Miles Glynn Naylor · Prevention of Future Deaths report

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Issued 10 Jan 2020•West Yorkshire (West)

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Doors permitting access to the hinge pin side
  2. Failure to adequately manage ligature risks from personal items

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. Bradford District Care NHS Foundation Trust

    Conduct detailed daily safety checks across all inpatient areas, including admissions, leave, observations, risk assessments, incidents and care plans.

  2. Bradford District Care NHS Foundation Trust

    Review ligature assessments and new ligature incidents through the monthly Ligature Environmental Risk and Safety group to identify learning.

  3. Bradford District Care NHS Foundation Trust

    Continue reviewing processes for managing patients’ personal belongings and associated ligature risks.

  4. Bradford District Care NHS Foundation Trust

    Install high-specification full-door alarms in designated bedrooms on high-risk wards, including Oakburn Ward.

  5. Bradford District Care NHS Foundation Trust

    Develop and submit a business case for environmental improvements and high-specification full-door alarms on identified bedrooms across eight high-risk wards.

  6. Bradford District Care NHS Foundation Trust

    Implement standard multidisciplinary ligature-risk assessments using the Manchester Audit Tool, with documented mitigations, staff access, induction materials, visual aids and training.

  7. Bradford District Care NHS Foundation Trust

    Review the blanket-restrictions policy and procedure for mental-health inpatient services.

  8. Bradford District Care NHS Foundation Trust

    Provide each inpatient ward with a dedicated Consultant Psychiatrist to support daily multidisciplinary review of care and risks.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Bradford District Care NHS Foundation Trust

    Replacing all inpatient doors is constrained by significant capital expense, so improvements are being delivered through the ongoing capital programme in stages.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. Bradford District Care NHS Foundation Trust

    Potential ligature items are not routinely removed; individual risk assessment, care planning and increased observations are used where clear clinical risk exists.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Doors permitting access to the hinge pin side

Wider context from the report

“(1) The jury formally recorded their opinion as part of the conclusion to the inquest that the Bradford District Care NHS Foundation Trust should carry out a review of its management of its ligature risks from personal items. (2) During the course of evidence, questions were raised about the design of the doors on Oakdale ward, and whether access to the hinge pin side of the doors might be prevented by the use of covers similar to the finger guards in use in children’s nurseries and similar premises). ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to adequately manage ligature risks from personal items

Wider context from the report

“(1) The jury formally recorded their opinion as part of the conclusion to the inquest that the Bradford District Care NHS Foundation Trust should carry out a review of its management of its ligature risks from personal items. (2) During the course of evidence, questions were raised about the design of the doors on Oakdale ward, and whether access to the hinge pin side of the doors might be prevented by the use of covers similar to the finger guards in use in children’s nurseries and similar premises). ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Conduct detailed daily safety checks across all inpatient areas, including admissions, leave, observations, risk assessments, incidents and care plans.

Verbatim wording from the response

“In addition to the above which specifically relates to ligature risks, the Trust has made significant improvements on all inpatient wards over the last year. The Trust introduced detailed daily checks in all inpatient areas. These checks include considering admissions, leave, observations, clinical risk assessments, incidents and care plans, maintaining the Trust’s focus on the key question of: “Are we Safe Today?”.”

Source location

2020-0005-Response-from-Bradford-District-NHS-Trust
Page 2 · response
Published 8 February 2020

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

Review ligature assessments and new ligature incidents through the monthly Ligature Environmental Risk and Safety group to identify learning.

Verbatim wording from the response

“All ligature risk assessments are reviewed and monitored by the monthly Ligature Environmental Risk and Safety group. The group also assesses all new ligature incidents that are with or without an anchor point to consider any learning requirements.”

Source location

2020-0005-Response-from-Bradford-District-NHS-Trust
Page 2 · response
Published 8 February 2020

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

Continue reviewing processes for managing patients’ personal belongings and associated ligature risks.

Verbatim wording from the response

“The Trust continues to review the processes which are in place regarding personal belongings. In doing this the Trust recognise there is a balance to be struck of ensuring a patient’s safety against taking steps that may be seen as negatively impacting on a patient’s improvement in their mental health.”

Source location

2020-0005-Response-from-Bradford-District-NHS-Trust
Page 1 · response
Published 8 February 2020

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

Install high-specification full-door alarms in designated bedrooms on high-risk wards, including Oakburn Ward.

Verbatim wording from the response

“The Trust acknowledges the concerns raised during the inquest and a need to review the design of the doors in our in-patient wards. In June 2019, a business case was developed and submitted to the Trust Board which included environmental improvements and the introduction of high specification full door alarms on identified bedrooms on 8 high risk wards, including Oakburn. Work has begun installing these doors in designated rooms on high risk wards as part of phase 1 development and is due to be completed by April 2020.”

Source location

2020-0005-Response-from-Bradford-District-NHS-Trust
Page 2 · response
Published 8 February 2020

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

Develop and submit a business case for environmental improvements and high-specification full-door alarms on identified bedrooms across eight high-risk wards.

Verbatim wording from the response

“The Trust acknowledges the concerns raised during the inquest and a need to review the design of the doors in our in-patient wards. In June 2019, a business case was developed and submitted to the Trust Board which included environmental improvements and the introduction of high specification full door alarms on identified bedrooms on 8 high risk wards, including Oakburn. Work has begun installing these doors in designated rooms on high risk wards as part of phase 1 development and is due to be completed by April 2020.”

Source location

2020-0005-Response-from-Bradford-District-NHS-Trust
Page 2 · response
Published 8 February 2020

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

Implement standard multidisciplinary ligature-risk assessments using the Manchester Audit Tool, with documented mitigations, staff access, induction materials, visual aids and training.

Verbatim wording from the response

“In April 2019 the Trust undertook a review of how ligature risks are assessed and managed in our in-patient areas. A new approach has been introduced (Manchester Audit Tool) which grades ligature risk based on four factors. The four factors are:”

Source location

2020-0005-Response-from-Bradford-District-NHS-Trust
Page 2 · response
Published 8 February 2020

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

Review the blanket-restrictions policy and procedure for mental-health inpatient services.

Verbatim wording from the response

“The Trust has reviewed the policy for Blanket Restrictions: Oversight, Use & Reporting Policy & Procedure for Mental Health Inpatient Services. It is important that wherever possible the least restrictive option will be used to maximise patient experience and independence as this is seen as an important part in the mental health of a patient being improved.”

Source location

2020-0005-Response-from-Bradford-District-NHS-Trust
Page 1 · response
Published 8 February 2020

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

Provide each inpatient ward with a dedicated Consultant Psychiatrist to support daily multidisciplinary review of care and risks.

Verbatim wording from the response

“In July 2019 the Trust introduced a model where each in-patient ward has a dedicated Consultant Psychiatrist, this has provided the team with a greater opportunity for”

Source location

2020-0005-Response-from-Bradford-District-NHS-Trust
Page 1 · response
Published 8 February 2020

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

Replacing all inpatient doors is constrained by significant capital expense, so improvements are being delivered through the ongoing capital programme in stages.

Verbatim wording from the response

“The Trust acknowledges the concerns raised during the inquest and a need to review the design of the doors in our in-patient wards. In June 2019, a business case was developed and submitted to the Trust Board which included environmental improvements and the introduction of high specification full door alarms on identified bedrooms on 8 high risk wards, including Oakburn. Work has begun installing these doors in designated rooms on high risk wards as part of phase 1 development and is due to be completed by April 2020.”

Source location

2020-0005-Response-from-Bradford-District-NHS-Trust
Page 2 · response
Published 8 February 2020

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

Potential ligature items are not routinely removed; individual risk assessment, care planning and increased observations are used where clear clinical risk exists.

Verbatim wording from the response

“The Trust continues to review the processes which are in place regarding personal belongings. In doing this the Trust recognise there is a balance to be struck of ensuring a patient’s safety against taking steps that may be seen as negatively impacting on a patient’s improvement in their mental health.”

Source location

2020-0005-Response-from-Bradford-District-NHS-Trust
Page 1 · response
Published 8 February 2020

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026