19 Jul 2024 Benjamin Noah Frances Harrison · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Misalignment of healthcare information-sharing policy and staff practice with PSI64/2011 View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
HM Prison and Probation Service Oxleas NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Oxleas NHS Foundation Trust
Share relevant medication and safety-risk information during weekly Safety Intervention Meetings.
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Oxleas NHS Foundation Trust
Introduce a Practice Development Nurse role to support healthcare-team training, guidance and policy compliance.
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Oxleas NHS Foundation Trust
Deliver PSI 64/2011 and relevant policy guidance through teaching, read-and-sign procedures, handovers and supervision, with training records retained.
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Oxleas NHS Foundation Trust
Review, update and disseminate healthcare policies to staff using the latest versions.
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HM Prison and Probation Service
Embed a process with the healthcare provider for sharing relevant information about prisoners with in-possession medication, including discussion at weekly safety intervention meetings.
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Benjamin Noah Frances Harrison · 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
Benjamin Harrison died in HMP Rochester on 9 May 2022 after inhaling fumes from a medication heated with a vape pen. The inquest identified concerns including insufficient overnight healthcare cover, failure to inform the night orderly that he appeared to be under the influence, inadequate guidance for monitoring and escalation, and weaknesses in medication briefing and information sharing.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Misalignment of healthcare information-sharing policy and staff practice with PSI64/2011
Wider context from the report “(3) In evidence there were discrepancies between the policies in place and the understanding of healthcare staff as to what information could be shared with prison staff and when it should be shared .
Some healthcare staff in evidence indicated they would not share information about medication in any circumstances .
The healthcare policy and practice of healthcare staff in relation to information sharing does not align with PSI64/2011 that information can be shared without a prisoner's consent if it is considered necessary to protect the individual or anyone else from the risk of death or serious harm.
There was no clear process as to how or where the information would be shared and recorded either where a prisoner had consented to information sharing or where consent had not been given but it was nevertheless necessary to share the information.
” Source location Benjamin Noah Frances Harrison · Prevention of Future Deaths report
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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 Share relevant medication and safety-risk information during weekly Safety Intervention Meetings.
Verbatim wording from the response “This guidance is that the clear verbal briefing should include all prisoners who are ‘at risk’, and not all prisoners. It would not be possible to include all prisoners who have medication in possession in a nightly verbal briefing when up to a third of the total population are prescribed In Possession medication. It would not be practical and could distract from the prisoners who are at risk, and who require inclusion in the clear verbal briefing to ensure safety. We have agreed with prison colleagues that healthcare will share relevant information within the weekly Safety Intervention Meeting and discuss men with in-possession medication who may be at risk, so that prison managers responsible for those individuals are aware of any prescribed medication that may inform any risk management decisions.” Source location Response from Oxleas NHS Foundation Trust
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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 Introduce a Practice Development Nurse role to support healthcare-team training, guidance and policy compliance.
Verbatim wording from the response “3. To support addressing understanding of policies, we have a new Practice Development Nurse (PDN) joining the team in September 2024, to ensure that the healthcare team are up to date with all relevant training and guidance. The PDN will share the clear guidance set out in chapter 2 of PSI 64/2011 and ensure via teaching sessions, read-and-sign procedure and supervision that this guidance is understood and followed by the nursing and wider healthcare team. There are mechanisms in place to share relevant safety and risk information on NOMIS, and this would have included sharing information of the risks of misusing a Fentanyl patch.” Source location Response from Oxleas NHS Foundation Trust
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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 Deliver PSI 64/2011 and relevant policy guidance through teaching, read-and-sign procedures, handovers and supervision, with training records retained.
Verbatim wording from the response “3. To support addressing understanding of policies, we have a new Practice Development Nurse (PDN) joining the team in September 2024, to ensure that the healthcare team are up to date with all relevant training and guidance. The PDN will share the clear guidance set out in chapter 2 of PSI 64/2011 and ensure via teaching sessions, read-and-sign procedure and supervision that this guidance is understood and followed by the nursing and wider healthcare team. There are mechanisms in place to share relevant safety and risk information on NOMIS, and this would have included sharing information of the risks of misusing a Fentanyl patch.” Source location Response from Oxleas NHS Foundation Trust
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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 Review, update and disseminate healthcare policies to staff using the latest versions.
Verbatim wording from the response “Our Quality Manager has very recently reviewed all policies, updated them to the latest versions and shared their location with all staff. Our PDN will have the responsibility of ensuring that the healthcare team are aware of all relevant policies, that they understand the policies and the importance of following them, and that these are shared and discussed in teaching sessions, handovers, and supervisions. Training records will be kept in order to evidence this.” Source location Response from Oxleas NHS Foundation Trust
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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 Embed a process with the healthcare provider for sharing relevant information about prisoners with in-possession medication, including discussion at weekly safety intervention meetings.
Verbatim wording from the response “You have also raised a concern that night staff did not receive a briefing about prisoners who had medication in their possession. I have been informed by the Governor that the prison is working with the healthcare provider to embed a process for sharing relevant information about at risk prisoners who have medication in their possession. This will include time to discuss in possession medication at the weekly safety intervention meeting where complex and high risk prisoners are discussed by a multi-disciplinary team including prison and healthcare managers.” Source location Response from HMPPS
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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 are assigned to Oxleas NHS Foundation Trust because they relate to healthcare rather than prison responsibilities.
Verbatim wording from the response “Following evidence heard at the inquest, you have raised concerns about the appropriate monitoring of prisoners suspected to be under the influence of illicit substances during the night state and that prison staff were not sufficiently briefed about prisoners keeping medication in their possession. You have also raised a concern in relation to healthcare staff sharing relevant medical information with prison staff. I note that you have also addressed your report to Oxleas NHS Foundation Trust and therefore I will only be responding to the first two concerns as these relate to prison responsibilities. I am grateful to you for bringing your concerns to my attention.” Source location Response from HMPPS
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16 Jan 2024 Trevor Alan MONERVILLE · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Inadequate communication about prisoners’ health conditions View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Trevor Alan MONERVILLE · 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
Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate communication about prisoners’ health conditions
Wider context from the report “b. Communication between healthcare and prison staff especially when Trevor was returned to the wing , between the prison staff and family , briefing by prison managers to officers on the wing about Trevor’s condition were all inadequate.
Evidence was heard about the lack of integration of various IT systems which contributed to poor communication. In spite of the evidence from PPG regarding the sensitivity of medical records which should not be disclosed to the prison staff, I remain concerned that there was no effective monitoring and management of Trevor on the wing once the ACCT was closed. There was no mechanism in place for prison and healthcare staff to report their concerns about Trevor’s non compliance with taking his medication to Security, thus preventing the cell from being searched for retained medication.
” Source location Trevor Alan MONERVILLE · Prevention of Future Deaths report
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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 Regional Multi Professional Complex Case Clinic escalation for the most complex patients.
Verbatim wording from the response “Practice Plus Group operates an integrated healthcare model. Any patients pending transfer back to the main wing with ongoing needs are to be discussed at the Multi Professional Complex Case Clinic (MPCCC) prior to transfer. This allows oversight of all departments within the integrated team and a holistic complex care plan to be created. The MPCCC is led by the GP, attended by all clinical leads, and any relevant staff involved in patient care. For individual cases prison partners may be invited to attend and a care plan created with a named coordinator allocated. Practice Plus Group has now implemented a further point of escalation to Regional MPCCC. For the most complex of patients, attendees will include healthcare, prison staff and, on occasion, representatives from NHS England.” Source location Response from Practice Plus Group
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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 Work with NHS England to clarify routine health-information sharing and processes for risk or safeguarding concerns.
Verbatim wording from the response “HMPPS recognises that, information sharing is vital to effective health management of people in prison and is working closely with NHSE to increase staff confidence and support effective information sharing by offering clarity about the general and routine sharing of health information and where risk/safeguarding concerns have been raised.” Source location Response from HM Prison and Probation Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Practice Plus Group cannot resolve integration of healthcare and prison IT systems because SystmOne is commissioned by NHS England and medical records are confidential.
Verbatim wording from the response “As to lack of integration of various systems, this is not an issue that Practice Plus Group can resolve. SystmOne is commissioned by NHS England and Practice Plus Group is commissioned to use SystmOne. As with patients in the community, medical records are highly sensitive and personal to the individual. They are not shared with prison staff for reasons of medical confidentiality.” Source location Response from Practice Plus Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.
Verbatim wording from the response “There are Information Sharing protocols in place, as directed by national policy, which underpin the exchange of information between healthcare and prison staff. There are several regular meetings involving healthcare and prison staff where individual issues are raised and addressed, including the Safety Intervention Meeting and Multi-Disciplinary Complex Case Clinic, both of which are held weekly.” Source location Response from HM Prison and Probation Service
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4 Jan 2024 Stephen COSTER · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Absence of a protocol or policy for healthcare-prison communication when monitoring sick prisoners on the wing at night View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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Stephen COSTER · 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
Stephen Coster died from meningoencephalitis owing to Streptococcus pneumoniae after becoming seriously unwell while detained at HMP Lewes. The inquest found delays in providing treatment and transferring him to hospital, with concerns including inadequate observations and assessment, poor record keeping, failures to escalate, and breakdowns in communication and leadership between prison and healthcare staff.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a protocol or policy for healthcare-prison communication when monitoring sick prisoners on the wing at night
Wider context from the report “c. Healthcare staff failed to provide the prison staff with an adequate care plan so that Stephen Coster could be monitored effectively. Evidence was heard that there was no protocol or policy in place regarding communication between Healthcare staff and Prison staff for the monitoring of sick prisoners on the wing at night .
” Source location Stephen COSTER · Prevention of Future Deaths report
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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 an agreed system clarifying prison welfare checks, healthcare clinical observations, required check levels and clinically appropriate inpatient transfers.
Verbatim wording from the response “The prison has also conducted a further review, together with healthcare, to consider how best to manage the care and monitoring of unwell prisoners. An agreed system is now in place which clarifies that prison staff are responsible for welfare checks and medical staff are responsible for clinical observations. Healthcare staff inform prison staff of the need for checks on a particular prisoner and what level of check is required. Where healthcare feel it is clinically appropriate, a move to the inpatient unit at the prison will be facilitated so that healthcare staff are present to undertake all observations.” Source location Response from HM Prison and Probation Service
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Concerns raised 1
Incomplete information sharing between healthcare and prison security staff View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
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Thomas Victor HUNTLEY · Prevention of Future Deaths report
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Report summary
Thomas Victor Huntley died in HMP Winchester after he was found unresponsive in his cell on 28 May 2020, following a planned act intended to end his life. The inquest identified concerns about missing and inadequately recorded risk information, failures in ACCT documentation and risk assessment, inadequate observations, information sharing between prison and healthcare staff, and ligature risks in cells.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Incomplete information sharing between healthcare and prison security staff
Wider context from the report “Information sharing.
In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff. Healthcare staff record and share their information within SystemOne which the prison security staff do not have access to. Prison security staff record information within NOMIS which healthcare staff do not have access to.
Evidence from witnesses revealed that these information systems are not necessarily fully reviewed for relevant information prior to attending ACCT meetings .
In addition a decision relating to Mr Huntley’s care (i.e. the move to a different cell) was taken by healthcare staff at their own meeting when they did not have the benefit of information available to prison staff.
████████ of HMP Winchester informed me that a Safety Intervention Meeting was now carried out weekly, chaired by a Senior Governor and attended by representatives of the prison, physical and mental health care providers and the probation service. This meeting covers each person subject to an ACCT and any relevant information is share via the ACCT case manager, NOMIS and the multi disciplinary team. ████████ could not assist me with whether this was a HMP Winchester initiative or had a wide application across the prison estate.
My concern is therefore that the current procedures and policies for sharing information are incomplete or not fully complied with . This renders the information which separate teams make decisions about a prisoner incomplete and increases the risk that important factors are not considered.
” Source location Thomas Victor HUNTLEY · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational staff cannot access healthcare records because medical confidentiality prevents direct access to SystmOne.
Verbatim wording from the response “While SystmOne, the electronic system used by healthcare staff to record medical information cannot be accessed by operational staff for reasons of medical confidentiality, the appropriate sharing of information is encouraged through a range of methods, for example the morning operational meeting is multi-disciplinary and allows all those working with individuals to provide updates and ensure necessary information is shared. The Daily Briefing sheet and wing observation books are also vital tools to ensure all staff are aware of concerns regarding a prisoner.” Source location Response from HM Prison and Probation Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing multidisciplinary meetings, briefing sheets and observation books are considered sufficient to share necessary prisoner safety information.
Verbatim wording from the response “While SystmOne, the electronic system used by healthcare staff to record medical information cannot be accessed by operational staff for reasons of medical confidentiality, the appropriate sharing of information is encouraged through a range of methods, for example the morning operational meeting is multi-disciplinary and allows all those working with individuals to provide updates and ensure necessary information is shared. The Daily Briefing sheet and wing observation books are also vital tools to ensure all staff are aware of concerns regarding a prisoner.” Source location Response from HM Prison and Probation Service
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24 Oct 2022 Bradleigh Trevor Barnes · Prevention of Future Deaths report Dorset
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Concerns raised 1
Absence of a local operating policy on the use of force between prison and healthcare services View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
HM Prison and Probation Service NHS England Oxleas NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Oxleas NHS Foundation Trust
Implement a memorandum of understanding governing healthcare attendance at, and planned participation in, use-of-force interventions.
View source
NHS England
Write to prison healthcare providers requiring agreed local procedures covering healthcare roles during restraint and monitoring, recording and response to vital signs during and after incidents.
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NHS England
Request assurance from regional commissioning directors that the required local procedures have been implemented and evidenced by April 2023.
View source
HM Prison and Probation Service
Produce a memorandum of understanding defining healthcare roles during planned and unplanned use-of-force incidents and required post-incident actions.
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Bradleigh Trevor Barnes · 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
Bradleigh Trevor Barnes was found suspended by a ligature in his cell at HMP YOI Portland on 28 December 2019. The inquest concluded that the death was suicide. Concerns included a lack of national NHS guidance for healthcare staff on the use of force in prison and the absence of a local operating policy between the prison and healthcare provider at HMP YOI Portland.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Absence of a local operating policy on the use of force between prison and healthcare services
Wider context from the report “ii. There is no local operating policy on the use of force at HMP YOI Portland between the healthcare and the prison and I request that the Governor of HMP YOI Portland and the Chief Executive of Oxleas consider putting a local instruction policy in place.
” Source location Bradleigh Trevor Barnes · Prevention of Future Deaths report
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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 memorandum of understanding governing healthcare attendance at, and planned participation in, use-of-force interventions.
Verbatim wording from the response “We have now put in place a memorandum of understanding between healthcare and the prison regarding attendance of healthcare and all planned use of force interventions in accordance with the HM Prison Service, Prison Service Order: Order Number 1600 – Use of Force (see attached)” Source location Response from NHS Oxleas
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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 Write to prison healthcare providers requiring agreed local procedures covering healthcare roles during restraint and monitoring, recording and response to vital signs during and after incidents.
Verbatim wording from the response “Whilst the guidance and PSA referred to above were already in place around the time of Bradleigh’s death, NHS England recognises there is learning to be taken from the sad events in this case, and will be writing to all prison healthcare providers, via our seven regional commissioning teams, requiring them to work with their prison governor and have an agreed local operating procedure in place that includes:” Source location Response from NHS England
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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 Request assurance from regional commissioning directors that the required local procedures have been implemented and evidenced by April 2023.
Verbatim wording from the response “NHS England’s central team will request assurance from our regional Directors of Commissioning that the above actions have been implemented and evidenced by April 2023. We are happy to provide you with a further update at this time if you consider this would assist?” Source location Response from NHS England
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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 Produce a memorandum of understanding defining healthcare roles during planned and unplanned use-of-force incidents and required post-incident actions.
Verbatim wording from the response “Following evidence heard at the inquest you have raised a concern that there was no local operating policy on the use of force between the prison and the healthcare provider. There is a new healthcare provider at the prison, Oxleas NHS Foundation Trust – Offender Healthcare Services. When healthcare providers are commissioned, part of the contract refers to the fact that they must adopt HMPPS policies and be guided by them. The contract began on 1 December 2022 and a memorandum of understanding (MOU) has been produced by the Governor of HMP Portland and the Service Director of Oxleas NHS Foundation Trust, setting out the role of healthcare during planned and unplanned use of force incidents as well as post incident actions to be followed to ensure the wellbeing of prisoners and staff.” Source location Response from HM Prison & Probation Service (1)
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policies and the local memorandum of understanding address healthcare roles during planned and unplanned use of force incidents.
Verbatim wording from the response “Following evidence heard at the inquest you have raised a concern that there was no local operating policy on the use of force between the prison and the healthcare provider. There is a new healthcare provider at the prison, Oxleas NHS Foundation Trust – Offender Healthcare Services. When healthcare providers are commissioned, part of the contract refers to the fact that they must adopt HMPPS policies and be guided by them. The contract began on 1 December 2022 and a memorandum of understanding (MOU) has been produced by the Governor of HMP Portland and the Service Director of Oxleas NHS Foundation Trust, setting out the role of healthcare during planned and unplanned use of force incidents as well as post incident actions to be followed to ensure the wellbeing of prisoners and staff.” Source location Response from HM Prison & Probation Service (1)
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16 May 2019 Daniel Davey · Prevention of Future Deaths report Oxfordshire
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Concerns raised 1
Failure of prison and healthcare staff to jointly manage in-possession medication risks and intervene promptly View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
HM Prison and Probation Service Midlands Partnership University NHS Foundation Trust Practice Plus Group Health And Rehabilitation Services Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Midlands Partnership University NHS Foundation Trust
Remind staff to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.
View source
Midlands Partnership University NHS Foundation Trust
Work with Care UK, Pharmacy and Safer Custody on medication reviews and stop checks under the ACCT procedure.
View source
Practice Plus Group Health And Rehabilitation Services Limited
Review in-possession medication risk assessments after specified incidents, changed circumstances, ACCT openings, or other identified safety concerns.
View source
Practice Plus Group Health And Rehabilitation Services Limited
Conduct random medication spot checks and review or remove in-possession status when discrepancies or patient-safety concerns arise.
View source
HM Prison and Probation Service
Issue guidance requiring ACCT case managers to discuss in-possession medication routinely and complete risk assessments with healthcare input.
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HM Prison and Probation Service
Distribute a safety briefing on in-possession medication risks and required action during fabric checks or cell searches to all staff.
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HM Prison and Probation Service
Include stockpiled medication and temporary removal considerations in future local ACCT case-manager training.
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Daniel Davey · 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
Daniel Davey, aged 21, died at John Radcliffe Hospital on 12 January 2018 after deliberately overdosing on propranolol in his cell at HMP Bullingdon Prison. The report raises concerns about healthcare attendance at ACCT reviews, risk assessments and management of in-possession medication, cell searches, and failures to share and act on information relevant to his safety.
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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 jointly manage in-possession medication risks and intervene promptly
Wider context from the report “2. Reviews of ‘in possession’ medication risk assessments – The second concern also relates to prison and healthcare. In particular, it relates to a prisoner placed on an ACCT. I heard evidence that, initially, a template is used at the reception healthcare screen to determine if medication should be held in possession or not. I was told that, now, this is subsequently reviewed by the prescriber and, on opening an ACCT, there is an automatic review of the risk assessment in accordance with CUK’s new policy.
In the case of Mr Davey, there was an initial risk assessment at reception and he was deemed suitable for in possession medication, but this was not reviewed when he was subsequently placed on the 2 ACCT documents in December and January or when he disclosed to a mental health nurse on 29 December that he had a plan to kill himself. I understand that new systems are in place (with healthcare) but it would be reassuring if there is a system of audit to ensure compliance, namely, that the in possession risk assessments are reviewed. I appreciate a review might not necessarily result in medication being taken away. I also appreciate this is a difficult area in view of patient confidentiality and, of course, the danger that a prisoners physical or mental health could be put at risk if medication is taken away.
A related concern is the fact that prison officers did not appear to have in mind the risks associated with in possession medication . It appeared to be disregarded because it was information that was not available to them and it was therefore deemed a matter for healthcare. I am concerned that there is a danger in leaving the issue of in possession medication solely to healthcare. There could be a time delay of several hours or even longer between a prisoner having a mental health crisis and healthcare involvement/reassessment . It appears there needs to be joint liaison between the ACCT case manager and healthcare and a plan to intervene and remove medicine if necessary .
This leads to a final related concern. There is the question of cell searches for stockpiled medication and the collection of properly held in possession medication when there is a change of risk such as an ACCT document being opened. I did not hear much evidence about practice or policies relating to searching and potentially removing medication. This is clearly a task that rests with prison staff and it would be helpful to have further information about this.
” Source location Daniel Davey · Prevention of Future Deaths report
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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 Remind staff to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.
Verbatim wording from the response “Response:
As was stated at the inquest, our prescriber’s always record on the prescription form whether the medication they are prescribing should be held in possession. We have reminded our staff to ensure when they are reviewing any medication that they, where necessary, include an update of the ‘Medication In possession risk assessment’ which goes onto SystmOne, which in turn will feed into the ACCT. This ensures that both dispensing staff and prison staff are aware of any changes and respond accordingly, this will include the removal of any medicines currently being held.” Source location 2019-0267-Response-by-Midlands-NHS-Trust
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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 Work with Care UK, Pharmacy and Safer Custody on medication reviews and stop checks under the ACCT procedure.
Verbatim wording from the response “As part of the ACCT LOP we are committed to working with colleagues in Care UK, Pharmacy and Safer Custody regarding medication reviews and “stop checks”.” Source location 2019-0267-Response-by-Midlands-NHS-Trust
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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 Review in-possession medication risk assessments after specified incidents, changed circumstances, ACCT openings, or other identified safety concerns.
Verbatim wording from the response “HMP Bullingdon also adheres to the Care UK “In possession policy for Prisons” which reviews ‘in possession’ status:” Source location 2019-0267-Response-by-Care-UK
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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 random medication spot checks and review or remove in-possession status when discrepancies or patient-safety concerns arise.
Verbatim wording from the response “I would like to provide assurance that random spot checks are undertaken to support concordance and reduce the risk of diversion or stockpiling for overdose.” Source location 2019-0267-Response-by-Care-UK
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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 Issue guidance requiring ACCT case managers to discuss in-possession medication routinely and complete risk assessments with healthcare input.
Verbatim wording from the response “Your second concern relates to reviews of in possession medication risk assessments. I understand Care UK and Midlands Partnership NHS Foundation Trust will be replying to you separately on this point. At Bullingdon, if the ACCT case manager is concerned about the immediate welfare of an individual they are required to conduct a review immediately, and to ensure that there is healthcare input to that review. The prison has issued guidance to all case managers stating that in possession medication is one of the topics that should routinely be discussed in ACCT reviews, and that a risk assessment must be conducted, informed by the advice of healthcare staff. If this advice is not immediately available then ACCT case managers can at their discretion remove in possession medication until they can confirm that it is safe for the prisoner to continue to have it in their own possession.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
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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 Distribute a safety briefing on in-possession medication risks and required action during fabric checks or cell searches to all staff.
Verbatim wording from the response “Lastly, you asked about the policy for cell searches for stockpiled medication. The safer custody department has distributed a safety briefing on in possession medication to all staff to ensure that they are aware of the risks and know what action to take if they discover unusual amounts of in possession medication when conducting fabric checks or cell searches. In future, the issue of stockpiled medication will also be covered in the local ACCT case manager training so that, when immediate actions plans are completed, consideration is given to the need to check for and remove in possession medication as a temporary measure before a full assessment and review has taken place.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
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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 Include stockpiled medication and temporary removal considerations in future local ACCT case-manager training.
Verbatim wording from the response “Lastly, you asked about the policy for cell searches for stockpiled medication. The safer custody department has distributed a safety briefing on in possession medication to all staff to ensure that they are aware of the risks and know what action to take if they discover unusual amounts of in possession medication when conducting fabric checks or cell searches. In future, the issue of stockpiled medication will also be covered in the local ACCT case manager training so that, when immediate actions plans are completed, consideration is given to the need to check for and remove in possession medication as a temporary measure before a full assessment and review has taken place.” Source location 2019-0267-Response-by-HM-Prison-Probation-Service
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing monthly audits, policy reviews and spot checks are considered sufficient to manage in-possession medication risks.
Verbatim wording from the response “I can confirm that HMP Bullingdon is fully compliant with Care UK’s mandatory monthly audit in ensuring all prisoners have an ‘in possession status’ recorded on their medical notes from reception.” Source location 2019-0267-Response-by-Care-UK
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Safer Custody Governor is taking forward responsibility for including medication-risk awareness in case manager training.
Verbatim wording from the response “I have met with the Safer Custody Governor and discussed the need for prison staff to have a joint responsibility when considering ‘in possession’ medication is a potential risk. The Safer Custody Governor is recommending this awareness is included in case manager training and is taking this action forward.” Source location 2019-0267-Response-by-Care-UK
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10 Jan 2019 Natasha Learline CHIN · Prevention of Future Deaths report Surrey
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Concerns raised 1
Lack of medication information sharing with discipline staff View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Natasha Learline CHIN · 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
Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and training.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of medication information sharing with discipline staff
Wider context from the report “1. The prison officer with responsibility for the wing on which Miss Chin was resident was not privy to what medication she was prescribed nor when it should be administered. There is no system in place for consent to be obtained from prisoners for this information to be shared with discipline staff.
2. The Sodexo Justice Service Protocols in respect of opiate and alcohol withdrawal did not adequately mirror the National Protocols and were, in parts, unclear and difficult to comprehend.
3. Nurses failed to make any datix referrals in respect of missed medications.
4. The following matters have to date not been formally audited by Sodexo Justice Services:
i.) Whether prisoners who do not attend for prescribed medications are followed up and the reason for non-attendance is properly recorded.
ii.) Whether critical medication is administered on time.
iii.) Whether proper observations are undertaken in line with national or local protocols in respect of opiate and alcohol withdrawal.
iv.) Whether medical records on System 1 are accurately recorded.
v.) Whether the Patient Guidance Directions in respect of prescribing by nurses are adhered to, and whether medical records are checked before any prescriptions are made by nurses pursuant to the directive.
5. As a consequence it is not possible for Sodexo Justice Services to know whether the matters raised in 4.(i) to (v) have been adequately addressed.
6. The response by Sodexo Justice Services to the issues identified in the report dated the 13th April 2016 of Her Majesty’s Chief Inspector of Prisons in respect of non-administration of prescribed medication was inadequate. It does not appear that there was a clear line of governance in respect of this matter.
7. Whether there is adequate training:
i.) of discipline and clinical staff, including agency staff, to make them aware of the signs and dangers of opiate and alcohol withdrawal.
ii.) of clinical staff in respect of the completion of opiate and alcohol withdrawal scales.
” Source location Natasha Learline CHIN · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to communicate elevated NPS-related risk to Healthcare and prison officers View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Jerome Jason Omri 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
Jerome Jason Omri Jones was a serving prisoner who died in hospital after being found unresponsive in his cell, following suspected use of a synthetic cannabinoid and in the context of a congenital heart defect. The concerns included the absence of guidance for additional checks after repeated NPS use, no clear method for communicating his increased risk to healthcare or prison officers, and limited access by drug workers to relevant medical information.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate elevated NPS-related risk to Healthcare and prison officers
Wider context from the report “(2)The inquest heard evidence from two Forward Trust Drug workers who although not medically qualified, considered that Mr Jones was at a ‘higher’ risk from NPS use due to using NPS with his existing congenital heart defect. I was told there was no method of communicating this to either Healthcare or prison officers to enable further periodic checks to be undertaken particularly in light of the recent incident on 20/10/17.
” Source location Jerome Jason Omri JONES · Prevention of Future Deaths report
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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 Notify staff that healthcare determines when additional checks are needed and must communicate this to prison discipline staff.
Verbatim wording from the response “establishment. All staff were notified of this last month by way of a Notice to Staff which also reminded them that healthcare staff are responsible for determining when additional checks of prisoners at risk from repeated use of psychoactive substances are necessary, and that this must be communicated by them to all prison discipline staff.” Source location 2018-0369-Response-by-HM-Prison-Probation-Service
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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 Issue a notice reminding Forward Trust drug workers how to share information with prison and healthcare staff.
Verbatim wording from the response “In September, a staff notice was also issued by the Governor to all Forward Trust Drug workers at the establishment to remind them of how to share information with prison and healthcare staff. To further improve communication between Forward Trust drug workers and healthcare staff, every member of Forward Trust will be given access to SystmOne by April 2019, in order that they can both enter information onto the system and access it.” Source location 2018-0369-Response-by-HM-Prison-Probation-Service
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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 Give every Forward Trust member access to SystmOne to enter and access information.
Verbatim wording from the response “In September, a staff notice was also issued by the Governor to all Forward Trust Drug workers at the establishment to remind them of how to share information with prison and healthcare staff. To further improve communication between Forward Trust drug workers and healthcare staff, every member of Forward Trust will be given access to SystmOne by April 2019, in order that they can both enter information onto the system and access it.” Source location 2018-0369-Response-by-HM-Prison-Probation-Service
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11 Jan 2018 John Martin Chapman · Prevention of Future Deaths report Lancashire
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Concerns raised 1
Failure to routinely share prisoner self-harm and well-being information with reception healthcare staff View source
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John Martin Chapman · 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 Martin Chapman was transferred to HMP Wymott on 23 January 2014, and information about two previous self-harm or threatened self-harm incidents was not passed to the reception nurse. He was found hanging in his cell on 21 March 2014; the inquest concluded that he died as a result of accidental hanging. The report identified concerns about the lack of a formal mechanism for sharing relevant self-harm and welfare information between prison and healthcare staff during reception.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to routinely share prisoner self-harm and well-being information with reception healthcare staff
Wider context from the report “1. TO THE GOVERNOR HMP WYмott
Although evidence was heard to the effect that currently at reception at HMP Wymott the CNomis entries relating to a newly arrived prisoner are scrutinised by prison reception staff to ascertain whether there are any self-harm or welfare alerts, it did not appear that a direction exists to pass relevant information to the nurse carrying out the reception medical screen .
2. TO THE GOVERNOR AND HEAD OF HEALTHCARE
There does not appear to be a mechanism at reception whereby information relevant to the self-harm or well-being of a prisoner is routinely shared by prison staff with medical staff carrying out a reception medical screen including alerts on the CNomis system . As a result, there appears to be a danger that significant alerts concerning a prisoner might not come to the attention of the reception nurse to enable the nurse to take appropriate action and make relevant entries within the medical records.
Those in authority, giving evidence on behalf of the prison and healthcare on the subject of reception practice, saw merit in there being a formal procedure agreed between prison discipline staff on the one hand and healthcare staff on the other, for the sharing of information relevant to a prisoner’s well-being, and for this to be accomplished promptly .
” Source location John Martin Chapman · Prevention of Future Deaths report
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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 Provide reception staff with PSI 07/2015, require them to read and comply with it, and monitor completion through performance records.
Verbatim wording from the response “Every member of staff in reception at HMP Preston has been provided with a copy of the PSI and set an objective to read and comply with it in their Staff Performance and Development Record. Line managers will monitor the achievement of this objective. Copies of the PSI are also available in the reception area.” Source location 2018-0007-Response-by-HM-Prison-and-Probation-Service
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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 Routinely pass PER forms to the reception nurse and require documentation in SystemOne that each form was received and considered.
Verbatim wording from the response “As you note in your report, you were advised during the inquest that the prison and healthcare intended to hold a meeting to discuss ways in which the sharing of information during the reception process might be improved. I can advise you that this meeting took place recently on March 1st.
As a result of the meeting between the prison and healthcare it has been agreed that henceforth PER forms will be passed to the reception nurse as a matter of routine and the nurse must then document within the SystemOne record that the form has been received and considered. It is hoped that this “check” may be incorporated into the record system, as part of the existing reception health screen template, and this possibility is currently being explored.
Thank you once again for bringing your concern to my attention.” Source location 2018-0007-Response
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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 Explore incorporating a PER-form receipt check into the existing reception health-screen template.
Verbatim wording from the response “As you note in your report, you were advised during the inquest that the prison and healthcare intended to hold a meeting to discuss ways in which the sharing of information during the reception process might be improved. I can advise you that this meeting took place recently on March 1st.
As a result of the meeting between the prison and healthcare it has been agreed that henceforth PER forms will be passed to the reception nurse as a matter of routine and the nurse must then document within the SystemOne record that the form has been received and considered. It is hoped that this “check” may be incorporated into the record system, as part of the existing reception health screen template, and this possibility is currently being explored.
Thank you once again for bringing your concern to my attention.” Source location 2018-0007-Response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CNomis is not managed by healthcare, and reception nurses are not routinely granted access to it.
Verbatim wording from the response “As a result there appears to be a danger that significant alerts concerning a prisoner might not come to the attention of the reception nurse”
It is, of course, recognised that it is important to share relevant information and the reception nurse would expect prison officers always to communicate any significant information regarding risk or welfare of which they were aware – whether this be contained in a PER document, on CNomis, or otherwise. As you were made aware during the inquest, it was not the practice, at the time, for the PER document to be passed by prison officers to the reception nurse and, regards CNomis, this is not a system managed by healthcare and nurses are not routinely granted access to it.” Source location 2018-0007-Response
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18 Dec 2017 MARK ANTHONY DOYLE · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to share relevant healthcare information on prisoners’ ACCT records View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Care UK
Embed procedures for identifying and sharing relevant prisoner risks and triggers with prison staff, supported by senior-management audits.
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MARK ANTHONY DOYLE · 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 Anthony Doyle was found suspended by a ligature attached to his cell window bars on 21 March 2017 and died in hospital on 28 March 2017 from injuries sustained in the suspension. The inquest identified concerns including errors in recording a significant anniversary on his ACCT, his transfer from F Wing, and a delay in responding to his cell bell. Further concerns related to ACCT review and information-sharing practices, unclear criteria and recording for transfers from F Wing, and the lack of mandatory first-aid training for existing prison officers.
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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 relevant healthcare information on prisoners’ ACCT records
Wider context from the report “(2) Although, ████████, Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared , in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily record .
” Source location MARK ANTHONY DOYLE · Prevention of Future Deaths report
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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 Embed procedures for identifying and sharing relevant prisoner risks and triggers with prison staff, supported by senior-management audits.
Verbatim wording from the response “Response: Following the inquest I have reflected and reviewed healthcare processes and there have been discussions within the healthcare team. Going forward we will ensure that the Local Operating Procedures (LOPs) are embedded, with senior management undertaking audits, to ensure that where any relevant risks and triggers are identified, we will share information with the prison in the following ways:–” Source location Response from Care UK
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.