Recurring concern

Unsafe interoperability between prison custody and healthcare procedures

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First reported 13 Jan 2014•Latest report 20 May 2026

Definition

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.

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
35

Distinct published reports

Individual concerns
40

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
88

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service17
Ministry of Justice10
Department of Health and Social Care4
Oxleas NHS Foundation Trust4
Care UK3
NHS England3
Northamptonshire Healthcare NHS Foundation Trust3
Pentonville Prison3
Prisons and Probation Ombudsman3
Government Legal Department2
Herefordshire and Worcestershire Health and Care NHS Trust2
HM Inspectorate of Prisons2
Lowdham Grange Prison2
Nottinghamshire Healthcare NHS Foundation Trust2
Practice Plus Group2

Concerns and responses across reports

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

  1. Inner North London

    AI-generated summary

    William DAVIES · 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

    William Davies was found unresponsive in his cell at HMP Pentonville and died from natural causes, identified as coronary artery atherosclerosis. Concerns were raised about unclear procedures and delays in requesting an ambulance after a life-threatening call, as well as uncertainty among prison healthcare staff about responsibilities and verification of death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unclear process for attending prisoners with life-threatening conditions

    Wider context from the report

    “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances. ”

    Source location

    William DAVIES · 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

    Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.

    Verbatim wording from the response

    “• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.”

    Source location

    Response from Care UK
    Page 1 · response
    Published 5 November 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review emergency care arrangements, including staff training and standardisation of emergency bags.

    Verbatim wording from the response

    “• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.”

    Source location

    Response from Care UK
    Page 1 · response
    Published 5 November 2014

    Open published response

  2. Liverpool

    AI-generated summary

    Wilfred Roy Aspinwall · 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

    Wilfred Roy Aspinwall was a frail prisoner with several co-morbidities who sustained falls, including a hip fracture, and later died after a gradual deterioration in health on 21 April 2013. The inquest concluded that he died from natural causes. A substantive concern was that the PPO report and Clinical Review had not been shared with the healthcare provider at HMP Liverpool.

    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 PPO reports and Clinical Reviews with prison healthcare providers

    Wider context from the report

    “At the inquest hearing it was clear that the PPO report and Clinical Review had not been sent to nor shared with the Healthcare provider at HMP Liverpool. It might be considered good practice for future reports, in all prison fatalities should to be sent to either the head of healthcare and/or the commissioning NHS Trust to ensure that recommendations have an optimal effect. ”

    Source location

    Wilfred Roy Aspinwall · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    David Andrew Llewellyn O’GARRO · 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

    David Andrew Llewellyn O’Garro suffered a sudden death in epilepsy while occupying a single cell at HMP Pentonville, with nobody present to raise the alarm during what was likely his final seizure. Concerns included the failure to complete or locate a cell sharing risk assessment and a lack of clarity and shared understanding among prison staff about ensuring prisoners with epilepsy had a cellmate.

    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 reliable communication of healthcare cell-sharing instructions to prison officers

    Wider context from the report

    “The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy. No HMP Pentonville CSRA was ever found for Mr O’Garro. During the inquest: - one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate; - a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works; - one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book. Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville. ”

    Source location

    David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Teesside

    AI-generated summary

    Andrew Ronald Hall · 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

    Andrew Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.

    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 correctly document information provided by mental healthcare nursing staff to Prison Officers

    Wider context from the report

    “1. In the assessment of risk and risk management the jury found (inter alia) information provided by mental healthcare nursing staff to Prison Officers was not correctly documented. ”

    Source location

    Andrew Ronald Hall · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Record mental health risk information received during ACCT reviews and monitor that contributions are documented.

    Verbatim wording from the response

    “You are concerned that information about risk provided by mental healthcare nursing staff to prison staff was not correctly documented (point 1). ACCT reviews are chaired by supervising officers who record any information about risk that is received from the mental health team. Where a prisoner has mental health issues, a member of the mental health team is invited to attend all ACCT reviews. The mental health team has received ACCT training, and further training sessions are arranged when new members join the team. Mental health staff play an active role in the management of ACCT plans, and a significant number of ACCTs are opened by the team. The prison’s regular management checks confirm that members of the mental health team attend reviews and that their contributions are recorded.”

    Source location

    2014-0122-Response-by-NOMS
    Page 1 · response
    Published 12 March 2014

    Open published response

  5. County Durham and Darlington

    AI-generated summary

    Zeeyad Hamadi · 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

    Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.

    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 policy or guidance for prison staff and health care providers managing complex privately funded transfers

    Wider context from the report

    “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented. Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS. ”

    Source location

    Zeeyad Hamadi · 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

    Delays and limitations in liaison and communication between prison and hospital health care staff

    Wider context from the report

    “(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand. ”

    Source location

    Zeeyad Hamadi · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Record keeping, prison-hospital liaison, bed-watch security and prison ownership issues are not for the Department of Health to respond to.

    Verbatim wording from the response

    “I consider that several of the issues you have raised regarding record keeping, liaison between prison and hospital medical staff, security issues such as bed-watch and ownership of the situation at the prison, are not for my Department to respond.”

    Source location

    2014-0014-Response-by-Department-of-Health
    Page 2 · response
    Published 13 January 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The National Offender Management Service is expected to address record keeping, liaison, bed-watch security and ownership issues.

    Verbatim wording from the response

    “I note that you have sent a copy of this Regulation 28 report to the National Offender Management Service (NOMS) and I would expect them to properly address these issues.”

    Source location

    2014-0014-Response-by-Department-of-Health
    Page 2 · response
    Published 13 January 2014

    Open published response
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Data last updated 7 September 2026