8 Apr 2026 Jonathan Mark Thornton · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Lack of formal information sharing and reliable handover between the CFT and Prison Healthcare View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
HM Prison and Probation Service Ministry of Justice Northamptonshire Healthcare NHS Foundation Trust Nottingham Prison Nottinghamshire Healthcare 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. 10
Northamptonshire Healthcare NHS Foundation Trust
Establish practical information-sharing arrangements and named contacts between community forensic and prison healthcare teams.
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Nottinghamshire Healthcare NHS Foundation Trust
Implement a formal information-sharing procedure requiring prompt, secure, documented handover of clinical and risk information, standard documents, and escalation when contact fails.
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Nottinghamshire Healthcare NHS Foundation Trust
Share and agree the information-sharing guidance with CFT staff, Prison Healthcare providers, and HMP Lincoln to establish consistent cross-organisational expectations.
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Nottinghamshire Healthcare NHS Foundation Trust
Embed the information-sharing guidance through team briefings, clinical supervision, and induction for new staff.
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Nottinghamshire Healthcare NHS Foundation Trust
Maintain a dedicated CFT Link Worker as a consistent Prison Healthcare contact with oversight of information sharing, timely responses, continuity, and service liaison.
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Nottinghamshire Healthcare NHS Foundation Trust
Establish bimonthly interface meetings with HMP Nottingham Prison Healthcare teams to review cases, address communication issues, monitor guidance adherence, and escalate risks.
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Nottinghamshire Healthcare NHS Foundation Trust
Work jointly with Northamptonshire Healthcare NHS Foundation Trust to clarify responsibilities, availability expectations, responsiveness, and escalation pathways.
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Nottinghamshire Healthcare NHS Foundation Trust
Conduct quarterly audits of information-sharing timeliness, documentation completeness, and escalation, and report findings to relevant quality and accountability groups.
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HM Prison and Probation Service and Ministry of Justice and Nottingham Prison
Issue and disseminate information-sharing guidance to prisons through booklet, wallet-sized and intranet formats.
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HM Prison and Probation Service and Ministry of Justice and Nottingham Prison
Ask the Information Sharing Advisory Group to examine the circumstances of Mr Thornton’s death, identify learning and assess whether updated guidance is needed.
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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.
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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 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
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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 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
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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
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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 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
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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 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
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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
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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 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
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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 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
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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
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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 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
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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 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
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24 Mar 2026 Ronald William MEIKLE · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Failure to reliably consolidate and share relevant prisoner risk information View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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 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
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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 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
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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 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
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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 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
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29 Sep 2025 Jake Hickey Girton · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to inform the hospital of release from police custody View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Metropolitan Police Service
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
Metropolitan Police Service
Complete mapping of existing information-sharing pathways for releases from custody.
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Metropolitan Police Service
Develop a protocol for lawful, prompt notification of appropriate mental health services when people in crisis are released from custody.
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Metropolitan Police Service
Work with mental health partners to develop consistent London-wide arrangements, accountability lines and welfare escalation routes after release.
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Metropolitan Police Service
Develop guidance for custody and investigating officers on identifying risk, recording indicators and initiating referrals or notifications before release.
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AI-generated summary
Jake Hickey Girton · 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
Jake Hickey Girton was admitted to psychiatric hospital following suicidal ideation and serious, sustained alcohol misuse, and was later arrested after an incident on the ward. He was released from police custody without the psychiatric Trust being informed and was subsequently found deceased at home on 26 January 2024; the inquest identified concerns about the failure to notify the Trust and the lack of evidence of reflection or remediation by the Metropolitan Police Service.
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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 inform the hospital of release from police custody
Wider context from the report “1. Evidence heard from a Metropolitan Police Inspector at inquest indicated that the police officer who was investigating the offence for which Jake was arrested was under an obligation to inform that complainant (the hospital) of Jake’s release from custody . There is no evidence to suggest this was done . Evidence from the Psychiatric trust at inquest indicates that on the 17th January 2024, there were under the impression that Jake would remain in police custody, and had they known he was released, greater efforts may have occurred to support Jake in the community.
” Source location Jake Hickey Girton · Prevention of Future Deaths report
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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 Complete mapping of existing information-sharing pathways for releases from custody.
Verbatim wording from the response “A review has already been undertaken in relation to information sharing with Mental Health Trusts which has identified a gap in current arrangements. Specifically, there is no consistent mechanism to ensure Mental Health services are notified when an individual is released from custody. This gap can result in missed opportunities for early intervention and continuity of care.” Source location Response from Metropolitan Police
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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 Develop a protocol for lawful, prompt notification of appropriate mental health services when people in crisis are released from custody.
Verbatim wording from the response “2. The MPS is developing a protocol, agreed through local partnership governance to ensure that when a person identified as being in mental health crisis or having been arrested in a mental health setting, is released from custody, relevant information can be shared promptly and lawfully with the appropriate Mental Health Trust or Community Mental Health Team, if known. This protocol is being aligned with data protection and safeguarding requirements under existing information governance frameworks.” Source location Response from Metropolitan Police
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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 mental health partners to develop consistent London-wide arrangements, accountability lines and welfare escalation routes after release.
Verbatim wording from the response “3. The MPS is working with Mental Health Trust Leads and the Joint Mental Health and Police Group (JMHPG) to develop consistent arrangements across London. This includes establishing clear lines of accountability and escalation routes where concerns arise about a person’s welfare post release.” Source location Response from Metropolitan Police
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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 Develop guidance for custody and investigating officers on identifying risk, recording indicators and initiating referrals or notifications before release.
Verbatim wording from the response “4. Additional guidance is being developed for custody and investigating officers, supported by the MPS Mental Health Lead. This will reinforce the importance of identifying those at risk, recording relevant indicators and initiating the appropriate referral or notification before release.” Source location Response from Metropolitan Police
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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 DPS review was appropriate and went as far as expected because it identified no conduct, performance or organisational learning.
Verbatim wording from the response “The MPS Directorate of Professional Standards (DPS) conducted a comprehensive review into this matter as per their remit and standard operating procedure. It was determined that this incident did not meet the definition of a Death or Serious Injury¹ (DSI) following police contact as defined in the Independent Office for Police Conduct (IOPC) Statutory Guidance. Upon conducting DSI reviews, the expectation is for DPS to also consider whether there is an obvious conduct matter, performance matter or opportunity for individual or organisational learning. In this instance, the review did not identify any such learning.” Source location Response from Metropolitan Police
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22 Jan 2025 Nathan Harry SHEPHERD · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of the prison-to-probation process to share and locate key risk information 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
Ministry of Justice
Use the new digital referral process to combine prison and probation information, including custodial behaviour and suicide and self-harm risk, for Approved Premises assessments.
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Nathan Harry SHEPHERD · 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
Nathan Harry Shepherd died in hospital on 16 January 2024 after being found suspended from a ligature in his room at approved premises, following an unsuccessful attempt to gain immediate entry because the room had been barricaded. The inquest concluded that the death was suicide, with medical cause of death recorded as hypoxic brain injury and hanging. Concerns included the lack of policies and training for barricaded-room incidents, movable furniture that enabled barricading, ligature points, inadequate assurance of agency staff first-aid and CPR capability, and ineffective sharing of risk 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 of the prison-to-probation process to share and locate key risk information
Wider context from the report “6. Evidence from Probation and Prison staff showed a lack of understanding of how the prison system could update the probation system and where that information could be found . This meant that key information was not shared effectively creating a risk that probation staff in the community would not have a full picture of risk .
” Source location Nathan Harry SHEPHERD · 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 Use the new digital referral process to combine prison and probation information, including custodial behaviour and suicide and self-harm risk, for Approved Premises assessments.
Verbatim wording from the response “There is now a new digital referral process in place that pulls information from both prison and probation systems as part of the referral process, allowing for much more accurate and timely sharing of information. The information is pulled directly from CNOMIS into a live referral document and this is reviewed by the practitioner and also the AP Manager who assesses the referral. The information includes custodial behaviour and issues around suicide and self harm risk.” Source location Response from HMPPS
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Concerns raised 1
Failure of LDS and police information sharing about custody mental health presentation View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Midlands Partnership University NHS Foundation Trust National Police Chiefs’ Council NHS England Sussex Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
NHS England
Develop a standard template and guidance with NPCC and CPS for transferring relevant Liaison and Diversion assessment information to police.
View source
Sussex Police
Maintain documented, verbally delivered and CCTV-recorded custody handovers, with live risk updates, shared access, audit trails, staff training and peer review.
View source
Sussex Police
Record custody risks and concerns discussed with Liaison and Diversion staff on the detainee’s risk assessment and care plan.
View source
National Police Chiefs’ Council
Consider best practice through the Betterment Workstream, including a nationally recognised pre-arrival risk assessment for communicating custody risks.
View source
National Police Chiefs’ Council
Raise NHS Trust information-sharing failures between criminal justice pathways as a detainee welfare concern.
View source
Midlands Partnership University NHS Foundation Trust
Add a standard template for written information shared with police colleagues to the Custody Pathway SOP.
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Miles Ethan Hurley · 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
Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.
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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 LDS and police information sharing about custody mental health presentation
Wider context from the report “4. Memorandum of Understanding between Midlands Partnership University NHS Foundation Trust, Sussex Police and Mitie
The MOU does not adequately address the practical issues facing an LDS and the police services to ensure appropriate management of mental health assessment and ongoing care whilst an individual is in Custody. There is an absence of local or national ‘Standard Operating Procedures’ or guidelines as to when to obtain a mental health assessment if an individual is intoxicated, a lack of formal documentation procedures, or steps to be taken to encourage further sharing of available information between the LDS service and the police (the LDS practitioner was not fully informed of Miles’s presentation at arrest , was not informed of the concerns raised by the family regarding Miles’s acute deterioration in his mental health and had no access to police records to be better informed ). Nor are there any appropriate templates available with regard to liaison between LDS and the police to ensure consistency and accuracy of available evidence.
” Source location Miles Ethan Hurley · Prevention of Future Deaths report
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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 Develop a standard template and guidance with NPCC and CPS for transferring relevant Liaison and Diversion assessment information to police.
Verbatim wording from the response “‘NHS England to provide clear guidance to practitioners on what information should be uploaded to police custody logs to ensure consistency and relevance for decision-makers (e.g. custody welfare, bail, police and court outcomes). To be achieved in collaboration with the CPS and local police services.’” 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 Maintain documented, verbally delivered and CCTV-recorded custody handovers, with live risk updates, shared access, audit trails, staff training and peer review.
Verbatim wording from the response “At the point of handover, the Principal Sergeant will refer to a handover document (a copy of which is supplied at Appendix 1) from which they will brief the oncoming team verbally. All members of the current duty team and the oncoming team will be present. They are each given a copy of the handover document which they can refer to during the briefing. The briefing is delivered by the Principal Custody Sergeant in person and is recorded on CCTV which is accessible at any time.” Source location Response from Sussex Police
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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 Record custody risks and concerns discussed with Liaison and Diversion staff on the detainee’s risk assessment and care plan.
Verbatim wording from the response “LDS Nurses will proactively triage detainees listed on the Custody White Board between 08:00hrs and 20:00hrs. This is a virtual white board accessed via NICHE which LDS nurses can independently access at any time. It contains details of all detainees in each Custody Centre. A Professional Discussion will be held between the LDS Nurse and Principal Sergeants to identify assessments that may need to be prioritised.” Source location Response from Sussex Police
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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 Consider best practice through the Betterment Workstream, including a nationally recognised pre-arrival risk assessment for communicating custody risks.
Verbatim wording from the response “The practice of arresting officers risk assessments being formally completed prior to arrival at custody is inconsistent across forces. Best practice is being considered through the NPCC Betterment Workstream to include a nationally recognised pre arrival risk assessment in place to communicate risks and concerns that may have been raised.” Source location Response from NPCC
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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 Raise NHS Trust information-sharing failures between criminal justice pathways as a detainee welfare concern.
Verbatim wording from the response “f) NHS Trust information sharing has also been raised as a concern by the NPCC in that the inability or refusal to share clinical records between criminal justice pathways adds risk to a detainees welfare.” Source location Response from NPCC
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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 Add a standard template for written information shared with police colleagues to the Custody Pathway SOP.
Verbatim wording from the response “In direct response to your concerns raised during the inquest into Mr Hurley’s death regarding the lack of guidelines to support a Liaison and Diversion practitioner as to when it is appropriate to undertake a formal mental health assessment if an individual is intoxicated rather than feeling obliged to do so because of their availability, MPFT are currently reviewing the Custody Pathway SOP. It has been agreed with the Senior Leadership Team in MPFT Health and Justice Services that written guidelines, regarding assessment of individuals who are intoxicated, are needed for MPFT staff. MPFT Custody Team Leaders are meeting on the 9th October 2024 to review the SOP to add:” Source location Response from Midlands Partnership NHS Trust
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26 Jul 2024 Zara Natasha Aleena · Prevention of Future Deaths report East London
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Concerns raised 1
Unclear and incomplete sharing of risk information between probation and the MPS View source
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Zara Natasha Aleena · 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
Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.
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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 Unclear and incomplete sharing of risk information between probation and the MPS
Wider context from the report “(14)The system in place for sharing risk information between the probation service and the MPS was unclear . Only very limited intelligence was shared with the MPS . There was no explanation as to why that information was shared, when more concerning risk related information was not shared .
” Source location Zara Natasha Aleena · 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 Use CONNECT and Proactive Management Plans as the primary searchable police record for integrated offender management.
Verbatim wording from the response “Since 2022, the MPS has introduced CONNECT, a large-scale technology system for crime and intelligence reporting and record keeping. This has provided police offender managers with access to a feature called Proactive Management Plans (“PMP”). PMPs are now the primary police record for IOM offender management. PMPs allow IOM records to be searchable, linked with other police records and readily available to all MPS staff. HM Prison & Probation Service do not have direct access to these records, but PMPs create a permanent record of what has been shared between the MPS and its partners.” Source location Response from Metropolitan Police
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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 Develop and use a process map guiding Police Offender Managers and supervisors to obtain, record and manage risk information before and after prison releases.
Verbatim wording from the response “Following inquest, the MPS has reflected on the sufficiency of information sharing from the HM Prison & Probation Service and the need for clarity around recalls to prison. The MPS has developed a new process map, which provides clarity and guidance for Police Offender Managers to ask HM Prison & Probation Service a broad range of questions, with the intention to increase the likelihood of all relevant information being shared with IOM partners. The new process highlights and clarifies the actions to be undertaken by Police Offender Managers and their supervisors, both before and after prison releases, including the recording of informed risk management decisions.” Source location Response from Metropolitan Police
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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 mandatory professional registration for Probation Officers to strengthen continuing development, performance and accountability.
Verbatim wording from the response “5.1. We accept that in this case up to date and accurate assessments of ████████
████████’s risk were not shared with partner agencies. We are committed to improving professional standards of practice and have introduced mandatory professional registration for Probation Officers, which aims to sharpen focus on Continuous Professional Development and drive improved performance and personal accountability to deliver public protection. Whilst managers do oversee Probation Officer work, we would not expect them to check every referral before it is made. The professional standards will, alongside increased staffing levels and improved digital checks/safeguards, ensure that Probation Officers do all that is required of them, including the sharing of risk information with partner agencies, whose contribution is vital to the efficacy of risk management plans.” Source location Response from HMPPS and MoJ
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3 Jun 2024 Tcherno Bari · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Lack of formal notification of police disagreement about risk category 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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AI-generated summary
Tcherno Bari · 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
Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.
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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 formal notification of police disagreement about risk category
Wider context from the report “(6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category . BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information.
” Source location Tcherno Bari · Prevention of Future Deaths report
Open source report
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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 information with health systems on establishing multi-agency governance, delivery structures, risk management, escalation and communication.
Verbatim wording from the response “To support implementation, NHS England has shared information with health systems about setting up multi-agency governance and delivery structures to oversee delivery, manage risks and escalations and enable open communication between local” 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 Issue guidance to health systems covering multi-agency governance, delivery structures and real-time and retrospective escalation processes.
Verbatim wording from the response “partners, including to resolve any challenges. Information has also been shared on escalation protocols, including the need for local partners to set up real-time escalation processes (in response to a situation that is currently live) and retrospective escalation processes (to review situations that have occurred, learn lessons and agree changes going forward). This information will be included in guidance that NHS England will issue to health systems shortly.” Source location Response from NHS England
Open published response
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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 Review and update the WMP Missing Person Policy to address daily appraisal attendance, clinician risk assessments, recording, and investigation-closure notifications.
Verbatim wording from the response “BSMHFT and send an appropriate staff member, as required. The WMP missing persons policy will be updated to reflect this.” Source location Response from West Midlands Police
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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 Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.
Verbatim wording from the response “Your report raises concerns about missing persons policy and Right Care, Right Person (RCRP), and I note that you have directed your report to the Department of Health and Social Care (DHSC) as a party to the National Partnership Agreement (NPA) on RCRP. I also note that you have raised concerns with other relevant partners, including representatives from Birmingham and Solihull Mental Health NHS Foundation Trust, West Midlands Police and NHS England. Given the operational independence of police forces and the autonomy of clinical decision making, those partners are best placed to respond to some of the concerns you raise. DHSC does have a role in setting guidance and direction to the mental health sector and I will respond on these points in particular.” Source location Response from DHSC
Open published response
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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 The mental health trust cannot formally record differing risk opinions because it lacks access to police systems.
Verbatim wording from the response “The PFD Report also addresses the issue of difference between the WMP and BSMHFT risk categories. BSMHFT does not have access to WMP systems or to the COMPACT log which is used to record a missing person investigation so could not use this to formally indicate a difference in opinion. However, the WMP missing persons policy will be updated to remind all officers, when attending such calls to identify the mental health trust’s risk category and to recognise the importance of clinician’s expertise in determining the risk assessment. Officers will be reminded that they must consider risk from the stakeholder/partner perspective and obtain the rationale of the treating clinician where there is a difference. This should then be recorded on COMPACT and fed back to WMP supervisors and shared with the reporting partner agency.” Source location Response from West Midlands Police
Open published response
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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 Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.
Verbatim wording from the response “As you are aware, police forces are operationally independent and so it is for the National Police Chiefs’ Council, the College of Policing and West Midlands Police to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Bari, and I know they have written to you separately on this matter.” Source location Response from the Home Office
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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 Each Chief Constable decides whether and when to implement Right Care Right Person and which elements of the national framework to adopt.
Verbatim wording from the response “As Policing is operationally independent, each Chief Constable has to decide whether and when to implement Right Care Right Person and how much of the framework set out in the National Partnership Agreement and supporting guidance they wish to adopt.” Source location Response from the Home Office
Open published response
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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 The APCC cannot mandate its members to undertake actions in response to the identified safety concerns.
Verbatim wording from the response “As a membership body, the APCC cannot mandate actions upon its members. However, our role does include the provision of advice and recommendations to inform our members’ local activities, including the development of evidence-based guidance.” Source location Response from APCC
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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 Operational implementation of Right Care, Right Person is assigned to Chief Constables rather than Police and Crime Commissioners.
Verbatim wording from the response “At a local policing level, PCCs are not responsible for making operational policing decisions, including the implementation of Right Care, Right Person, this is a decision for Chief Constables. Rather, PCCs are responsible for scrutinising their Chief Constables and holding them to account for the delivery of their duties. Additionally, PCCs have responsibilities to commission services, and where necessary, to bring partners together and work with them.” Source location Response from APCC
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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 RCRP did not apply because the case was treated as a missing person involving immediate risk requiring police response.
Verbatim wording from the response “The Missing persons framework is another distinct policy area which falls outside of RCRP when it is established that a persons whereabouts cannot be ascertained and all reasonable enquiries have been made by the informant to ascertain their whereabouts.” Source location Response from NPCC
Open published response
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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AI-generated summary
Thomas Victor HUNTLEY · 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 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.
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 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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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational 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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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing 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
Open published response
27 Nov 2020 Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to pass relevant incident and vulnerability information to ambulance and hospital staff View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Agnès Blandine Marthe MARCHESSOU · 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
Agnès Marchessou had experienced fragile mental health for four or five years before her death. After her arrest on 4 July 2020, she was knocked over by a bus on 8 July and taken to hospital. The principal concerns were that police did not pass key information about the incident and her stated reasons for stepping into the road to ambulance or hospital staff, did not promptly make relevant enquiries or record her potential vulnerability, and showed confusion about the required process.
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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 pass relevant incident and vulnerability information to ambulance and hospital staff
Wider context from the report “The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms Marchessou to hospital, nor to any of the doctors or nurses at the hospital.
2. Ms Marchessou told the police officers that she had blacked out and could not remember what had happened, then that she thought she had stepped into the road as the result of a panic attack. She also said that she had stepped in front of the bus because she was upset about being denied contact with her children.
The police officers did not pass on the crucial information that Ms Marchessou said she had stepped in front of the bus because she was upset about being denied contact with her children, either to the emergency ambulance crew or to the treating doctors or nurses.
” Source location Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report
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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 Improve officers’ sharing of vital incident information with colleagues, ambulance crews and medical staff.
Verbatim wording from the response “Officer 1 interviewed the bus driver at the scene of the collision whilst Officer 2 dealt with Ms Marchessou in the ambulance. This would be normal practice where two parties were involved, with each officer initially dealing with their casualty, witness or other party involved. The senior officer has discussed this incident in detail with Officer 1, providing him with the opportunity to reflect on the decisions he made. It was evident from their discussion that the officer was reflective as he recognised that he would deal with a similar incident differently next time. He would now relay the bus driver’s account to his colleague who was dealing with Ms Marchessou at the scene and subsequently provide this information to the medical staff at the scene and at the hospital.” Source location 2020-0255-Letter-from-Metropolitan-Police-Redacted.pdf
Open published response
28 Jun 2019 Heather Birchall · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1
Failure to provide healthcare professionals with complete relevant mental-health information for frontline assessments View source
This report raised 1 other concern. 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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AI-generated summary
Heather Birchall · 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
Heather Birchall, who was homeless and had mental health problems and alcohol dependence, died after consuming excess amounts of medication alongside alcohol; bronchopneumonia also contributed to the mechanism of death. The principal concern was that healthcare professionals assessing people in police custody might lack relevant mental health information because of confidentiality barriers, potentially limiting informed decisions about further care and safeguarding life.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide healthcare professionals with complete relevant mental-health information for frontline assessments
Wider context from the report “One of the concerns that arose relates to G4S healthcare professionals and any other healthcare professional in this situation when asked to carry out a front line assessment which could include mental health features, that those individuals may not have the fullest amount of information that is available so that they can make an informed decision as to whether or not for example further healthcare input is required , such as an example a formal mental health at assessment. Whilst a problem insofar as getting a complete picture did not seem to be quite such an issue when personnel from LADS were available it would appear that out of those hours, if a G4S healthcare professional wanted to make enquiries insofar as an individual’s mental health background which potentially might be within the knowledge of the relevant healthcare trust, that when an approach is made to the Street Triage team out of hours that more often than not the issue of confidentiality was raised to withhold information or I felt that equally there was a danger that selective information might only be passed at best to the G4S healthcare operative . The concern that I was left with was that the healthcare professionals from G4S and arguably at the end of the day Wiltshire Police who ultimately responsibility it is to safeguard life when an individual is in Police custody are effectively trying to do a job, through their contract service providers (G4S), in circumstances whereby in trying to discharge their duty having regard to Article 2 of European Convention of Human Rights they were doing so effectively, as a consequence of patient confidentiality, with one arm tied behind their back.
” Source location Heather Birchall · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.