Recurring concern

Unsafe interoperability between prison custody and healthcare procedures

First to latest report 13 Jan 2014 — 20 May 2026

Reports that mention this concern
35
Times this concern has been raised
40
Stated actions linked to this concern
88

What this concern includes

Includes failures of the dedicated prison custody–healthcare interface, including incompatible or poorly understood procedures, unclear responsibilities, inadequate appreciation of each function's limitations, and failures to share safety-relevant information needed for coordinated prisoner care.

What is not included
  • Excludes generic inter-agency cooperation or communication failures with no explicit prison custody and healthcare interface.
  • Excludes failures confined to a single healthcare process, such as clinical assessment or treatment, where cross-function interoperability is not the unsafe condition.
  • Excludes ordinary prison staffing, training or facility deficiencies unless they directly prevent custody and healthcare procedures from operating safely together.
  • Excludes custody-transition medical-information failures where the concern is limited to transferring or reviewing records rather than wider interoperability of procedures and responsibilities.

Reports and published responses 35 reports

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

  1. Nottinghamshire

    AI-generated summary

    Ricky Crosher and Matthew Osborne · 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

    Ricky Crosher and Matthew Osborne were prisoners at HMP Lowdham Grange who died by suicide in October and November 2023, respectively. Both had been identified as at increased risk of suicide and self-harm and placed on ACCT plans, but the plans and welfare checks were not managed in accordance with policy. The report identified concerns about Safer Custody staffing and systems, the safety and management of the Care and Separation Unit, learning from deaths, retention of evidence, and cooperation between prison and healthcare staff.

    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 a safe and productive working relationship between prison and healthcare staff

    Wider context from the report

    “6. Failure to ensure a safe and productive working relationship between prison and healthcare staff ”

    Source location

    Ricky Crosher and Matthew Osborne · 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

    Maintain Head of Healthcare leadership, cross-team meeting participation, strategic planning, and competent deputy cover to support integrated working.

    Verbatim wording from the response

    “Our Head of Healthcare plays a key role in facilitating integrated working practices between healthcare and prison teams. They are a core member of, and consistent attendee at, key meetings at the prison including a new Tri-partite Meeting, which deals with issues concerning safer custody, security, and drug strategy, and the Local Delivery Board, whose members also include NHS England and the Local Authority. A member of the strategic leadership team, the Head of Healthcare has also contributed to an integrated two-year strategy for the prison. If the head of healthcare is unable to attend (e.g., due to annual leave or training), then a suitably competent colleague deputises on their behalf to ensure continuity of services provided and sustained improved working relationships between the Trust and HMP Governor(s).”

    Source location

    Response from Northamptonshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 28 July 2026

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    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

    Participate in prison-healthcare meetings, including violence-reduction and segregation meetings, to support safer custody and transitions.

    Verbatim wording from the response

    “Members of our healthcare team contribute to a range of meetings with prison staff including the Prison Council, the Specialist Interventions meeting, and two new meetings – the ‘Top 30 Most Violent’ meeting, and Segregation meeting. The latter two meetings have been put in place to embed strategies for reducing violence across the prison, and to safely manage transitions between ‘normal location’ and the ‘segregation unit’. Members of our team now attend daily ACCT reviews with prison staff enabling early identification of those that may require additional support.”

    Source location

    Response from Northamptonshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 28 July 2026

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    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

    Attend daily ACCT reviews with prison staff to identify prisoners who may require additional support.

    Verbatim wording from the response

    “Members of our healthcare team contribute to a range of meetings with prison staff including the Prison Council, the Specialist Interventions meeting, and two new meetings – the ‘Top 30 Most Violent’ meeting, and Segregation meeting. The latter two meetings have been put in place to embed strategies for reducing violence across the prison, and to safely manage transitions between ‘normal location’ and the ‘segregation unit’. Members of our team now attend daily ACCT reviews with prison staff enabling early identification of those that may require additional support.”

    Source location

    Response from Northamptonshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 28 July 2026

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    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

    Host Governor-grade prison colleagues in healthcare staff briefings at least monthly to reinforce integrated working.

    Verbatim wording from the response

    “We have welcomed Governor-grade colleagues from the prison team into healthcare staff briefings on at least a monthly basis, which helps reinforce the integrated approach between prison and healthcare teams we know from experience to be the most successful.”

    Source location

    Response from Northamptonshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 28 July 2026

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    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

    Operate a joint Duty Manager Rota providing a senior-manager contact during core hours for resolving or escalating prison-healthcare issues.

    Verbatim wording from the response

    “Beyond meetings, we have also collaborated with the prison team to establish a Duty Manager Rota. This provides a single point of contact for both prison and healthcare staff during core hours to a senior manager to resolve issues that may arise or to ensure they are escalated to the appropriate organisation for resolution where this is not possible.”

    Source location

    Response from Northamptonshire Healthcare NHS Foundation Trust
    Page 3 · response
    Published 28 July 2026

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    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

    Conduct daily healthcare-prison briefings and structured handovers to improve continuity of care and information sharing.

    Verbatim wording from the response

    “Your sixth concern is in relation to collaborative working between HMP Lowdham Grange and healthcare. In July 2025 Northamptonshire Healthcare NHS Foundation Trust assumed responsibility of HMP Lowdham Grange’s healthcare provider. Since this change in provider communication and working relationships between parties has improved significantly. Healthcare representatives attend the daily morning briefing and provide updates on any issues arising from the previous day. In addition, a structured daily handover takes place between healthcare and prison staff to ensure continuity of care and effective information sharing.”

    Source location

    Response from HMPPS
    Page 3 · response
    Published 28 July 2026

    Open published response

  2. 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

    Lack of a formal mechanism for sharing prisoners’ mental health risks and triggers with operational prison staff

    Wider context from the report

    “2. Information sharing between Prison Healthcare and Operational Prison Staff. This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team, but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for. Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners. It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this. I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death. ”

    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

    Failure to equip operational prison staff to identify and report behavioural deterioration

    Wider context from the report

    “2. Information sharing between Prison Healthcare and Operational Prison Staff. This case illustrated a lack of communication and information sharing between Prison Healthcare and the Operational Prison Staff which was concerning to me. I heard evidence that Prison Healthcare had in place a quasi ‘watch and wait’ plan for monitoring a potentially high-risk inmate. Not only was this plan not communicated to all of the healthcare team, but it relied upon reporting of deterioration in behaviours from operational prison staff who were completely unaware that (i) they were being tasked with this role; and (ii) what to look for. Furthermore, the operational prison staff told me that having a broad understanding (within the confines of confidentiality) of a prisoner’s mental health risks and triggers would improve the safety and security of the prison for the officers and prisoners. It would enable them to properly assess and manage risk, but that there was no effective mechanism in place by which to achieve this. I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death. ”

    Source location

    Jonathan Mark Thornton · 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

    Lack of formal information sharing and reliable handover between the CFT and Prison Healthcare

    Wider context from the report

    “1. Information sharing between the CFT and Prison Healthcare. During the course of the inquest, I heard that there had been various barriers to information sharing between the community forensic team and prison healthcare. There was no formal system in place for the handover of information between these teams at the time of Jonathan’s death or at the conclusion of the inquest. Prison Healthcare staff were often unavailable or uncontactable for handover meetings. The handover of information between CFT and Prison Healthcare is vital for the risk assessment and management of prisoners who are known to the CFT (often some of the most complex and high-risk prisoners). I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death. ”

    Source location

    Jonathan Mark Thornton · 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

    Establish regular information-sharing through daily briefings, SIM meetings, drug-strategy discussions, and communication across prison operational and healthcare teams.

    Verbatim wording from the response

    “Since taking over responsibility for healthcare services at HMP Nottingham on 19 November 2025, we have put in place regular and consistent ways of sharing information within the prison. This includes routine contact through daily morning briefings, SIM meetings, drug strategy discussions, and ongoing conversations with colleagues in reception, healthcare, and across the house blocks.”

    Source location

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

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a formal information-sharing procedure requiring prompt, secure, documented handover of clinical and risk information, standard documents, and escalation when contact fails.

    Verbatim wording from the response

    “1. Introduction of a Formal Information-Sharing Guidance Document (December 2025)”

    Source location

    Response from Nottingham Healthcare NHS Foundation Trust
    Page 1 · response
    Published 13 April 2026

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    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

    Share and agree the information-sharing guidance with CFT staff, Prison Healthcare providers, and HMP Lincoln to establish consistent cross-organisational expectations.

    Verbatim wording from the response

    “3. Guidance Shared with all CFT Staff”

    Source location

    Response from Nottingham Healthcare NHS Foundation Trust
    Page 2 · response
    Published 13 April 2026

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    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

    Embed the information-sharing guidance through team briefings, clinical supervision, and induction for new staff.

    Verbatim wording from the response

    “2. Embedding the Guidance Through Training and Supervision”

    Source location

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

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Maintain a dedicated CFT Link Worker as a consistent Prison Healthcare contact with oversight of information sharing, timely responses, continuity, and service liaison.

    Verbatim wording from the response

    “1. Appointment of a Dedicated CFT Link Worker”

    Source location

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

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    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

    Establish bimonthly interface meetings with HMP Nottingham Prison Healthcare teams to review cases, address communication issues, monitor guidance adherence, and escalate risks.

    Verbatim wording from the response

    “The Link Worker will also arrange and chair a bimonthly interface meeting with Prison Healthcare teams at HMP Nottingham. These meetings will:”

    Source location

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

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    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

    Work jointly with Northamptonshire Healthcare NHS Foundation Trust to clarify responsibilities, availability expectations, responsiveness, and escalation pathways.

    Verbatim wording from the response

    “3. Joint Working with Prison Healthcare Providers”

    Source location

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

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct quarterly audits of information-sharing timeliness, documentation completeness, and escalation, and report findings to relevant quality and accountability groups.

    Verbatim wording from the response

    “4. Quarterly Audit and Reporting”

    Source location

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

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    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 and disseminate information-sharing guidance to prisons through booklet, wallet-sized and intranet formats.

    Verbatim wording from the response

    “A national Information Sharing Advisory Group (ISAG) is in place, which aims to improve information sharing between health and prisons. In order to improve practice, HMPPS Health and Care Information Sharing guidance was issued to prisons in July 2022 in two formats (A5 booklet and wallet size) and is available on the HMPPS intranet. The guidance aims to improve and achieve a more consistent approach to the sharing of information between all”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 13 April 2026

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    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

    Ask the Information Sharing Advisory Group to examine the circumstances of Mr Thornton’s death, identify learning and assess whether updated guidance is needed.

    Verbatim wording from the response

    “partner agencies and to give staff confidence in decision making, to reduce risk to self and others, and to achieve better outcomes for all staff, people in prison and people under probation supervision. We will ask the ISAG to consider the circumstances of Mr Thornton’s death to identify learning and whether there is a need for additional updated guidance.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 13 April 2026

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    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

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    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

    Establish practical information-sharing arrangements and named contacts between community forensic and prison healthcare teams.

    Verbatim wording from the response

    “We have put practical arrangements in place between the Community Forensic Team and the Prison Healthcare Team at HMP Nottingham to make sure information is shared smoothly when someone comes into custody. This includes holding named contacts in each team.”

    Source location

    Response from Northampton Healthcare NHS Foundation Trust
    Page 2 · response
    Published 13 April 2026

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    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

    Healthcare information-sharing concerns have been referred to the relevant NHS trusts for separate consideration and response.

    Verbatim wording from the response

    “Although your concerns about the sharing of information between healthcare and prison staff have been referred to Nottinghamshire Healthcare NHS Foundation Trust and Northampton Healthcare NHS Foundation Trust for their separate consideration and response, HMPPS has also considered whether there is any supportive action that it can take.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 13 April 2026

    Open published response

  3. Inner South London

    AI-generated summary

    Mark Robert 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

    Mark Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.

    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 maintain QEH staff awareness of the limits of prison healthcare

    Wider context from the report

    “(2) I remain concerned a similar situation could arise as did in Mark’s case regarding a discharge back to prison from QEH without an MDT meeting despite repeated requests from prison healthcare and there could be a risk to life. I note PFD evidence provided regarding improved liaison between QEH and the prison GP but note no reference to liaison between QEH and the head of the healthcare in prison, who visited QEH twice in Mark’s case. Further, as recently as 2025 an incident occurred when there was a lack of understanding at QEH around the limited provision in healthcare in prison. I am concerned as to how awareness of the limits of prison healthcare will be disseminated on a continuing basis to new and locum staff at QEH. (QEH and Practice Plus Group) ”

    Source location

    Mark Robert Smith · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  4. Milton Keynes

    AI-generated summary

    Ronald William MEIKLE · 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

    Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

    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 reliably consolidate and share relevant prisoner risk information

    Wider context from the report

    “Concern 3: Fragmented information-sharing and record keeping The evidence demonstrated that relevant risk information was spread across multiple recording systems and was not always shared effectively between operational staff and clinical teams. This included information relevant to substance misuse, mental health, debt, bullying or coercion, self-isolation, intelligence about threats, recent presentation under the influence. Where critical safety information is held in separate systems and not reliably brought together, there is a foreseeable risk that warning signs will be missed and protective action delayed with obvious risk of harm or death. ”

    Source location

    Ronald William MEIKLE · 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

    Revise handover documentation, including a prompt to identify information requiring sharing with prison colleagues.

    Verbatim wording from the response

    “Concern 3: Information sharing and record keeping. Handover documentation has been revised. This has improved identification and escalation of concerns to prison colleagues. We are ensuring that healthcare attend multidisciplinary forums, weekly Safety Intervention Meetings, and daily wing briefings. We have added a prompt to our handover to ensure that staff consider what information needs to be shared with prison colleagues.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 2 · response
    Published 26 March 2026

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    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 healthcare participation in multidisciplinary forums, weekly Safety Intervention Meetings and daily wing briefings.

    Verbatim wording from the response

    “Concern 3: Information sharing and record keeping. Handover documentation has been revised. This has improved identification and escalation of concerns to prison colleagues. We are ensuring that healthcare attend multidisciplinary forums, weekly Safety Intervention Meetings, and daily wing briefings. We have added a prompt to our handover to ensure that staff consider what information needs to be shared with prison colleagues.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 2 · response
    Published 26 March 2026

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    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

    Healthcare services alone cannot mitigate all risks within custody.

    Verbatim wording from the response

    “Thank you for bringing your concerns to our attention. While healthcare services alone cannot mitigate all risks within custody, the Trust is committed to learning from Mr Meikle’s death and to strengthening how vulnerability is identified and responded to across Health and Justice services. Should you have any questions or comments, please do not hesitate to contact me.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

    Open published response

  5. Kent and Medway

    AI-generated summary

    Thomas Daniel RUGGIERO · 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

    Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing himself and died later that day. The report identifies concerns about the emergency cell bell system, incomplete ACCT documentation, confusion over calling a “code blue”, and staffing, experience and communication at the prison, with risks to future prisoners remaining.

    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 prison staff communication to relay the severity and complete scope of situations

    Wider context from the report

    “(4) Staffing / Experience / Communication etc. The evidence was that in November 2024, up to (and possibly more than) 90% of prison officers at HMP Swaleside were new in post and still in their probationary period. I was told in evidence by a Supervising Officer (SO) that on 16 November 2024, he 'possibly did not have the right mix of staff in terms of skills and experience to keep the wing safe'. In this inquest, the jury found that, "the communication between prison staff was insufficient and lacked clarity. Opportunities to increase formal observations or notify health care were missed. Staff communications failed to relay the severity and complete scope of the situation." The CCTV evidence clearly showed other prisoners regularly at Mr Ruggiero's cell door, silencing the call bell, banging and kicking at the door (including the wielding of a crutch to hit the door and observation panel), and verbally harassing Mr Ruggiero. The evidence from an SO was that he gave landing officers a clear instruction to intervene; however, it appeared that this did not happen. I was told that the level of officers still in their probationary period has now reduced. I was also told that additional staff training is now in place to address matters such as assertiveness, and that there is also an action plan (albeit I was not shown this). I was also made aware of the "Urgent Notification' (UN) from HM Chief Inspector of Prisons in relation to HMP Swaleside (December 2025), which included in the rationale, "Staff, many of whom lacked experience, were not confident in challenging poor behaviour and there was a lack of order and control." While some action has been taken, I am not sufficiently reassured that this has addressed the concern and I therefore consider that the risks remain. ”

    Source location

    Thomas Daniel RUGGIERO · 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

    Embed practical emergency-response simulations, including Code Blue scenarios, within local training and mentoring arrangements.

    Verbatim wording from the response

    “Practical emergency response simulations, including Code Blue scenarios, are being embedded within local training and mentoring arrangements. Compliance and learning will be monitored through incident reviews and feedback reported to the Safer Custody Management Team. Joint exercises with healthcare staff will continue, this joined up approach will strengthen shared understanding and embed a multidisciplinary approach when responding to medical emergencies.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

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    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

    Continue joint emergency-response exercises with healthcare staff to strengthen shared understanding and multidisciplinary response.

    Verbatim wording from the response

    “Practical emergency response simulations, including Code Blue scenarios, are being embedded within local training and mentoring arrangements. Compliance and learning will be monitored through incident reviews and feedback reported to the Safer Custody Management Team. Joint exercises with healthcare staff will continue, this joined up approach will strengthen shared understanding and embed a multidisciplinary approach when responding to medical emergencies.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 26 March 2026

    Open published response

  6. Essex

    AI-generated summary

    STUART CHRISTOPHER JAMES BERRY · 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

    STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.

    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 share critical suicide-risk information with prison staff

    Wider context from the report

    “In addition to failing to share crucial and obviously relevant information regarding Mr Berry’s extreme risk of suicide provided by the CPN at Court with prison staff, the jury found that the reception nurse, in the context of the clear information known to her, failed to: (a) document his risk of self-harm and suicide in the Systm One records and (b) failed to refer Mr Berry, that day, for an urgent review by the Mental Health team. CONCERN: Such comprehensive shortcomings in performance in respect of information sharing, conduct of assessments, basic documentation and escalation/referral on to relevant colleagues indicates (a) a failure in training of a very concerning kind, alongside (b) a failure in HCRG monitoring of standards, supervision and quality assurance processes to identify and address such extensive failures in performance. ”

    Source location

    STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report
    Page 6 · 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

    Establish and staff a dedicated Early Days in Custody Nurse role to oversee reception screening, risk assessment, information sharing, escalation, supervision, and quality assurance.

    Verbatim wording from the response

    “We are focusing on strengthening the interfaces between healthcare and custodial services, retraining reception nurses, and introducing a dedicated Early Days in Custody (EDiC) Nurse role.”

    Source location

    Response from HCRG
    Page 1 · response
    Published 20 January 2026

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    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 a formal Prisoner Warning Notice communication logbook and train relevant staff to record, communicate, and acknowledge custody-related risks.

    Verbatim wording from the response

    “• Prisoner Warning Notices (PWN): The PWN is received into the prison via secure email and it is the responsibility of the Reception Nurse to review this notification on receiving a patient into custody, consider it in their assessment of patient risk and take immediate appropriate action, including sharing with Custodial Managers and Officers covering reception.”

    Source location

    Response from HCRG
    Page 2 · response
    Published 20 January 2026

    Open published response

  7. Kent and Medway

    AI-generated summary

    Azroy Dawes-Clarke · 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

    Azroy Dawes-Clarke died in hospital on 10 November 2021 after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and treatment. The substantive concerns included inadequate communication and healthcare involvement, disproportionate and prolonged restraint, delays in recognising the arrest and starting CPR, unsuitable ligature-resistant materials, and gaps in staff training on ACCT procedures, first aid, basic life support, and the legal framework for medical emergencies.

    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

    Unclear prison officer roles in conveying prisoners lacking capacity to hospital

    Wider context from the report

    “(4) Whilst the use of force paperwork completed following Mr Dawes-Clarke’s physical restraint made mention of the Mental Capacity Act 2005, none of the officers (including the individual who completed the paperwork) appeared to have any basic understanding of the circumstances when the Mental Capacity Act may apply in a custodial setting. Equally, many were unclear as to what their role would be in conveying a prisoner who lacked the capacity to consent to their conveyance to hospital in a medical emergency. Answers in respect of handcuffing prisoners for the purpose of conveying them to hospital in a medical emergency varied. Answers in respect of the legal framework which applied when prison officers are involved in care and treatment of a prisoner (the particular issue in the present case being the conveyance to hospital and the decision to dress him) were inconsistent or incomplete. ”

    Source location

    Azroy Dawes-Clarke · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  8. 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

    Failure of prison and healthcare staff to share knowledge about people presenting with serious and enduring mental health illness

    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

    Establish forums for prison and healthcare staff to share knowledge about prisoners of concern.

    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

  9. Nottinghamshire

    AI-generated summary

    Anthony Binfield and 2 others · 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

    Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous 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

    Use of inaccessible email channels for risk pertinent information

    Wider context from the report

    “I am also concerned by the use of email to convey risk pertinent information. In this case, prison staff communicated their concerns about Anthony’s mental health to individual nursing Sodexo email inboxes, which the nurses were not expected to regularly access. The use of email means that such concerns are not accessible to other members of staff as they would be if they were recorded in PNOMIS or Systemone. ”

    Source location

    Anthony Binfield and 2 others · 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

    Failure to identify and share risk pertinent information between prison and healthcare staff

    Wider context from the report

    “There was a complete breakdown in the system of risk identification and information sharing. Prison and healthcare staff did not routinely consider information captured within the electronic systems, nor did they update the systems with risk pertinent information gathered during interactions with the prisoners. ”

    Source location

    Anthony Binfield and 2 others · 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 estate-wide email practices to ensure risk information reaches available healthcare staff.

    Verbatim wording from the response

    “Your concern regarding email being used to communicate with specific members of the healthcare team is also noted, and I have requested a review of the practice used across the Serco estate to ensure that staff are not just communicating with specific email addresses, in case the individual to whom the emails are addressed are not on shift.”

    Source location

    Response from Serco
    Page 2 · response
    Published 13 February 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

    Audit and quality-review documentation of risk information in wing observation books.

    Verbatim wording from the response

    “Discussions have taken place with the Head of Residential Services to discuss how appropriate risk pertinent information can be shared on the wings as part of effective information sharing with prison colleagues. Systems such as identifying clinical risk by adding a coloured dot to their name on the wing prisoner list are being scoped. Healthcare staff have been informed that they must document in the wing observation book any relevant risk pertinent information to alert staff to any potential issues. Again, this will be audited and reviewed for quality by the Head of Healthcare and Safer Custody Officer.”

    Source location

    Response from Nottingham NHS
    Page 2 · response
    Published 13 February 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

    Maintain generic healthcare email inboxes with daily administrative monitoring for non-urgent prison queries.

    Verbatim wording from the response

    “Email: Healthcare has generic email inboxes which are monitored daily by administrative staff which have been provided to the wings as a first point of contact for non-urgent issues. This includes a mailbox for each clinical pathway. A reminder has also been sent to Prison staff via the Governors secretary, to the wings, of the mailbox addresses and call signs on the radio for contacting healthcare. No personal emails should be used for patient related queries.”

    Source location

    Response from Nottingham NHS
    Page 3 · response
    Published 13 February 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

    Disseminate healthcare mailbox addresses and radio call signs to prison wings and staff.

    Verbatim wording from the response

    “Email: Healthcare has generic email inboxes which are monitored daily by administrative staff which have been provided to the wings as a first point of contact for non-urgent issues. This includes a mailbox for each clinical pathway. A reminder has also been sent to Prison staff via the Governors secretary, to the wings, of the mailbox addresses and call signs on the radio for contacting healthcare. No personal emails should be used for patient related queries.”

    Source location

    Response from Nottingham NHS
    Page 3 · response
    Published 13 February 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

    Develop collaborative information-sharing arrangements between the prison and healthcare provider and reinforce use of designated information systems.

    Verbatim wording from the response

    “Work is also ongoing to create a positive and collaborative relationship between the prison and the healthcare provider, to build better working relationships and ensure all are aware of their responsibilities in sharing information with colleagues. It will be reinforced to staff in all areas that information should be shared using the relevant systems, such as NOMIS, SystmOne, and observation books, rather than through emails.”

    Source location

    Response from HMPPS
    Page 3 · response
    Published 13 February 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

    Introduce and operate a digital Reception Screening Risk Assessment tool across Sodexo prisons to identify arrival risks and generate alerts for staff review.

    Verbatim wording from the response

    “- Sodexo have recently introduced a digital Reception Screening Risk Assessment (RSRA) tool across its prisons, implemented on CMS following 2 years of development and trialling led by Sodexo in partnership with Unilink”

    Source location

    Response from Sodexo
    Page 2 · response
    Published 13 February 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

    Remind staff across Sodexo prisons to record concerns in NOMIS and wing observation books.

    Verbatim wording from the response

    “○ Senior Staff morning meeting, including the Prison Director and Head of Healthcare. Within this meeting, prison staff present information about prisoners of concern following incidents or receiving of intelligence reports. ○ Weekly Safety Intervention Meeting (SIM). Attendance includes physical healthcare, mental health staff and psychology ○ Monthly Safer Custody Meeting ○ Complex case meetings, ad hoc, focusing on prisoners of concern ○ ACCT reviews ○ Briefings on each prison wing at each shift change. Staff concerns (prison or healthcare staff) are recorded in Wing Observation Book. Staff at all Sodexo prisons have been reminded of the importance of recording concerns in NOMIS and the wing observation book.”

    Source location

    Response from Sodexo
    Page 2 · response
    Published 13 February 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

    Implement the Information Sharing Position Statement to guide health-information sharing and consent decisions across the criminal justice system.

    Verbatim wording from the response

    “In 2023, NHS England’s national quality function for health and justice developed the Information Sharing Position Statement (ISPS). This supports a common understanding between NHS England and partners across the CJS about patient confidentiality and the sharing of health information (UK GDPR) which is considered more sensitive and therefore amounts to ‘special category’ data.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 13 February 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

    Complete nationally delivered training for staff using the new prison reception-screening template.

    Verbatim wording from the response

    “Reception screening: A new national template for prison reception screening for the male prison estate was launched on the 1 April 2025. Staff are in the process of receiving the Nationally delivered”

    Source location

    Response from Nottingham NHS
    Page 1 · response
    Published 13 February 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

    Amend the reception supervision proforma to record clinical staff access to digital Person Escort Records.

    Verbatim wording from the response

    “Part of the reception screening is the ability to access a digital Person Escort Record (PER). This is a prison document which follows the prisoner journey through their custodial sentence and contains risk pertinent information. There is no ability to audit this access however, the supervision proforma for the clinical staff in reception will be amended to ensure it forms part of the supervision record.”

    Source location

    Response from Nottingham NHS
    Page 2 · response
    Published 13 February 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

    Attend weekly Safety Interventions Meetings through Mental Health Team representation and quality-check attendance and information sharing.

    Verbatim wording from the response

    “Safety Interventions Meeting (SIM): We have worked with Prison colleagues to ensure that SIMs are attended on a weekly basis by a member of the Mental Health Team. This meeting is to discuss any patients of concern and highlight any specific issues relating to that individual. A Prison safeguarding referral form (Annex Q) is now in use and concerns can also be raised online via the DPS system. A random spot check of attendance and the quality of information shared will be randomly reviewed by the Head of Healthcare at HMP Lowdham Grange.”

    Source location

    Response from Nottingham NHS
    Page 2 · response
    Published 13 February 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

    Complete CSIP training for healthcare staff to support risk-information sharing.

    Verbatim wording from the response

    “CSIP: Patients can also be referred to CSIP (Challenge, Support and Intervention Plan). This is a prison risk management system and process that will enable information sharing on risk in the prison estate and also support the development of cross professional relationships. Healthcare staff are currently accessing the training for this, and full compliance is aimed to have been achieved by June 2025.”

    Source location

    Response from Nottingham NHS
    Page 2 · response
    Published 13 February 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

    Deliver healthcare training to prison officers through the prison staff induction programme, expanding from emergency response to mental-health awareness.

    Verbatim wording from the response

    “Training - Healthcare staff have arranged to attend the Prison staff induction programme so that they can deliver health training to the Prison Officers. Initially this will be focused on emergency response but will later include Mental Health awareness training. This was agreed at the Local Delivery Board and the first session was provided on 23 January 2025. Feedback from staff was very positive. Healthcare staff will continue to receive clinical risk, self-harm and suicide training, which is an inhouse training programme. Compliance will be achieved by July 2025.”

    Source location

    Response from Nottingham NHS
    Page 2 · response
    Published 13 February 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

    Continue providing healthcare staff training on clinical risk, self-harm and suicide.

    Verbatim wording from the response

    “Training - Healthcare staff have arranged to attend the Prison staff induction programme so that they can deliver health training to the Prison Officers. Initially this will be focused on emergency response but will later include Mental Health awareness training. This was agreed at the Local Delivery Board and the first session was provided on 23 January 2025. Feedback from staff was very positive. Healthcare staff will continue to receive clinical risk, self-harm and suicide training, which is an inhouse training programme. Compliance will be achieved by July 2025.”

    Source location

    Response from Nottingham NHS
    Page 2 · response
    Published 13 February 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

    Scope systems for sharing risk information with prison colleagues on residential wings.

    Verbatim wording from the response

    “Discussions have taken place with the Head of Residential Services to discuss how appropriate risk pertinent information can be shared on the wings as part of effective information sharing with prison colleagues. Systems such as identifying clinical risk by adding a coloured dot to their name on the wing prisoner list are being scoped. Healthcare staff have been informed that they must document in the wing observation book any relevant risk pertinent information to alert staff to any potential issues. Again, this will be audited and reviewed for quality by the Head of Healthcare and Safer Custody Officer.”

    Source location

    Response from Nottingham NHS
    Page 2 · response
    Published 13 February 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

    Review ACCT attendance and contributions through the safer-custody process to assure quality.

    Verbatim wording from the response

    “ACCT: Assessment, Care in Custody and Teamwork processes are being managed through a booking process with advance notification. All first ACCT reviews are attended by a registered nurse in line with the ACCT process. Subsequent follow up reviews are attended where possible or prioritised based on clinical risk and need. Phone and email contributions are also supported if required. The process of our ACCT attendance and contribution will be reviewed as part of the safer custody process to ensure the quality is as desired and required. As part of the ACCT process”

    Source location

    Response from Nottingham NHS
    Page 2 · response
    Published 13 February 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

    Share ACCT safety plans with patients and prison colleagues, with identified escalation routes, and audit this practice.

    Verbatim wording from the response

    “safety plans should be shared with the Patient and with prison colleagues with escalation routes identified. This will be reviewed and audited by the Head of Healthcare as part of local quality assurance processes.”

    Source location

    Response from Nottingham NHS
    Page 3 · response
    Published 13 February 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

    Introduce risk-sharing measures, including a triggers database and improved shift handovers, first-night processes and induction.

    Verbatim wording from the response

    “The identification and management of risk is a vital element of core prison officer duties. A range of measures are being introduced by the SMT at Lowdham Grange to ensure risks are”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 13 February 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

    Refresh the Safety Intervention Meeting to improve multidisciplinary information-sharing and strategic support for prisoners at risk.

    Verbatim wording from the response

    “The Safety Intervention Meeting (SIM) is being refreshed so that it provides a more effective mechanism for all those involved in the care of prisoners and to discuss those at risk, share information and ensure a strategic overview that pulls in all relevant information and agencies to ensure support is tailored to the individual. The Governor is committed to learning from deaths that have occurred and has introduced a meeting to focus on work to address issues raised in Reports to Prevent Future Deaths.”

    Source location

    Response from HMPPS
    Page 3 · response
    Published 13 February 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

    Work with NHS England to devise revised guidance on information-sharing in prison reception areas, including healthcare access to digital Person Escort Records.

    Verbatim wording from the response

    “We know that achieving full compliance with these policies can be challenging and we continue to work with healthcare partners and others to support Governors in implementing them, including through the HMPPS/NHSE Information Sharing Advisory Group which meets regularly to tackle issues in this area. For example, we are currently working with NHSE to devise revised guidance on information sharing in prison reception areas, focused particularly on healthcare staff access to the digital Person Escort Records (dPER).”

    Source location

    Response from HMPPS
    Page 3 · response
    Published 13 February 2025

    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

    Urgent information sharing involving safety risks should follow local safeguarding processes rather than the routine information-sharing statement.

    Verbatim wording from the response

    “The ISPS only relates to the general and routine sharing of health information for purposes connected with the care of individuals in the CJS and is not intended to cover the sharing of health information in situations where there is an urgent need to share”

    Source location

    Response from NHS England
    Page 3 · response
    Published 13 February 2025

    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

    Custodial staff cannot access healthcare records because of medical confidentiality, so they rely on healthcare staff to communicate risk information.

    Verbatim wording from the response

    “Our staff are also aware of the need to liaise with Healthcare staff and make appropriate referrals to Healthcare or signpost prisoners to do so. However, as you will be aware, due to medical confidentiality requirements, custodial staff are not permitted to access the healthcare IT system, System One. As a result, we rely on healthcare staff communicating any risk pertinent information to custodial staff or our Safer Custody Departments if and when they feel that medical information, or information disclosed by prisoners which may be relevant to their risk comes to their attention.”

    Source location

    Response from Serco
    Page 1 · response
    Published 13 February 2025

    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

    Resource constraints mean staff cannot always fully review PNOMIS records or previous ACCTs, although higher-risk cases are prioritised.

    Verbatim wording from the response

    “prisoner is transferred as individuals’ risks can change with their circumstances. Unfortunately, due to resource constraints, it is not always possible for staff to fully review PNOMIS or old ACCTs, although the expectation would be that staff prioritise these tasks for prisoners who have only recently been on an ACCT or are on an ACCT at the time of their arrival. Of course, any risk pertinent information should be communicated to the Safer Custody team on a prisoner’s arrival, so that necessary steps can be put in place to keep that prisoner safe. Serco staff are always encouraged to record all risk pertinent information and to share this information with each other (via handovers and wing observations books), with Safer Custody and with Healthcare, where applicable, by telephone or email.”

    Source location

    Response from Serco
    Page 2 · response
    Published 13 February 2025

    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

    Access to the digital Person Escort Record cannot be audited, preventing direct monitoring of whether staff access risk information.

    Verbatim wording from the response

    “Part of the reception screening is the ability to access a digital Person Escort Record (PER). This is a prison document which follows the prisoner journey through their custodial sentence and contains risk pertinent information. There is no ability to audit this access however, the supervision proforma for the clinical staff in reception will be amended to ensure it forms part of the supervision record.”

    Source location

    Response from Nottingham NHS
    Page 2 · response
    Published 13 February 2025

    Open published response

  10. Mid Kent and Medway

    AI-generated summary

    John Raymond EYRE · 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

    John Raymond Eyre was a serving prisoner whose health deteriorated in 2022, including recurrent neutropenic sepsis, and he died in hospital on 20 November 2022 from pneumonia, with liver disease also recorded. Concerns included the lack of a concrete escalation route when prison healthcare staff challenged his discharge and the absence of national guidance on returning a prisoner to custody when those concerns had not been considered by the consultant.

    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 national guidance or policy on returning prisoners to custodial settings when prison healthcare concerns have not been considered by the consultant

    Wider context from the report

    “(2) There was no national guidance document, or national policy in place, which outlined whether a prisoner should be returned to a custodial setting in the absence of the prison healthcare provider's concerns being considered by the patient's consultant. ”

    Source location

    John Raymond EYRE · 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

    Ask officials to consider whether hospital discharge guidance should explicitly require consideration of care-provider concerns before discharge to custodial settings.

    Verbatim wording from the response

    “As set out in the Hospital Discharge and Community Support Guidance (January 2024), NHS bodies should work closely with care providers and other partners to ensure people’s care is timely, optimal and co-ordinated, while also practising active risk management to reach a reasonable balance between safety and minimising delays when patients are ready to be discharged. I will ask my officials to consider whether an amendment to the hospital discharge guidance is required to make more explicit the obligation to consider concerns raised by care providers before the discharge of patients to custodial settings. Furthermore, as required and described in the Health and Social Care Act 2012, patients within secure settings should receive the same quality and access of healthcare as the rest of the population, both in terms of the range of interventions to meet their needs, and the quality”

    Source location

    Response from DHSC
    Page 1 · response
    Published 8 October 2024

    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