Recurring concern

Unreliable NOMIS safety-critical information access and visibility

First to latest report 4 Oct 2016 — 8 Apr 2026

Reports that mention this concern
8
Times this concern has been raised
10
Stated actions linked to this concern
9

What this concern includes

Includes failures of NOMIS or directly integrated NOMIS/DPS controls that impair authorised staff access to, visibility of, interpretation of, or effective use of safety-critical prisoner information, including healthcare access, risk assessments, alerts, prior ACCT information and records needed for multidisciplinary oversight.

What is not included
  • Excludes generic prison or healthcare communication, training, staffing or record-keeping deficiencies where NOMIS is not the deficient system.
  • Excludes failures of non-NOMIS systems, such as SystmOne, unless the report explicitly identifies their integration with or effect on NOMIS safety-critical information access.
  • Excludes failures to act on complete and clearly presented NOMIS information when the NOMIS access and visibility controls operated reliably.
  • Excludes the broader prison-healthcare interoperability concern when the assertion does not identify a NOMIS information-access, visibility or system-function deficiency.

Reports and published responses 8 reports

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

  1. Nottinghamshire

    AI-generated summary

    Jonathan Mark Thornton · 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

    Jonathan Mark Thornton died at Queens Medical Centre in Nottingham on 12 July 2024 after sustaining a severe head injury in an attack by a fellow inmate at HMP Nottingham on 28 June 2024. The report raises concerns about inadequate information sharing between community forensic, prison healthcare and operational prison staff, and about the categorisation and visibility of risk alerts on NOMIS/DPS, creating a risk of future deaths.

    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

    Unavailability of NOMIS/DPS alerts to Healthcare Staff

    Wider context from the report

    “3. Categorisation and visibility of alerts on NOMIS/DPS I heard that NOMIS/DPS has preset categorisation of alerts. The categories are limited and broad. This means that ‘violent’ prisoners – regardless of the particulars of that violence – will all be categorised together. This case illustrated quite clearly that there are certain categories of offender who require better particularisation of their risk. In this case, that was those prisoners with a history of assaulting fellow inmates. I was told that unless a prisoner has assaulted a cellmate, which would be subject to its own assessment, the operational prison staff would not necessarily know whether their violent behaviour was aimed at prison officers, other prisoners or simply a genera violent behaviour linked to their offending. Clearly, each of these categories gives rise to a particular risk within a prison setting. I am concerned that if more detailed categorisation and/or information is not provided to the operational prison staff within NOMIS/DPS alerts, with clear visibility, this gives rise to a risk of future death. I understand that this is controlled nationally. Moreover, I understand that the Healthcare Staff are unable to view NOMIS/DPS alerts. This gives rise to the same risk. ”

    Source location

    Jonathan Mark Thornton · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficiently detailed and visible NOMIS/DPS risk-alert categorisation for operational prison staff

    Wider context from the report

    “3. Categorisation and visibility of alerts on NOMIS/DPS I heard that NOMIS/DPS has preset categorisation of alerts. The categories are limited and broad. This means that ‘violent’ prisoners – regardless of the particulars of that violence – will all be categorised together. This case illustrated quite clearly that there are certain categories of offender who require better particularisation of their risk. In this case, that was those prisoners with a history of assaulting fellow inmates. I was told that unless a prisoner has assaulted a cellmate, which would be subject to its own assessment, the operational prison staff would not necessarily know whether their violent behaviour was aimed at prison officers, other prisoners or simply a genera violent behaviour linked to their offending. Clearly, each of these categories gives rise to a particular risk within a prison setting. I am concerned that if more detailed categorisation and/or information is not provided to the operational prison staff within NOMIS/DPS alerts, with clear visibility, this gives rise to a risk of future death. I understand that this is controlled nationally. Moreover, I understand that the Healthcare Staff are unable to view NOMIS/DPS alerts. This gives rise to the same risk. ”

    Source location

    Jonathan Mark Thornton · 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

    Review NOMIS/DPS alerts later in 2026 with safety, digital and policy experts to improve their consistency, clarity, visibility and usability.

    Verbatim wording from the response

    “The current system already contains more granularity than a single “violent” categorisation. However, we recognise that improvements are needed in consistency, clarity and visibility. A dedicated programme of work is scheduled to review alerts later this calendar year, subject to prioritisation, and will be undertaken in collaboration with safety experts, digital and policy colleagues. This work will strengthen both the quality and usability of alerts in order to reduce risk and support safer decision-making. We will ensure that the findings from this review inform future enhancements and address the matters you have raised.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 13 April 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

    Ensure findings from the NOMIS/DPS alerts review inform future enhancements addressing the identified concerns.

    Verbatim wording from the response

    “The current system already contains more granularity than a single “violent” categorisation. However, we recognise that improvements are needed in consistency, clarity and visibility. A dedicated programme of work is scheduled to review alerts later this calendar year, subject to prioritisation, and will be undertaken in collaboration with safety experts, digital and policy colleagues. This work will strengthen both the quality and usability of alerts in order to reduce risk and support safer decision-making. We will ensure that the findings from this review inform future enhancements and address the matters you have raised.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 13 April 2026

    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

    The Ministry of Justice is responsible for NOMIS/DPS alerts, so it will lead the response to concerns about their categorisation and visibility.

    Verbatim wording from the response

    “Your Report acknowledges that the Ministry of Justice (MoJ) is responsible for the NOMIS/DPS and states that you have sent a copy of this report to the Ministry of Justice for their response. We shall therefore defer to the MoJ in responding to your concerns about alerts within NOMIS/DPS.”

    Source location

    Response from Northampton Healthcare NHS Foundation Trust
    Page 3 · response
    Published 13 April 2026

    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

    NOMIS/DPS already provides more granularity than a single “violent” categorisation, although improvements in consistency, clarity and visibility are needed.

    Verbatim wording from the response

    “The current system already contains more granularity than a single “violent” categorisation. However, we recognise that improvements are needed in consistency, clarity and visibility. A dedicated programme of work is scheduled to review alerts later this calendar year, subject to prioritisation, and will be undertaken in collaboration with safety experts, digital and policy colleagues. This work will strengthen both the quality and usability of alerts in order to reduce risk and support safer decision-making. We will ensure that the findings from this review inform future enhancements and address the matters you have raised.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 13 April 2026

    Open published response

  2. Inner West London

    AI-generated summary

    Patryk Gladysz · 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

    Patryk Gladysz, who had schizophrenia and was detained at HMP Wandsworth, was found in his cell with a ligature around his neck on 5 January 2024 and died at St George’s Hospital. The inquest concluded that he had hung himself with a ligature, with his intentions unknown. Concerns included delays and staffing pressures affecting mental health assessments, inadequate communication between prison and healthcare staff, gaps in knowledge of his history and risks, and shortcomings in prison monitoring 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

    Inconsistent understanding among prison and healthcare staff of healthcare access to NOMIS

    Wider context from the report

    “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals. ”

    Source location

    Patryk Gladysz · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Deactivation of healthcare staff NOMIS accounts due to lack of use

    Wider context from the report

    “(4) Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals. ”

    Source location

    Patryk Gladysz · 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

    Improve healthcare staff understanding of how to use the NOMIS system.

    Verbatim wording from the response

    “You have also raised concerns around communication between prison and healthcare staff, including a lack of knowledge sharing and a lack of understanding about accessing the NOMIS system. I would agree that appropriate information sharing is essential to support the ongoing care provided to patients in prison settings. I understand that a number of fora have now been set up at HMP Wandsworth to facilitate the sharing of knowledge between prison and healthcare staff about prisoners of concern, including those with complex mental health needs, such as schizophrenia. Action has also been taken to improve understanding around the use of the NOMIS system by healthcare staff.”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 23 July 2025

    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 NOMIS training and support to the practice development nurse, new users and existing users requiring assistance.

    Verbatim wording from the response

    “All members of healthcare are expected to have an activated NOMIS account. Staff with deactivated accounts have been requested to be reinstated. There is no confirmed date for reactivation; however, confirmation has been received that the accounts of those still employed by the Trust have been reactivated. The practice development nurse (PDN) and team leader have been working with staff since the beginning of August, and it is anticipated that all staff will have access to NOMIS and be able to demonstrate this to their line manager before 15 October 2025. A record of this is being maintained and will continue to be monitored. Training and support on the use of NOMIS have been provided to the PDN and will be available to all new users and to existing users where support is required.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 23 July 2025

    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

    Reinstate and enable NOMIS access for healthcare staff, with access demonstrations recorded and monitored.

    Verbatim wording from the response

    “All members of healthcare are expected to have an activated NOMIS account. Staff with deactivated accounts have been requested to be reinstated. There is no confirmed date for reactivation; however, confirmation has been received that the accounts of those still employed by the Trust have been reactivated. The practice development nurse (PDN) and team leader have been working with staff since the beginning of August, and it is anticipated that all staff will have access to NOMIS and be able to demonstrate this to their line manager before 15 October 2025. A record of this is being maintained and will continue to be monitored. Training and support on the use of NOMIS have been provided to the PDN and will be available to all new users and to existing users where support is required.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 23 July 2025

    Open published response

  3. Dorset

    AI-generated summary

    Samuel Lewis Jones · 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 Lewis Jones died on 30 April 2021 after suspending himself by a ligature in his cell at HMP Portland. The concerns identified included the lack of systems and national guidance for recording and flagging significant dates, difficulties accessing key information in prison records, and insufficient national guidance on managing medication held in prisoners’ possession.

    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 of NOMIS information accessibility to support risk assessments

    Wider context from the report

    “iii. The accessibility of information recorded on NOMIS and the potential to miss key information which could impact on risk assessments. ”

    Source location

    Samuel Lewis Jones · Prevention of Future Deaths report
    Page 4 · 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

    Develop Digital Prison Services as the replacement case management system, including core functionality needed to cease using NOMIS.

    Verbatim wording from the response

    “Turning first to your concerns about key dates, as you know, NOMIS allows information to be shared throughout the system both within an establishment and nationally. We recognise that NOMIS, is no longer fit for purpose, and are currently developing a new case management system, Digital Prison Services (DPS). Whilst neither NOMIS nor DPS is currently able to record key dates, this is something that we will revisit as we continue to develop DPS. Our main focus for now, is to build the core functionality that is needed in DPS in order to enable us to cease the use of NOMIS.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 8 December 2023

    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

    Consider adding keyword searching to Digital Prison Services.

    Verbatim wording from the response

    “With regard to your third concern I have acknowledged above that NOMIS is not fit for purpose and explained that we are working on the development of DPS as a replacement. NOMIS does, however, provide the capacity for staff to search notes in various ways, including by type, subtype and date. The ability to search for key words is currently under consideration in the development of DPS, and we anticipate that this function will be available by 2025.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 8 December 2023

    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

    HMPPS is responsible for responding to concerns about national guidance and the accessibility of key information recorded on NOMIS.

    Verbatim wording from the response

    “It is my understanding that ████████, Director General for His Majesty’s Prison and Probation Service (HMPPS) is intending to write to you directly in response to the matters highlighted in concerns two and three.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 8 December 2023

    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

    Operational concerns should be addressed by HMPPS Director General of Operations, rather than by the Minister.

    Verbatim wording from the response

    “The concerns you have raised within your report are operational issues and it is therefore appropriate for ████████, DG Operations, HM Prison and Probation Service (HMPPS), to respond to them. I have seen the response from ████████ and I endorse the content of it, which sets out the action being taken by HMPPS to address your concerns.”

    Source location

    Response from Ministry of Justice
    Page 1 · response
    Published 8 December 2023

    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

    NOMIS and DPS currently lack key-date recording and keyword-search functions while DPS core development is prioritised; these enhancements are planned or under consideration.

    Verbatim wording from the response

    “Turning first to your concerns about key dates, as you know, NOMIS allows information to be shared throughout the system both within an establishment and nationally. We recognise that NOMIS, is no longer fit for purpose, and are currently developing a new case management system, Digital Prison Services (DPS). Whilst neither NOMIS nor DPS is currently able to record key dates, this is something that we will revisit as we continue to develop DPS. Our main focus for now, is to build the core functionality that is needed in DPS in order to enable us to cease the use of NOMIS.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 8 December 2023

    Open published response

  4. County Durham and Darlington

    AI-generated summary

    Michael Raymond SMITH · 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

    Michael Raymond SMITH entered HMP Durham on 10 July 2020, was transferred to SACU after being found to have packages concealed internally, and was discovered self-suspended on 11 July; he died in hospital on 13 July 2020. The principal concerns included the absence of medical and mental health assessments, inadequate staffing while he was subject to three-man unlock, delays in responding to the suspension, and weaknesses in SACU record keeping and multidisciplinary oversight.

    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

    Sparse NOMIS record keeping for SACU

    Wider context from the report

    “Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock. On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination. On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log, albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU, the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michael`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts ████████, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged lead him to SACU). ████████ is a highly potent ████████ which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the ████████ (which was never diagnosed), contributed to the Michael`s death. From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route). The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future. In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things: “There is clear management oversight of the SACU”. This is not what the evidence in the instance case showed. Rather, what it made clear was that: 1) the SACU staff log plus CCTV further demonstrated that officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing; 2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager); 3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing. You also stated: “I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”. This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is comprised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased. ”

    Source location

    Michael Raymond SMITH · 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

    Use a segregation weekly booklet consolidating recording sheets and documenting significant interactions for each prisoner.

    Verbatim wording from the response

    “The running of the SACU is further subject to daily checks undertaken by the Orderly Officer and Duty Governor, and the Governor undertakes a weekly in-charge check. Since Mr Smith’s death a new segregation weekly booklet has been introduced which amalgamates all previous segregation recording sheets together in one place. Each prisoner has their own booklet, which means an individual’s records are more readily accessible to staff. The booklet also contains a section to record any comments regarding significant interactions to ensure full records are maintained.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 4 January 2023

    Open published response

  5. Mid Kent and Medway

    AI-generated summary

    Lee Ryan Thrumble · 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

    Lee Ryan Thrumble was a serving prisoner who suspended himself by the neck in a cell at HMP Rochester on 17 April 2018 and died the following day. The inquest found that failures to meet his mental health needs and to respond adequately to deteriorating behaviour contributed to his death. The principal concern was that incomplete access by clinical staff to NOMIS information, linked to non-compulsory training, could prevent prisoners’ mental health needs and risks from being identified and managed appropriately.

    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 make NOMIS training compulsory for clinicians working with prisoners

    Wider context from the report

    “I am concerned that: (a) Lee died partly because of a lack of training which prevented staff from accessing and reviewing information. (b) NOMIS contains important information that can be of use to clinical staff when looking after prisoners. (c) Not all nurses can access NOMIS because it is not a compulsory part of their training. (d) The NOMIS training is already available, can be completed online and access to NOMIS can be gained within two days. (e) If the current situation continues there is a risk that prisoners may die as a result. This situation should be reviewed and consideration given to whether NOMIS training should be made compulsory for clinicians working within prisons in England and Wales. ”

    Source location

    Lee Ryan Thrumble · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  6. Inner North London

    AI-generated summary

    Tyrone GIVANS · 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

    Tyrone Givans, who was homeless, profoundly deaf and had a history of alcohol and drug use, was remanded into custody at HMP Pentonville after being arrested for assault. The jury concluded that he hanged himself in his cell, although his intentions were unclear. Principal concerns included Spice use in prison, duplicated prison and healthcare records that prevented access to earlier assessments, and inadequate recognition and support of his deafness and disabilities.

    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

    NOMIS failing to support necessary human intervention

    Wider context from the report

    “2. A past spelling error meant that there were two sets of NOMIS prison records for Mr Givans. This meant that there were then two sets of SystmOne healthcare records. This meant that staff did not have access to records of the assessments conducted before 8 February 2018. However, later consultations were not paused to make enquiries about this. The nature of the IT error was discovered after Mr Givans’ death, but at the time, staff did not seem to recognise the significance of having no earlier records. Evidence was given that NOMIS in its present form is unsatisfactory and does not lend itself to human intervention. The jury found that the IT system was unfit for purpose. ”

    Source location

    Tyrone GIVANS · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Bedfordshire and Luton

    AI-generated summary

    Mark Daniel VAGNONI · 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

    Mark Daniel Vagnoni, who had paranoid schizophrenia and was on remand at HM Prison Bedford, was found hanging in his cell on 11 July 2016 and died two days later. Concerns included the arrangements for risk assessment and observation after an ACCT was opened, the accessibility of information about previous ACCTs in NOMIS, and the lack of Wing Transfer documentation containing relevant risk 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

    NOMIS failing to alert staff to past ACCTs from the initial screen

    Wider context from the report

    “2. The jury expressed concerns that the NOMIS layout were not helpful to staff in that the staff needed to drill down beyond the initial screen to be alerted to past ACCTs ”

    Source location

    Mark Daniel VAGNONI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    NOMIS provides current alerts and accessible historical ACCT information, with staff training on locating prisoner information.

    Verbatim wording from the response

    “The current layout of NOMIS contains alerts on the home screen which allow staff to see important, current information on a prisoner, including whether they are on an open ACCT. Past information is easily accessible through the prisoner’s history section, and all prison staff who need to access NOMIS are trained in its use before being given access to the system. The course is designed to make staff aware of where and how the information about a prisoner is recorded.”

    Source location

    2017-0286-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 27 November 2017

    Open published response

  8. Central Hampshire

    AI-generated summary

    Haydn James Burton · 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

    Haydn James Burton, a prisoner at HMP Winchester, was found suspended from a ligature point in his cell on 15 July 2015 and died in hospital on 18 July 2015 from the delayed effects of ligature suspension. The concerns included inadequate implementation of ACCT plans and observations, uncertainty about confidentiality rules in the Prison Listener scheme, and limitations in recording and communicating information about closed ACCT plans.

    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

    Limitations of the NOMIS database in recording details of closed ACCT plans

    Wider context from the report

    “(3) The case highlighted the limitations of the NOMIS database in relation to recording details of closed ACCT plans meaning that prison staff are frequently unaware of important information about individuals gathered previously. The case showed that despite the national policy requiring Case Notes to be made of all ACCT plans this does not happen for all prisoners so that staff are ignorant even of the fact that there was a previous ACCT in place let alone the reason for it. The ACCT post-closure process should therefore be reviewed. I consider this is particularly relevant where an ACCT is closed and the prisoner is later released and then re-imprisoned or is transferred to a different establishment. ”

    Source location

    Haydn James Burton · 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

    Implement and embed a post-closure ACCT process requiring daily notification, plan circulation, interview updates, core-record filing and NOMS recording of ACCT openings and closures.

    Verbatim wording from the response

    “PSI 64/2011 requires staff to ensure that “The closure must be recorded within the case notes section of NOMS giving a brief summary of the relevant issues” (italics indicate a mandatory requirement). The Governor at Winchester has introduced a process whereby Wing Supervising Officers are informed each day of any ACCT post closure reviews which are due to be held, and provided with copies of the relevant ACCT plans. When the post closure interview has taken place, the ACCT is updated and returned to the Safer Prisons team to be filed within the prisoner’s core record. All Case Managers have been reminded of the importance of ensuring that the NOMS case notes are updated following an ACCT case review, and are using the ACCT alerts on NOMS to record the dates of an ACCT being opened and closed.”

    Source location

    2016-0346-Response-by-NOMS
    Page 2 · response
    Published 4 October 2016

    Open published response

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