PFD report

Brian Goodman · Prevention of Future Deaths report

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Issued 17 Apr 2019•Inner 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.

View original report
Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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.

Concerns raised1

  1. Failure to eliminate ligature points posed by door closing mechanisms
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.1

  1. Action

    Work with property services to consider alternative fire-door closures in higher-suicide-risk schemes.

    Stated by The Riverside Group LimitedStated plannedThe respondent said that this action was planned when they made their response on 14 June 2019.

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

  1. Position

    Full anti-ligature provision across supported housing schemes cannot be guaranteed because fire-risk responsibilities must also be balanced.

    Stated by The Riverside Group LimitedUnable 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

Failure to eliminate ligature points posed by door closing mechanisms

Wider context from the report

“(2) Whilst Mr Goodman’s wardrobe rail was recognised to be an obvious ligature point and removed in May 2018, no steps were taken to change the door closing mechanism in his room which could also be used as a ligature point. (3) The same type of door closing mechanisms continue to be used in One Support properties. ”

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

Work with property services to consider alternative fire-door closures in higher-suicide-risk schemes.

Verbatim wording from the response

“• The door closing mechanisms referred to continue to be widely used in care and support services, not only run by One Housing. These are in place on fire doors. We will work with our property services division to look at alternative closures for fire doors in our schemes where there is a higher risk of suicide. These are not in a position to be able to guarantee that all our supported housing schemes will be fully anti-ligature as we have to balance this with our responsibility as a landlord in terms of fire risk.”

Source location

2019-0129-Response-by-One-Housing
Page 1 · response
Published 14 June 2019

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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

Full anti-ligature provision across supported housing schemes cannot be guaranteed because fire-risk responsibilities must also be balanced.

Verbatim wording from the response

“• The door closing mechanisms referred to continue to be widely used in care and support services, not only run by One Housing. These are in place on fire doors. We will work with our property services division to look at alternative closures for fire doors in our schemes where there is a higher risk of suicide. These are not in a position to be able to guarantee that all our supported housing schemes will be fully anti-ligature as we have to balance this with our responsibility as a landlord in terms of fire risk.”

Source location

2019-0129-Response-by-One-Housing
Page 1 · response
Published 14 June 2019

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.1

  1. 1

    Implement Applied Suicide Intervention Skills Training for staff across the organisation’s services.

    Stated by The Riverside Group LimitedStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019.

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 Applied Suicide Intervention Skills Training for staff across the organisation’s services.

Verbatim wording from the response

“• We currently run Suicide Awareness Training every 2 months for our staff. We are now putting in place running Applied Suicide Intervention Skills Training (ASIST) which is more advanced for a group of staff across our range of services.”

Source location

2019-0129-Response-by-One-Housing
Page 1 · response
Published 14 June 2019

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