Concerns raised 2
Failure to carry out keyworker sessions as required View source Lack of knowledge of the required frequency of keyworker sessions 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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AI-generated summary
Aaron Lee Taylor · 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
Aaron Lee Taylor was discovered in his prison cell on 28 August 2023, having died between the evening of 27 August and the morning of 28 August 2023. The inquest heard that he had taken steps intending to take his own life and identified multiple failures in measures to prevent self-harm and suicide, including inadequate assessments, documentation, policy compliance and mental health interventions.
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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 carry out keyworker sessions as required
Wider context from the report “(2) Evidence was also heard that keyworker sessions were not being carried out as they should have been with a prisoner who had been identified as in need of support through the keyworker scheme. A prison officer with keyworker responsibilities gave evidence that they did not know how frequently keyworker sessions should take place
” Source location Aaron Lee Taylor · Prevention of Future Deaths report
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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 knowledge of the required frequency of keyworker sessions
Wider context from the report “(2) Evidence was also heard that keyworker sessions were not being carried out as they should have been with a prisoner who had been identified as in need of support through the keyworker scheme. A prison officer with keyworker responsibilities gave evidence that they did not know how frequently keyworker sessions should take place
” Source location Aaron Lee Taylor · 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 Prioritise vulnerable prisoners, including those on ACCTs, for at least one keyworker session monthly and track keywork progress through weekly performance meetings.
Verbatim wording from the response “In line with HMP Garth’s current regime management plan a priority keywork model is in place, ensuring that any prisoner who has been identified as vulnerable is prioritised. A staff information notice was issued in November 2025 advising staff that a minimum of one keywork session per month is expected for all prisoners who have been identified as a priority, and this includes those who are on an ACCT. In addition to these priority sessions, staff continue to provide keywork sessions for other prisoners wherever resources allow. Keywork progress is tracked through the weekly performance meeting.” 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 The priority keywork model and monthly sessions for vulnerable prisoners, including those on ACCTs, are considered sufficient to address concerns about support provision.
Verbatim wording from the response “In line with HMP Garth’s current regime management plan a priority keywork model is in place, ensuring that any prisoner who has been identified as vulnerable is prioritised. A staff information notice was issued in November 2025 advising staff that a minimum of one keywork session per month is expected for all prisoners who have been identified as a priority, and this includes those who are on an ACCT. In addition to these priority sessions, staff continue to provide keywork sessions for other prisoners wherever resources allow. Keywork progress is tracked through the weekly performance meeting.” Source location Response from HM Prison and Probation Service
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18 Jul 2025 Patryk Gladysz · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Staffing levels diluting key worker scheme requirements View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Patryk Gladysz · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patryk Gladysz, who had schizophrenia and was detained at HMP Wandsworth, was found in his cell with a ligature around his neck on 5 January 2024 and died at St George’s Hospital. The inquest concluded that he had hung himself with a ligature, with his intentions unknown. Concerns included delays and staffing pressures affecting mental health assessments, inadequate communication between prison and healthcare staff, gaps in knowledge of his history and risks, and shortcomings in prison monitoring and training.
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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 Staffing levels diluting key worker scheme requirements
Wider context from the report “(2) Staffing within HMP Wandsworth resulting in a dilution to the requirements for the key worker scheme .
” Source location Patryk Gladysz · 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 Increase prison officer staffing through recruitment, bringing HMP Wandsworth above its target staffing level.
Verbatim wording from the response “I have received assurance from the Governor of HMP Wandsworth that there has been improvement in staffing figures and that there is evidence of a higher retention rate as the months progress. There has been a recent recruitment intake which has added to the existing staffing group and has elevated HMP Wandsworth’s prison officer levels to above the target staffing figure.” Source location Response from 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 Assign a Custodial Manager to oversee keyworker allocation, training and data, with weekly management review.
Verbatim wording from the response “HMP Wandsworth now has an assigned Custodial Manager to provide robust oversight of allocation, training and data of the keyworker scheme. The data is shared weekly during the” Source location Response from 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 Automatically assign keyworkers to higher-risk prisoners to provide support at the earliest opportunity.
Verbatim wording from the response “morning meeting to provide consistent management oversight. Additionally, prisoners who are deemed to be higher risk are automatically assigned a keyworker to ensure they are provided with adequate support at the earliest opportunity. The combination of improvement in staffing and the allocation of managerial oversight to the keyworker scheme will contribute to an improvement in its delivery.” Source location Response from HM Prison and Probation Service
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25 Nov 2024 Jonathon Paul LAWLOR · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to provide sufficient key-working sessions for prisoners View source
Linked response
HM Prison and Probation 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. 6
HM Prison and Probation Service
Implement the new regime and business planning process to support increased quantity and quality of key work.
View source
HM Prison and Probation Service
Compile HMP Elmley’s Key Work Delivery Strategy to address and improve key-work provision.
View source
HM Prison and Probation Service
Provide dedicated staff for young offenders on each houseblock to support targeted risk and vulnerability management.
View source
HM Prison and Probation Service
Provide additional key-work sessions for prisoners on the neurodiverse landing and during weekends in the inpatient department and Care and Separation Unit.
View source
HM Prison and Probation Service
Add key-work delivery elements to the Regime Planning Template for establishments to use in regime planning.
View source
HM Prison and Probation Service
Raise the minimum key-work expectation to two sessions for every prisoner every four weeks in the 2025/26 regime-planning cycle.
View source See 3 more actions
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AI-generated summary
Jonathon Paul LAWLOR · 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
Jonathon Paul LAWLOR was held on remand at HMP Elmley and was found unresponsive in his cell on 19 October 2023. CPR and emergency treatment were provided, but he was declared dead at 11:47 hours; the post-mortem identified cocaine toxicity, and the inquest concluded that he died as a result of an accident. The principal concern was that he had received only two keywork sessions during four months on remand, reportedly because of staff shortages, raising broader concerns about the availability and suitability of keyworking for prisoners.
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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 provide sufficient key-working sessions for prisoners
Wider context from the report “(1) Mr. Lawlor only had two keywork sessions during the 4 months he was on remand at HMP Elmley. The reasons given were that staff shortages meant that key working sessions were not able to be offered . Offender Management in Custody(OMiC) guidance suggests that good practice entails an officer having a caseload of five or six prisoners who they will meet once a week for a key working meeting. The Prison and Probation Ombudsman who also investigated the death were aware that due to staff shortages the priority at the time of Mr. Lawlor's death were to have monthly sessions and that the prison was to increase provision as their staffing picture improved. On that basis they made no recommendations.
Whilst the number of keywork sessions Mr. Lawlor had did not play a part in his death it may be the case that key-working sessions for prisoners can assist with reducing risks for others in custody. Evidence heard at the inquest revealed that the target had been unachievable due to staffing pressures and as a large number of prisoners (approximately 70%) are on remand and stay between zero and six months the turnover is high and the prison is busy. There was also some scepticism as to whether it was the right model.
” Source location Jonathon Paul LAWLOR · 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 Implement the new regime and business planning process to support increased quantity and quality of key work.
Verbatim wording from the response “In January 2024 I wrote to all Area Executive Directors, Prison Group Directors and Governors setting out the HMPPS operational priorities for 2024/5 and the related core expectations. One of these priorities was to increase the quantity and quality of regimes, including key work, and to support this a new regime and business planning process has been introduced.” Source location Response from HMPPS
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 Compile HMP Elmley’s Key Work Delivery Strategy to address and improve key-work provision.
Verbatim wording from the response “Local action is also underway. The Custodial Manager who oversees keywork at HMP Elmley has been compiling a Key Work Delivery Strategy to take forward as we move into 2025. This strategy details HMP Elmley’s plan to address and improve the issue of key work within the establishment.” Source location Response from HMPPS
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 Provide dedicated staff for young offenders on each houseblock to support targeted risk and vulnerability management.
Verbatim wording from the response “HMP Elmley recognise that specific cohorts of prisoners are either more at risk of harm or self-harm or are more vulnerable to other incidences such as bullying. To manage this risk certain staff members have been identified and will work specifically with these cohorts, the aim being to have these staff upskilled in the areas that they are allocated to so they can help these individuals and lower the: violence, self-harm, non-compliance and bullying rates within the establishment. We currently have a member of staff from each houseblock dedicated to young offenders with the aim of increasing these dedicated cohorts over the coming months. Additional key work is also offered to those that reside on our neurodiverse landing and key work is offered each weekend within the in-patient department (IPD) and the Care and Separation Unit (CSU).” Source location Response from HMPPS
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 Provide additional key-work sessions for prisoners on the neurodiverse landing and during weekends in the inpatient department and Care and Separation Unit.
Verbatim wording from the response “HMP Elmley recognise that specific cohorts of prisoners are either more at risk of harm or self-harm or are more vulnerable to other incidences such as bullying. To manage this risk certain staff members have been identified and will work specifically with these cohorts, the aim being to have these staff upskilled in the areas that they are allocated to so they can help these individuals and lower the: violence, self-harm, non-compliance and bullying rates within the establishment. We currently have a member of staff from each houseblock dedicated to young offenders with the aim of increasing these dedicated cohorts over the coming months. Additional key work is also offered to those that reside on our neurodiverse landing and key work is offered each weekend within the in-patient department (IPD) and the Care and Separation Unit (CSU).” Source location Response from HMPPS
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 Add key-work delivery elements to the Regime Planning Template for establishments to use in regime planning.
Verbatim wording from the response “Key work is one of the core priorities for HMPPS in 2025/26. The expectation will be that key work delivery will increase in this cycle of regime planning, aligned to each establishment Regime Management Plan. Additional elements have been added to the Regime Planning Template to enable establishments in their key work delivery.” Source location Response from HMPPS
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 Raise the minimum key-work expectation to two sessions for every prisoner every four weeks in the 2025/26 regime-planning cycle.
Verbatim wording from the response “For 2025/6 the minimum expectation for key work delivery will rise to two key work sessions every four weeks as a minimum.” Source location Response from HMPPS
Open published response
31 May 2024 Frazer Charlie Williams · Prevention of Future Deaths report Dorset
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Concerns raised 1
Failure to deliver the keyworker scheme in line with national guidance View source
This report raised 16 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
Guys Marsh Prison
Introduce the Band 3 group to support delivery of the keyworker scheme.
View source
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AI-generated summary
Frazer Charlie Williams · 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
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.
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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 deliver the keyworker scheme in line with national guidance
Wider context from the report “x. The keyworker scheme is not being delivered in line with national guidance at HMP Guys Marsh.
” Source location Frazer Charlie Williams · 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 Introduce the Band 3 group to support delivery of the keyworker scheme.
Verbatim wording from the response “The Band 3 group will be introduced in September 2024.” Source location Response from HMPPS / HMP Guys Marsh
Open published response
2 Feb 2023 Jason Anthony Williams · Prevention of Future Deaths report Dorset
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Concerns raised 1
Failure of the keyworker programme to operate as planned View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jason Anthony Williams · 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
Jason Anthony Williams was found unresponsive in his cell at HMP Guys Marsh on 31 July 2020, and his death was confirmed by paramedics. The report states that synthetic cannabinoid intoxication was the medical cause of death and that he had deliberately taken drugs without intending fatal consequences. Concerns included inadequate guidance on vulnerable prisoners, shortcomings in the keyworker programme and NOMIS record keeping, and the absence of a Governor notice about increased psychoactive-substance risks.
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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 keyworker programme to operate as planned
Wider context from the report “ii. The current keyworker programme is not working as planned at HMP Guys Marsh and there was reference to this also being reflected nationally . I would request that consideration is given to a review being undertaken of the keyworker programme within the whole prison estate, and also specifically at HMP Guys Marsh.
” Source location Jason Anthony Williams · 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 Fully reinstate key work across the male closed prison estate.
Verbatim wording from the response “Key work is the foundation that supports prison safety by building relationships, and promoting opportunities for rehabilitation. While the Covid pandemic and staffing pressures have had a particularly negative impact on the key worker scheme across the prison estate, we are committed to ensuring that key work is fully reinstated across the male closed estate. With this in mind, the national Offender Management in Custody (OMiC) team will use evidence, data and learning to review and develop the current key work model to maximise the opportunity to deliver better outcomes directly associated with safety and reducing reoffending. This will include reviewing key work and OMiC sentence management, exploring ways in which the current delivery model can be made more flexible to better support delivery, taking into consideration different prison functions and prisoner cohorts.” Source location Response from 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 Review and develop the current key-work and OMiC sentence-management model using evidence, data and learning to improve safety and outcomes.
Verbatim wording from the response “Key work is the foundation that supports prison safety by building relationships, and promoting opportunities for rehabilitation. While the Covid pandemic and staffing pressures have had a particularly negative impact on the key worker scheme across the prison estate, we are committed to ensuring that key work is fully reinstated across the male closed estate. With this in mind, the national Offender Management in Custody (OMiC) team will use evidence, data and learning to review and develop the current key work model to maximise the opportunity to deliver better outcomes directly associated with safety and reducing reoffending. This will include reviewing key work and OMiC sentence management, exploring ways in which the current delivery model can be made more flexible to better support delivery, taking into consideration different prison functions and prisoner cohorts.” Source location Response from HM Prison & Probation Service
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.