PFD report

Miles Glynn Naylor · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 10 Jan 2020•West Yorkshire (West)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear 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

Source document

Full report text

This is the full text from the original published report.

Open published report

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
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

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

    Stated by Bradford District Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.
  2. Action

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

    Stated by Bradford District Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 February 2020.
  3. Action

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

    Stated by Bradford District Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.

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

  1. Position

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

    Stated by Bradford District Care NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

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

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 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

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

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

    Stated by Bradford District Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.
  2. 2

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

    Stated by Bradford District Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 February 2020.
  3. 3

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

    Stated by Bradford District Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.
  4. 4

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

    Stated by Bradford District Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.

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

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

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
Back to top

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