PFD report

Michaela Jade Christoforou · Prevention of Future Deaths report

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Issued 25 May 2014•North London

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

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.

Report evidence summary

Concerns raised1

  1. Failure of all unit staff to carry ligature cutters
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.3

  1. Action

    Have clinical staff carry ligature cutters during a six-month trial beginning in September 2014.

    Stated by Care UK Mental Health Partnerships LimitedStated plannedThe respondent said that this action was planned when they made their response on 25 May 2014.
  2. Action

    Develop a protocol covering the carrying and management of ligature cutters.

    Stated by Care UK Mental Health Partnerships LimitedStated in progressThe respondent said that this action was in progress when they made their response on 25 May 2014.
  3. Action

    Locate nine sets of ligature cutters throughout Rhodes Farm, with three on each floor.

    Stated by Care UK Mental Health Partnerships LimitedStated completedThe respondent said that this action was complete when they made their response on 25 May 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The stated ligature-cutter actions are considered sufficient to meet the concerns, so no additional safety work is proposed.

    Stated by Care UK Mental Health Partnerships LimitedNo action considered necessaryThe respondent said that 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

Failure of all unit staff to carry ligature cutters

Wider context from the report

“That all staff at the unit did not carry with them a ligature cutter. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Have clinical staff carry ligature cutters during a six-month trial beginning in September 2014.

Verbatim wording from the response

“2. Clinical staff will carry ligature cutters for a six month trial period commencing in September 2014.”

Source location

2014-0285-Response
Page 1 · response
Published 25 May 2014

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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 a protocol covering the carrying and management of ligature cutters.

Verbatim wording from the response

“3. A protocol/procedure is being developed that covers all aspects concerned with the carrying and management of ligature cutters.”

Source location

2014-0285-Response
Page 1 · response
Published 25 May 2014

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

Locate nine sets of ligature cutters throughout Rhodes Farm, with three on each floor.

Verbatim wording from the response

“1. There are now nine sets of ligature cutters located throughout Rhodes Farm (three on each floor).”

Source location

2014-0285-Response
Page 1 · response
Published 25 May 2014

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

The stated ligature-cutter actions are considered sufficient to meet the concerns, so no additional safety work is proposed.

Verbatim wording from the response

“I trust that the above action is sufficient to meet the concerns that you have expressed. If there is any further information you require please do not hesitate to contact me.”

Source location

2014-0285-Response
Page 1 · response
Published 25 May 2014

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.2

  1. 1

    Liaise with NHS England regarding ligature-cutter safety arrangements.

    Stated by Care UK Mental Health Partnerships LimitedStated in progressThe respondent said that this action was in progress when they made their response on 25 May 2014.
  2. 2

    Work with a specialist knife company to develop a discreet, tamper-proof knife.

    Stated by Care UK Mental Health Partnerships LimitedStated in progressThe respondent said that this action was in progress when they made their response on 25 May 2014.

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

Liaise with NHS England regarding ligature-cutter safety arrangements.

Verbatim wording from the response

“5. Care UK is liaising with NHS England, our customer, regarding this issue.”

Source location

2014-0285-Response
Page 1 · response
Published 25 May 2014

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

Work with a specialist knife company to develop a discreet, tamper-proof knife.

Verbatim wording from the response

“4. Care UK is working with a specialist knife company with the intention of developing a knife that is both discrete and tamper proof.”

Source location

2014-0285-Response
Page 1 · response
Published 25 May 2014

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

Official responses located
1/1

Data last updated 7 September 2026