Recurring concern

Failure to verify staff receipt and understanding of safety policies

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First reported 6 Jan 2014•Latest report 29 Jun 2026

Definition

What this concern includes

Includes only assertions that directly instantiate the manually reviewed condition ‘Failure to verify staff receipt and understanding of safety policies’ and satisfy this evidence boundary: Two distinct reports directly support absence of checks that staff received, read and understood critical internal policies. Excludes the assertion about broadly advertising a drug-misuse policy, which does not establish staff receipt or comprehension and may concern a different audience.

Not included

  • Excludes deficiencies in a specifically named clinical, operational or hazard-control system when that system provides the more specific supported boundary.
  • Excludes failures to follow a current and clearly communicated policy when policy governance and implementation controls themselves are reliable.
  • Excludes generic organisational governance, training or communication deficiencies without a direct internal safety-policy management connection.
  • Excludes substantive clinical or operational hazards where no deficiency in the associated internal safety-policy process is identified.
  • Excludes manifestations outside the manually reviewed boundary: Two distinct reports directly support absence of checks that staff received, read and understood critical internal policies. Excludes the assertion about broadly advertising a drug-misuse policy, which does not establish staff receipt or comprehension and may concern a different audience.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
8

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

A2Dominion Housing Group Limited1
College of Policing1
Dyfed-Powys Police1
GeoAmey PECS Limited1
Greater Manchester Police1
HM Prison and Probation Service1
HM Prison & Probation Service1
Mandeville Grange Nursing Home1
Medacs Healthcare Limited1
South Western Ambulance Service NHS Foundation Trust1
Wiltshire Police1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Lancashire and Blackburn with Darwen

    AI-generated summary

    Johnpaul Digweed · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Johnpaul Digweed died by suicide by hanging in his cell at HMP Garth between 17:06 on 12 April 2024 and 11:31 on 13 April 2024. The concerns included failures to open an ACCT process after incidents of self-harm, inadequate assurance about staff training and information-sharing, and welfare observations not being carried out in accordance with prison procedures, including when observation panels were obscured.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure critical welfare-check instructions are received and understood by affected staff

    Wider context from the report

    “2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not aware of the instructions which were issued by email. As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff. In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths ”

    Source location

    Johnpaul Digweed · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Introduce daily mandatory knowledge-check sessions for operational and non-operational staff, recording attendance, completion and understanding to reinforce ACCT and welfare-check practice.

    Verbatim wording from the response

    “The prison have begun introducing daily knowledge check sessions for both operational and non-operational staff, and additional staffing resources are being secured to support the delivery of this initiative. Attendance and completion of the knowledge check sessions will be required and formally recorded, with staff providing written confirmation they have attended a session, and that the content is understood. A training log will be maintained by the prison’s Learning and Capabilities Team to monitor attendance and completion rates.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 3 September 2026

    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

    Make hard copies of current staff notices available on every residential wing for reference and use during staff briefings.

    Verbatim wording from the response

    “To ensure that staff notices are accessible to all operational staff, hard copies of current notices will be made available on each residential wing so they can be referenced by staff at all times and used by managers and supervising officers during staff briefings.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 3 September 2026

    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

    Add read-and-understood acknowledgements to staff-notice emails and create a response database to identify non-responders for follow-up.

    Verbatim wording from the response

    “In addition, all emails containing staff notices will include an acknowledgement function requiring recipients to confirm they have read and understood the content of the notice. This acknowledgement will be used to create a database to record which members of staff have responded, and aid the identification of those who have not thus enabling appropriate follow-up action where necessary.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 3 September 2026

    Open published response

  2. Buckinghamshire

    AI-generated summary

    Sheila Ann Nicholls · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sheila Ann Nicholls died after choking on food during respite care at Mandeville Grange Nursing Home on 19 November 2023. Her family had warned the nursing home about her swallowing difficulties, but important information was not recorded or shared, and she was given food that was unsuitable or insufficiently prepared. The report raised concerns about policy management, emergency response training, and the investigation and learning from adverse incidents.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to verify staff circulation and understanding of internal policies

    Wider context from the report

    “1. Mandeville Grange Nursing Home considered several existing policies required improvement, and so they were rewritten following Sheila’s death, some using template documents from a health and safety outsourcing website. However, some rewritten policies still included clauses that remained irrelevant to the nursing home (e.g. regarding ‘oral suction devices’), and several policies remained undated and unsigned, and it was therefore far from clear which policies had been ratified and were in force; with poor version control overall. It was not always clear when policies had been written or by whom; when and by whom they had been reviewed; and if and when they were circulated, and to which staff members. It was also unclear from the evidence of staff members, whether policies were properly embedded and/or understood, and/or had been read by all staff, as there were no checklists confirming staff had read and understood the policies. At the time of the inquest, staff training on new policies was said to be ongoing, and planned staff competency assessments had yet to be arranged. Deficient management of internal policies creates a risk of death to future residents where there is an inability to verify and record that all policies: (a) are relevant to Mandeville Grange in the first instance; (b) have been ratified and are in force; (c) have been reviewed as required; and (d) have been circulated to all relevant staff, with confirmation of those policies having been read and understood. ”

    Source location

    Sheila Ann Nicholls · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Rewrite, tailor, implement and monitor the full suite of 85 internal policies through controlled review, staff circulation, acknowledgments, training and compliance checks.

    Verbatim wording from the response

    “Having considered this further, we took the decision to engage C4Q to re-write all of our policies to ensure they are (i) relevant (ii) specific and (iii) that we remain up to date with current legislation. ████████ (our new Nominated Individual) is managing this process.”

    Source location

    Response from Mandeville Grange Nursing Home
    Page 1 · response
    Published 13 January 2025

    Open published response

  3. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Kesia Blaine Waller · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kesia Blaine Waller, aged 17, was found suspended from a ligature at her residential housing unit on 20 January 2020 and died in hospital on 25 January 2020 after life-sustaining treatment was withdrawn following a catastrophic hypoxic brain injury. The concerns included inadequate staff training and equipment to respond to a young person suspended from a ligature, and ineffective communication and implementation of policies and training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure that staff read, understand and can apply key policies and training

    Wider context from the report

    “At Kesia’s Inquest I heard that her place of residence, City Road in Winchester, was a residential housing unit for vulnerable young people aged 16-21. The facility meets a housing need only for the young persons placed there. It was found on the evidence that A2 Dominion employees did not have sufficient training or tools (i.e. implements) in place to prepare staff for the situation that they faced on the 20th January 2020 when they found Kesia hanging in her room, nor could they carry out any physical actions to assist her (i.e. cut her down). There appeared to be no prior appreciation of the risk(s) of self-harm, overdose or attempted suicide of residents, and so on discovering Kesia suspended in her room, the staff were inadequately prepared on multiple levels. (a) I heard that whilst there has been additional training for the staff on areas of risk such as self-harm, overdose and/or suicide, there have been no physical changes in terms of the provision of tools and implements that staff could use should they be confronted by a young person in distress and/or in need of life-saving attention. It appears to me that without multi-factorial changes there remains a real and significant risk that staff at the residential units will remain unable to take any immediate and potentially life-saving action. The only tools and equipment that remain supplied is a standard home-style first aid kit which is entirely ineffective if a young person has suspended themselves from a ligature. (b) Although additional training and courses have been added to both the induction training and on-going professional development of staff within the residential units similar to City Road, I remain concerned by the way in which key policies and training are communicated and implemented as this does not appear to have changed. It was clear from the evidence that updates to policies are emailed to employees with a request that the employee responds to the email to confirm receipt. This proved to be wholly ineffective as what appeared to be expected by the company was that the employee would read, digest and understand the policy, and confirm when he/she had done so. The employee on duty on the 20th January 2020 was clearly unfamiliar with the appropriate policies and had only confirmed that he had received the email (which appeared to be all that was required) and not that he had actually read, digested and understood the appropriate policy/policies; how to apply them in practice and what was reasonably expected of him. Although enhanced risk training is now place, it appears to me that without any enhanced diligence to ensure that policies are actually read and understood by those working face-to-face with the vulnerable young adults then the overall effectiveness of risk training and identification is severely flawed. ”

    Source location

    Kesia Blaine Waller · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Add policies and procedures to team-meeting agendas for discussion, minute-taking and auditing of staff understanding and application.

    Verbatim wording from the response

    “also been added to the agenda of all team meetings. Any changes and amendments are discussed at team meetings to check understanding and how these will be applied in practice, this is also minuted and audited.”

    Source location

    2021-0187-Response-from-A2Dominion_Published
    Page 3 · response
    Published 4 June 2021

    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

    Upgrade HR software to improve digital records of training and policy reading and automate the policy-change confirmation process.

    Verbatim wording from the response

    “As an organisation, we are also upgrading our HR software systems, which includes improved digital records of training undertaken and policies and procedures read. This will enhance the ‘purple ribbon’ process set out above by automating it. This is due to be implemented by 2022/23.”

    Source location

    2021-0187-Response-from-A2Dominion_Published
    Page 3 · response
    Published 4 June 2021

    Open published response

  4. Wiltshire and Swindon

    AI-generated summary

    Eugeniusz Niedziolko · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Eugeniusz Niedziolko, who was heavily intoxicated and vulnerable, was left alone in an unheated public lavatory after police and ambulance staff decided he did not require hospital care. He was found unresponsive several hours later and died from acute alcohol toxicity and hypothermia. The report identifies concerns about failures to follow protocols, assess and communicate critical information, provide appropriate training, and consider available options for keeping him safe and monitored.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to verify receipt and understanding of critical policies and procedures

    Wider context from the report

    “d) COMMUNICATION OF POLICY AND PROCEDURE I am aware that following this incident the 2009 Agreement between the Hospitals, Ambulance Trust and Wiltshire Police as regards the assessment of people who appear to be drunk and need of medical assessment was circulated. A newer agreement was also subsequently entered into in June 2017. I am surprised and concerned that even now front-line officers, who gave evidence, were unaware of either of these 2 agreements. It would appear that important communications are being sent out but that there is no effective system in place to check that the important information is received and more importantly is understood. This also applies to e-learning which is capable of abuse if the same questions are asked at the end of modules. Interestingly, I heard from Consultant Paramedic, ████████ that in relation to their e-learning systems random questions are asked at the end of e-learning modules in an attempt to overcome the risk of abuse. I fully appreciate that front line officers are under huge amounts of pressure with increasing workloads and less resources but my fear is that there will be a repeat of this incident and other issues arising that may lead to a death occurring through the lack of effective communication of policies and procedures which, at the end of the day, are designed to guide front line personnel and ultimately protect them. With busy workloads, an expectation that these documents will be read is unrealistic and arguably idealistic. ”

    Source location

    Eugeniusz Niedziolko · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Billy Paul Thomas Salton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of staff knowledge of MEDACS policies and protocols

    Wider context from the report

    “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy. 2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is. 3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record. 4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted. 5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters. 6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate. 7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen. 1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy). 2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody. 3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked. 4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded. 1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody. 2. Staff should be reminded that all cell checks should be accurately documented. 3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY. ”

    Source location

    Billy Paul Thomas Salton · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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

    Require new healthcare staff to complete three-day clinical shadowing and sign that they received guidance on locating and using policies.

    Verbatim wording from the response

    “I agree that it is important that all staff know where to look to seek guidance and where the policies are to refer to. I would like to reassure you that before they start work alone, all new healthcare staff complete a 3 day shadowing period with an experienced clinician. During this 3 day period they are made aware of the content of the Medacs policies and procedures and how these can be located whilst on duty and they are now required to sign to say they have had this information. All policies and procedures are located in every custody suite in both hard copies in a file and on the desktops of the medical room computers. Every time a policy is reviewed or revised a communication is disseminated from the Head of Clinical Services via all lead clinicians by e-mail and the relevant policy is updated in the folder and the desktop.”

    Source location

    2014-0002-Response-by-Medacs
    Page 1 · response
    Published 6 January 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

    Maintain hard-copy and electronic policy access in every custody suite and disseminate revised policies through lead clinicians.

    Verbatim wording from the response

    “I agree that it is important that all staff know where to look to seek guidance and where the policies are to refer to. I would like to reassure you that before they start work alone, all new healthcare staff complete a 3 day shadowing period with an experienced clinician. During this 3 day period they are made aware of the content of the Medacs policies and procedures and how these can be located whilst on duty and they are now required to sign to say they have had this information. All policies and procedures are located in every custody suite in both hard copies in a file and on the desktops of the medical room computers. Every time a policy is reviewed or revised a communication is disseminated from the Head of Clinical Services via all lead clinicians by e-mail and the relevant policy is updated in the folder and the desktop.”

    Source location

    2014-0002-Response-by-Medacs
    Page 1 · response
    Published 6 January 2014

    Open published response
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Data last updated 7 September 2026