Louise Crane

Parliamentary Under Secretary of State 
for  Patient Safety, Women’s Health and Mental 
Health  

39 Victoria Street  
London  
SW1H 0EU  
020 7210 4850  

Mr Ian Potter  
St Pancras Coroner’s Court, 
Camley Street,  
London, 
N1C 4PP   

                                                                                            15 September 2025  

Dear Mr Potter,  

Thank you for your Regulation 28 report to prevent future deaths dated 23 June 2025 
about the death of Louise Elizabeth Amy Crane. I am replying as the Minister for Mental 
Health.       

Firstly, I would like to say how saddened I was to read of the circumstances of Louise’s 
death,  and  I  offer  my  sincere  condolences  to  her  family  and  loved  ones.  The 
circumstances  your  report  describes  are  concerning  and  I  am  grateful  to  you  for 
bringing these matters to my attention.   

I have noted the contents of your report, and the matter of concern raised regarding a 
lack  of  a  nationwide  policy  or  approach  to  anti-ligature  measures  in  mental  health 
settings.  In  preparing  this  response,  departmental  officials  have  liaised  with  NHS 
England who will also be responding to you directly.   

The Care Quality Commission have issued guidance for providers about reducing harm 
from ligatures in mental health wards. This can be found at www.cqc.org.uk/guidance-
providers/mhforum-ligature-guidance.  

I  understand  your  concerns  around  the  need  for  a  more  consistent  approach  to 
antiligature measures. I am assured that in recent years NHS England has issued a 
National Patient Safety Alert and other guidance to providers regarding ligature point 
risk assessments and tools.    

The  Patient  Safety Alert  set  out  actions  to  change  and  update  existing  policies  and 
procedures,  including  ensuring  that  ligature  risk  assessments  were  up  to  date  and 
reflective of latest guidance. We can share, in confidence, more details on the alert with 
the Coroner on request.  

More  broadly,  NHS  England’s  mental  health,  learning  disability  and  autism  inpatient 
quality transformation programme will support cultural change and a new model of care 
for  the  future  across  all  NHS-funded  mental  health  inpatient  settings.  Local  health 

  
  
 
   
         
  
   
 systems have now published their 3-year plans for localising and realigning inpatient 
care in line with this vision.  

We are also committed to delivering the Suicide Prevention Strategy for England, which 
aims to reduce suicide rates and address the risk factors contributing to suicide, as well 
as improving support for those who have self-harmed or are bereaved by suicide. The 
strategy  highlights  the  need  to  provide  tailored,  targeted  support  to  priority  groups, 
including those at higher risk. At a national level, this includes people in contact with 
mental health services.  

Personalised  approaches  to  suicide  prevention  are  also  important,  and  locally  I 
understand that North London NHS Trust is a member of the Zero Suicide Alliance and 
has developed a structured Suicide Prevention Strategy of its own.   

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

                                                     All good wishes,

Mr Ian Potter 
HM Assistant Coroner  
Inner North London 
St Pancras Coroner’s Court  
Camley Street 
London 
N1C 4PP 

Dear Mr Potter, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

21 August 2025 

Re: Regulation 28 Report to Prevent Future Deaths – Louise Elizabeth Amy 
Crane who died on 19 September 2024.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  23 
June  2025  concerning  the  death  of  Louise  Elizabeth  Amy  Crane  on  19  September 
2024. In advance of responding to the specific concerns raised in your Report, I would 
like to express my deep condolences to Louise’s family and loved ones. NHS England 
is keen to assure the family and yourself that the concerns raised about Louise’s care 
have been listened to and reflected upon.   

Your report raises the concern that there is a lack of a nationwide policy / approach to 
anti-ligature measures in mental health settings. My response has been informed by 
NHS England’s regional London and national Mental Health Teams.  

In  recent  years,  NHS  England  has  acted  upon  the  concerns  raised  above  and  has 
adopted a comprehensive, nationwide approach to anti-ligature measures. In March 
2020, NHS England and Improvement (now NHS England) issued a National Patient 
Safety Alert specifically addressing ligature and ligature point risk assessment tools 
and  policies,  sent  via  the  Central  Alerting  System  to  all  providers  –  with  mandated 
executive  oversight,  and  compliance  monitored  by  the  Care  Quality  Commission 
(CQC). North London NHS Foundation Trust (NLFT) has confirmed to NHS England 
that it became compliant with this alert on 1 June 2020.  

The Department of Health & Social Care’s Health Building Note 03-01 (Adult Acute 
Mental Health) and NHS England’s Health Building Note 03-02 (CAMHS) require all 
fittings – doors, furniture, lighting, sanitary ware – to be ligature-resistant with sloped 
or tamper-proof fixtures.  

CQC guidance from November 2023 on this issue recommends a blend of therapeutic, 
home-like environments with embedded safety including collapsible rails, concealed 
fixings,  anti-ligature  fixtures,  well  placed  sightlines  and  mirrors/outdoor  visibility. 
Additionally, all mental health inpatient locations must regularly assess and mitigate 
ligature  risks,  removing  anchor  points  where  possible.  Any  failure  may  count  as  a 
‘Never Event’.  

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 NHS England also advocates the importance of not relying on environmental solutions 
alone as a means of reducing the risk of harm. We recognise that the quality of the 
therapeutic relationship between staff and patients remains the strongest predictor of 
good clinical outcomes for people receiving inpatient mental health care.  

A  personalised  approached  to  suicide  prevention  is  essential,  ensuring  that  any 
environmental  adaptations  and  interventions  are  part  of  a  comprehensive  and  co-
produced care and treatment plan.  

A qualified, well-trained workforce (including mental health and general nurses) is vital, 
underpinned by competence frameworks for self-harm prevention and active ligature 
awareness training, including drills and response preparedness.  

NHS England has been supporting mental health services to deliver a personalised 
approach to the risk of harm to self through the introduction of national guidance and 
a national improvement programme for all NHS commissioned inpatient services; the 
National Culture of Care Standards and Programme. As part of our National Culture 
of  Care  programme,  we  have  commissioned  the  National  Confidential  Inquiry  into 
Suicide and Safety  in  Mental  Health  (NCISH)  to  work  with  providers  to  move away 
from risk stratification tools to personalised safety management. This is to ensure that 
services are aware of and following the most up to date evidence base for responding 
to and managing the risk of harm to self.  

The North London Mental Health Partnership has conducted a Patient Safety Incident 
Response Report for this incident and made the following recommendations: 

1.  All  Registered  Mental  Health  Nurses  and  shift  coordinators  to  continue  to 

implement the shift coordination guidance and handover standards.  

2.  To  ensure  staff  are  aware  of  compliance  with  the  requirements  during 

prescribed general observation and engagement policy. 

3.  Share  and  reiterate  the  escalation  protocol  to  all  staff  with  emphasis  on  the 

expected actions of each staff member.  

4.  Escalate the concern to the Associate Director of Nursing for physical health 

for consideration and review of emergency bags.  

NHS  England  will  continue  to  engage  with  local  teams  for  updates  on  these 
recommendations.  NLFT  advise  that  that  they  are  compliant  with  anti-ligature 
guidance  and  that  all  anti-ligature  fixtures  and  fittings  are  procured  from  approved 
suppliers, who are required to design their solutions in accordance with the guidance. 
They are also a member of the Zero Suicide Alliance and has developed a structured 
Suicide Prevention Strategy.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Louise, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

 
 
 
 
 
 
 
 Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director  
NHS England