PFD report

Ms Natasha Ford · Prevention of Future Deaths report

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Issued 13 Feb 2017•Black Country

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
2

Named on the report

Responses found
1

Of 2 recipients

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 maintain restrictions on plastic bags
    Part of recurring concern: Inadequate control of access to means of self-harm
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.2

  1. Action

    Restrict plastic bags across all hospitals under a blanket policy and maintain the ban.

    Stated by CAS Behavioural HealthStated completedThe respondent said that this action was complete when they made their response on 8 June 2018.
  2. Action

    Review the reducing restrictive practice policy using relevant Care Quality Commission guidance.

    Stated by CAS Behavioural HealthStated completedThe respondent said that this action was complete when they made their response on 8 June 2018.

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

  1. Position

    The blanket ban on plastic bags in all hospitals fully addresses the concerns, so no additional responsive work is identified.

    Stated by CAS Behavioural HealthExisting 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

Failure to maintain restrictions on plastic bags

Wider context from the report

“1. Evidence emerged during the inquest that there was a previous incident on the 27 July 2017 where she had placed a plastic bag over her head. Plastic bags were then restricted for a short time and then blanket restrictions were removed. This was due to a change in policy in procedure and in line with reducing restrictive practice policy and procedure. ”

Is this part of a recurring concern?

Yes — Inadequate control of access to means of self-harm.

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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

Restrict plastic bags across all hospitals under a blanket policy and maintain the ban.

Verbatim wording from the response

“Following the review of the relevant Policy, CAS Behavioural Health has introduced a blanket policy restricting the use of plastic bags in all their hospitals. This Policy was put in place in October 2017 and a copy is enclosed. As a result of this policy, no patients in any CAS hospitals are permitted to have access to plastic bags in hospital. This applies to all patients, notwithstanding the risk assessments undertaken in respect of each patient.”

Source location

2018-0052-Response-by-CAS
Page 2 · response
Published 8 June 2018

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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

Review the reducing restrictive practice policy using relevant Care Quality Commission guidance.

Verbatim wording from the response

“After the incident on 19 September 2017 and the subsequent sad death of Ms Ford, CAS Behavioural Health reviewed the approach taken in its Policy and Procedure on Reducing Restrictive Practice. In doing so, it has taken into account guidance published by the Care Quality Commission entitled “Brief Guide: The Use of “Blanket Restrictions” in Mental Health Wards”. Whilst the CQC guidance adopts the approach of the Mental Health Act Code of Practice, it does acknowledge that all mental health inpatient services have some prohibited or “contraband” items and that certain prohibited items, including plastic bags, should not be challenged by the CQC for breaking the approach to blanket restrictions in the Code of Practice.”

Source location

2018-0052-Response-by-CAS
Page 1 · response
Published 8 June 2018

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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

The blanket ban on plastic bags in all hospitals fully addresses the concerns, so no additional responsive work is identified.

Verbatim wording from the response

“Following the review of the relevant Policy, CAS Behavioural Health has introduced a blanket policy restricting the use of plastic bags in all their hospitals. This Policy was put in place in October 2017 and a copy is enclosed. As a result of this policy, no patients in any CAS hospitals are permitted to have access to plastic bags in hospital. This applies to all patients, notwithstanding the risk assessments undertaken in respect of each patient.”

Source location

2018-0052-Response-by-CAS
Page 2 · response
Published 8 June 2018

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