemporaneous clinical record keeping by nurses
Wider context from the report
“1. The lack of appropriate contemporaneous clinical record keeping by the nurse in charge as well as other nurses. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of regular training in automated external defibrillator use
Wider context from the report
“6. Regular training on all the applicable policies/procedures and use of an Automated Electronic Defibrillator. ”
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 Safety Matters (Legal) Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of regular training on applicable policies and procedures
Wider context from the report
“6. Regular training on all the applicable policies/procedures and use of an Automated Electronic Defibrillator. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised14

Failure of serious incident investigations to obtain relevant information and make additional enquiries

Patient access to ligatures and other objects usable for self-harm or against others

Failure to prevent repeated access to and use of ligatures

Lack of appropriate contemporaneous clinical record keeping by support workers

Lack of appropriate clinical supervision of nurses and support workers

Lack of a clear clinical assessment and plan for repeated self-harm attempts

Lack of an auditing process for care plans and risk assessments

Inadequate communication of self-harm information, observation completion and records between nurses in charge and support workers

Failure to complete patient observations as directed

Failure to complete and update care plans and risk assessments after MDT meetings or ward rounds

Failure to keep accurate records of patient observations

Lack of appropriate contemporaneous clinical record keeping by nurses

Lack of regular training in automated external defibrillator use

Lack of regular training on applicable policies and procedures