Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of clear guidance on ligature incidents and self-harm risk
The earlier warning
Francesca Whyatt · 21 Aug 2017 · Karon Monaghan, London Inner (West)
“There is no clear guidance or criteria on the circumstances in which a ligature incident/s (or other self-harming incident/s) should be treated as an SUI such as to trigger an SUI investigation.”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 6 Sept 2019 · Shannon Quinn · Zafar Siddique · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Francesca Whyatt · 21 Aug 2017
“There is no clear guidance or criteria on the circumstances in which a ligature incident/s (or other self-harming incident/s) should be treated as an SUI such as to trigger an SUI investigation.”
Later · Shannon Quinn · 6 Sept 2019
“There was an escalating risk of use of ligatures and incidents of self-harm and little if any measures were introduced to try and provide a ligature free environment.”
What happened next
No web check of the stated actions has been published for this chain.