Recurring concern

Unreliable handling of family and friend safety concerns about prisoners

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First reported 27 Nov 2016•Latest report 22 Dec 2021

Definition

What this concern includes

Includes prison arrangements for receiving, recording, triaging, communicating, investigating, escalating and responding to health or welfare concerns raised by a prisoner’s family or friends, including formal written responses, staff procedures for receiving such calls, and onward transfer of relevant correspondence to prison healthcare or other responsible professionals.

Not included

Excludes generic family communication or involvement failures where the concern is not raised by family or friends about a prisoner’s health or welfare within a prison setting.
Excludes clinical assessment, treatment, observation or safeguarding failures after a family concern has been reliably received and acted upon.
Excludes generic prison correspondence, telephone, record-keeping or communication deficiencies that are not specifically part of handling family or friend safety concerns.
Excludes concerns raised solely by prisoners, staff or professionals unless the assertion also concerns the same prison family-and-friend concern-handling process.
Excludes the broader existing concern about handling family and carer safety concerns in patient care where no prison-specific family-or-friend concern process is identified.

Reports: 4
Individual concerns: 8
Date range: 2016–2021
Stated actions: 4

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service2

Ministry of Justice2

Central and North West London NHS Foundation Trust1

Essex Partnership University NHS Foundation Trust1

Guys Marsh Prison1

High Down Prison1

HM Prison Service1

Home Office1

NHS England1

Practice Plus Group Hospitals Limited1

Wandsworth Prison1

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.

22 Dec2021
Dorset
Concerns raised3
1. Failure to provide a formal written response to family or friends raising prisoner health or welfare concerns
2. Failure to keep a computer record of family or friend concerns and measures taken to address them
3. Failure to use a structured approach for responding to family or friend concerns about prisoner health or welfare
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Respond to families and friends with updates about actions taken on their concerns, subject to security limitations.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Log family and friend concerns, record actions taken, and share relevant risk information on prisoners’ NOMIS records.
  Stated by HM Prison and Probation ServiceStated completed
AI-generated summary

Kyle Nel · 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

Kyle Nel, a serving prisoner at HMP Guys Marsh, was found unconscious in his cell on 9 June 2018 and was subsequently declared dead after resuscitation attempts. The inquest recorded the medical cause of death as aspiration of gastric contents associated with synthetic cannabinoid (5F-ADB), also known as “Spice”, use, with a conclusion of misadventure. Concerns included the prison’s handling and recording of welfare concerns raised by families and the ability to pass drugs and other prohibited items between prison units through security fences.

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 provide a formal written response to family or friends raising prisoner health or welfare concerns
Wider context from the report
“i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented. ”
Source location
Kyle Nel · 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
Failure to keep a computer record of family or friend concerns and measures taken to address them
Wider context from the report
“i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented. ”
Source location
Kyle Nel · 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
Failure to use a structured approach for responding to family or friend concerns about prisoner health or welfare
Wider context from the report
“i) I have concerns that when members of a prisoner’s family or friends contact the prison raising concerns as to the health or welfare of a prisoner, there needs to be structured approach and computer record kept of those concerns, the measures taken to deal with the concerns and a formal written response to the family or friends who have raised those concerns. It is understood that while there are potential security and confidentiality issues that may arise from this process suitable measures should be considered and implemented. ”
Source location
Kyle Nel · 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
Respond to families and friends with updates about actions taken on their concerns, subject to security limitations.

Verbatim wording from the response
“Custody hotline and mailbox contains an out of office message with instructions on how to raise an emergency concern out of hours. All concerns raised are now logged on a database, managed by the Safer Custody team, along with a record of the action taken, and a note is placed on the individual’s NOMIS record so that information regarding a prisoner’s risk is shared with all relevant staff. The Safer Custody team respond to any concerns raised by families and friends, providing an update on what has happened and what actions have been taken. Of course, there are instances where staff are not able to provide detail for security reasons but in these circumstances an explanation is provided to families in line with the HMPPS policy framework on Strengthening Prisoners’ Family Ties.”

Source location
2021-0426-Response-from-HMPPS_Published
Page 2 · response
Published 23 December 2021
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
Log family and friend concerns, record actions taken, and share relevant risk information on prisoners’ NOMIS records.

Verbatim wording from the response
“Custody hotline and mailbox contains an out of office message with instructions on how to raise an emergency concern out of hours. All concerns raised are now logged on a database, managed by the Safer Custody team, along with a record of the action taken, and a note is placed on the individual’s NOMIS record so that information regarding a prisoner’s risk is shared with all relevant staff. The Safer Custody team respond to any concerns raised by families and friends, providing an update on what has happened and what actions have been taken. Of course, there are instances where staff are not able to provide detail for security reasons but in these circumstances an explanation is provided to families in line with the HMPPS policy framework on Strengthening Prisoners’ Family Ties.”

Source location
2021-0426-Response-from-HMPPS_Published
Page 2 · response
Published 23 December 2021
Open published response
31 May2017
Inner West London
Concerns raised2
1. Failure to provide an effective pathway for family health information to reach relevant prison welfare teams
2. Failure to maintain comprehensive records of family health-information contacts
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Issue and disseminate guidance requiring prisons to maintain 24/7 emergency contact routes for families and share prisoner risk information appropriately.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Require staff to record contact with prisoners’ families on NOMIS so information is disseminated to all departments, including healthcare.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 1
1. Position
  Existing emergency contact and information-sharing processes adequately address families’ reporting of prisoners’ health concerns.
  Stated by HM Prison and Probation ServiceExisting arrangements considered sufficient
AI-generated summary

Jonathan David Palmer · 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 David Palmer was found suspended from a ligature in his cell at HMP Wandsworth on 19 November 2015 and was declared dead after resuscitation efforts were abandoned. The Inquest found the cause of death to be hanging. The substantive concerns included the lack of an effective system for families to provide and have health information disseminated within the prison, and apparently ineffective controls on contraband such as Spice.

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 provide an effective pathway for family health information to reach relevant prison welfare teams
Wider context from the report
“1. There is no effective system by which the family of a prisoner can input information they deem relevant to a prisoner's health needs and be assured this will be disseminated to relevant teams within the prison, with appropriate records being maintained in order to be able to demonstrate this has been done. Families can be a source of valuable medical information, particularly, where GP records have not been obtained and the individual himself may not be a reliable source. It would be beneficial to have a clear, publicised conduit for a family to provide relevant medical information to a specified department. The Inquest was informed that a single point of contact has now been established, but it remains unclear whether comprehensive records of all contacts will be maintained, or whether this will result in the timely dissemination of information to those with a role in the prisoner's welfare, such as healthcare staff, RAPt or the chaplains. As the Personal Officer scheme appears to have been abandoned at HMP Wandsworth there is no alternative individual for a concerned family to approach. ”
Source location
Jonathan David Palmer · 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
Failure to maintain comprehensive records of family health-information contacts
Wider context from the report
“1. There is no effective system by which the family of a prisoner can input information they deem relevant to a prisoner's health needs and be assured this will be disseminated to relevant teams within the prison, with appropriate records being maintained in order to be able to demonstrate this has been done. Families can be a source of valuable medical information, particularly, where GP records have not been obtained and the individual himself may not be a reliable source. It would be beneficial to have a clear, publicised conduit for a family to provide relevant medical information to a specified department. The Inquest was informed that a single point of contact has now been established, but it remains unclear whether comprehensive records of all contacts will be maintained, or whether this will result in the timely dissemination of information to those with a role in the prisoner's welfare, such as healthcare staff, RAPt or the chaplains. As the Personal Officer scheme appears to have been abandoned at HMP Wandsworth there is no alternative individual for a concerned family to approach. ”
Source location
Jonathan David Palmer · 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
Issue and disseminate guidance requiring prisons to maintain 24/7 emergency contact routes for families and share prisoner risk information appropriately.

Verbatim wording from the response
“Your report has been passed to the Safer Custody and Public Protection Group in Her Majesty’s Prison and Probation Service (HMPPS – the agency that has replaced NOMS), which is responsible for sharing learning from deaths in prison custody.”

Source location
2017-0173-Response-by-HM-Prison-Probation-Service
Page 1 · response
Published 4 August 2017
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
Require staff to record contact with prisoners’ families on NOMIS so information is disseminated to all departments, including healthcare.

Verbatim wording from the response
“At HMP Wandsworth, a Governor’s Order has been issued to all staff, stating that contact with prisoners’ families must be recorded on the National Offender Management Information system (NOMIS). This is to ensure dissemination of information to all departments including healthcare. You also expressed concern at what appeared to be ineffective steps taken to control the inflow of contraband material into the prison.”

Source location
2017-0173-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 4 August 2017
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
Existing emergency contact and information-sharing processes adequately address families’ reporting of prisoners’ health concerns.

Verbatim wording from the response
“Your first point is that there was no effective system by which the family of a prisoner can report their concerns about a prisoner’s health needs and be assured that this information will be disseminated appropriately.”

Source location
2017-0173-Response-by-HM-Prison-Probation-Service
Page 1 · response
Published 4 August 2017
Open published response
17 Feb2017
Essex
Concerns raised2
1. Failure to formally record concerns raised by a prisoner’s family
2. Failure to communicate concerns raised by a prisoner’s family
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Dean Gary Saunders · 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

Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.

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 formally record concerns raised by a prisoner’s family
Wider context from the report
“6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family. ”
Source location
Dean Gary Saunders · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate concerns raised by a prisoner’s family
Wider context from the report
“6. FOR NOMS:- The meaningful involvement of families in the ACCT process, including by ensuring the formal recording, and communication of concerns raised by a prisoner’s family. ”
Source location
Dean Gary Saunders · Prevention of Future Deaths report
Page 4 · concerns
Open source report
27 Nov2016
Surrey
Concerns raised1
1. Failure of Gate House staff to understand the proper procedure for safety or wellbeing concern calls
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Matthew RUSSELL · 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

Matthew Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of Gate House staff to understand the proper procedure for safety or wellbeing concern calls
Wider context from the report
“b. Ensuring that all Gate House staff understand the proper procedure to adopt when receiving a call from a prisoner's family or friends expressing concerns for that prisoner’s safety or wellbeing. ”
Source location
Matthew RUSSELL · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Failure to provide a formal written response to family or friends raising prisoner health or welfare concerns

Failure to keep a computer record of family or friend concerns and measures taken to address them

Failure to use a structured approach for responding to family or friend concerns about prisoner health or welfare

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Failure to provide an effective pathway for family health information to reach relevant prison welfare teams

Failure to maintain comprehensive records of family health-information contacts

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to formally record concerns raised by a prisoner’s family

Failure to communicate concerns raised by a prisoner’s family

Concerns raised1

Failure of Gate House staff to understand the proper procedure for safety or wellbeing concern calls

Actions described in response 2

Actions described in response 2

Respondent positions 1