Recurring concern

Failure to provide clinicians with complete prisoner information for safe assessment

First to latest report 5 May 2016 — 20 Dec 2024

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
4

What this concern includes

Includes failures in prison or custody arrangements that prevent clinicians from accessing, consolidating or reviewing complete safety-relevant information about a prisoner when needed for clinical assessment, including fragmented custodial records and inaccessible healthcare records during prisoner transfers.

What is not included
  • Excludes general clinical-record incompleteness or unavailability outside prison or custody settings.
  • Excludes failures to act on complete prisoner information after clinicians can reliably access and review it.
  • Excludes generic prison communication, documentation or IT deficiencies unless they directly prevent clinicians from accessing complete prisoner information for assessment.
  • Excludes broader prison risk-information, NOMIS or custody-to-prison-healthcare transfer concerns when the assertion is confined to those separately named systems or interfaces.

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Haydar Jefferies · 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

    Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.

    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 a composite 24-hour information document for clinicians reviewing CSU prisoners

    Wider context from the report

    “3. There is no composite document for clinicians to review to see all relevant information recorded by custodial staff about a CSU prisoner for the proceeding 24 hour period. ”

    Source location

    Haydar Jefferies · Prevention of Future Deaths report
    Page 5 · 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

    Hold morning multidisciplinary briefings for Care and Separation Unit staff, healthcare and mental health colleagues to share documented concerns before healthcare rounds.

    Verbatim wording from the response

    “You have raised a concern that there is no composite document for clinicians to review which contains relevant information recorded by prison staff about prisoners in the Care and Separation Unit (CSU). There is now a morning briefing for CSU staff, attended by healthcare and the mental health team which takes place prior to healthcare’s rounds, when all CSU prisoners are reviewed. Documented concerns are shared each morning at the briefing. Collaborative working and communication between prison staff, healthcare and mental health colleagues has improved through multi-disciplinary meetings which support the sharing of relevant risk information and actions to help prisoners identified as at risk of suicide and self-harm.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 27 December 2024

    Open published response

  2. Exeter and Greater Devon

    AI-generated summary

    Samuel Thomas Jordan · 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

    Samuel Thomas Jordan, aged 25, was imprisoned at HMP Exeter and was found hanging in a single-occupancy cell after an incident with his cell mate on 26 March 2020. The inquest concluded that he died by suicide while suffering from mental illness. The jury identified the lack of access to records from a temporary GP practice, including information about his mental health and current medication, as a contributory factor in his death.

    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 access to temporary GP practice records through the NHS Spine

    Wider context from the report

    “During the four months before his imprisonment, Samuel Jordan had been receiving treatment for severe anxiety while registered as a temporary patient with a medical practice in Launceston, Cornwall. Samuel had come to Cornwall from his home in Whitchurch, Hampshire where he was registered with another GP practice. On entering HMP Exeter, the prison Healthcare obtained a summary of Samuel’s GP records from Hampshire via the NHS spine. The records from the Launceston practice were not sent to the prison since the NHS spine only operates to transmit records from the permanent GP practice and not a practice consulted on a temporary basis. As a result, Exeter Prison Healthcare was unaware of Samuel’s mental health issues immediately before coming to Prison and was unaware of a current medication prescription lack of which the jury found contributed to Samuel’s death. The inquest heard that prisoners coming to prison frequently were nomadic and frequently had registered with GP practices on a temporary basis and records from such practices not coming to the notice of prison healthcare as such records are not accessible through the NHS spine. Lack of access through the NHS Spine to the records of the practice where Samuel was registered as a temporary patient was, the jury found, a contributory factor in Samuel’s death. ”

    Source location

    Samuel Thomas Jordan · 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

    Improve information sharing between the detained estate and wider NHS by enabling access to Spine-connected services, including PDS, eRS and GP2GP Transfer.

    Verbatim wording from the response

    “NHS England has been working to improve the processes around information sharing between the detained estate and the wider NHS. This includes enabling access to a range of Spine connected services including Personal Demographics Service (PDS), Electronic Referral Service (eRS) and GP2GP Transfer. As a result of these changes, some patients transferring into the detained estate will have a GP2GP transfer whereby the patient’s electronic GP record is sent from their previously registered GP Practice to the new GP Practice that they register with within the detained estate. Further details are available via the links below:”

    Source location

    Response from NHS England
    Page 1 · response
    Published 12 February 2024

    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

    Provide GP2GP electronic transfer of community GP records into and out of healthcare systems across the adult male and children’s secure estate.

    Verbatim wording from the response

    “Patients within the adult male and children and young people’s secure estate (adult male prisons, young offender institutions and secure training centres) have the opportunity to register with healthcare at their place of detention. This means a GP2GP transfer can now take place, electronically transferring the patient’s community GP record into the clinical system in place across the secure estate, and then back out to the community when the patient registers with a GP on release. The ability for a GP2GP transfer of a community GP record into the prison healthcare system was rolled out to the male prison estate between February and July 2022, so this option was not available at the time of Samuel’s death, but I hope provides assurance around current practice.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 12 February 2024

    Open published response

    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

    Existing temporary-registration and detained-estate information-sharing processes are considered sufficient, subject to consent and direct contact where necessary.

    Verbatim wording from the response

    “In summary, there are existing processes around the management of temporary resident patients. These support GP Practices to take over the management of patients by registering them permanently at the new practice where this is appropriate. Where care continues to be provided on a temporary basis, there are existing information flows to send information about the care episode back to the patients’ registered GP Practice via the GMS3 form, where the patient has consented, and for this information to then be integrated into the patients’ registered GP record so that”

    Source location

    Response from NHS England
    Page 2 · response
    Published 12 February 2024

    Open published response

  3. Manchester North

    AI-generated summary

    Mr Bradley Fraser Brown · 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

    Mr Bradley Fraser Brown was a serving prisoner who died in prison on 14 August 2017 after being found suspended by a ligature from a cell light fitting. The report identifies concerns about his late weekend transfer, limited access to healthcare records and assessments, reduced weekend healthcare provision, and the absence of national guidance on late prison transfers.

    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 provide clinicians with access to transferring prisoners’ full healthcare records

    Wider context from the report

    “1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted. There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe. The same concern applies, in principle, to public/bank holidays. There are different levels of healthcare at the weekends as compared to weekdays. This gives cause for concern given the inherent susceptibilities with which prisoners frequently present. Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known). By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities) timely risk assessment is critical in the prevention of self-harm leading to death. Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database. There is no national guidance in relation to late transfers/cut-off points etc. 2. Commissioning of Mental Health/Healthcare Services: As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action. These issues are not unique to the Prison involved in Mr Brown’s case. ”

    Source location

    Mr Bradley Fraser Brown · 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

    Issue HMP Haverigg staff a reminder to confirm transfers with Healthcare so medical records are promptly reassigned and available on arrival.

    Verbatim wording from the response

    “Prior to any transfer there is a requirement for Healthcare staff at the sending establishment to assess each prisoner to ensure that any health concerns are recorded and communicated to the receiving prison and to confirm that the prisoner is medically fit to be moved. A notice has been issued to all staff at HMP Haverigg, which was the transferring prison in Mr Brown’s case, reminding them to confirm to Healthcare staff any transfer, so that medical records are reassigned promptly in order that they are immediately available when the prisoner arrives at the new establishment.”

    Source location

    2018-0374-Response-by-HM-Prison-and-Probation-Service
    Page 2 · response
    Published 10 May 2019

    Open published response

  4. Leicester City and South Leicestershire

    AI-generated summary

    Ahmedreza Fathi · 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

    Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.

    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 ready access to relevant risk-assessment and case-management information across healthcare and prison records

    Wider context from the report

    “1. Healthcare complex case planning was not robust or effective, and was not reviewed or updated in response to subsequent events. Multi-disciplinary team meetings, if they took place, were not formalised and there was no ready access to all relevant information relating to risk assessment and case management through either System1 (the medical record storage and case management system) held by healthcare, or the ACCT document held by the prison. ”

    Source location

    Ahmedreza Fathi · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026